Health Insurance and Plastic Surgery
Health insurance can – in certain cases – cover plastic surgery but not cosmetic surgery. Although the details of what your policy provides depend on your coverage, here are the basics you need to know.
Cosmetic vs. Reconstructive Surgery
Health insurance plans often cover certain plastic surgery procedures when the plastic surgery is performed for reconstructive reasons rather than cosmetic reasons. Damage that resulted from an accident or a birth defect is often considered reconstructive. Sometimes, health insurance might cover part of a plastic surgery bill – for example, correcting a deviated septum as part of a rhinoplasty might qualify for partial payment. If your surgery improves a medical problem, such as improving breathing, then that portion of the expense will likely be covered. Generally, scars which do not cause pain, acne scars, and removal of skin such as a tummy tuck or thigh lift are not covered.
Breast Surgery and Insurance Coverage
Federal law requires that health insurance cover the cost of breast reconstruction following a mastectomy for cancer (ADD) or the genetic disposition for cancer. The Women’s Health and Cancer Rights Act (WHCRA), signed into law on October 21, 1998 helps protect women with breast cancer who choose to have breast reconstruction after mastectomy. This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction.
Under the WHCRA, mastectomy benefits must cover:
- Reconstruction of the breast that was removed by mastectomy
- Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy
- Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction
- Any physical complications at all stages of mastectomy and reconstruction, including lymphedema
Your insurance benefits, regardless of your diagnosis, may have a yearly deductible and may require that you pay co-insurance. Co-insurance is when health costs are paid for less than the full amount agreed upon with your physician and your insurance plan, and the patient must pay the difference.
Breast reduction may also be covered when a person suffers from chronic back pain, shoulder pain, and chronic rashes below the breasts provided it meets your insurance company’s medical criteria. Breast enlargement for purely cosmetic purposes is not covered under health insurance. Every health plan provides different benefits and to know for certain what your plan covers requires reviewing those benefits in detail.
