If you are considering breast reconstruction after a mastectomy, it is completely natural to have questions about the financial side of the procedure. Many patients worry whether insurance will cover reconstruction and what their out-of-pocket costs might be.
At the New York Group for Plastic Surgery, board-certified plastic and reconstructive surgeon Dr. Jordan M. S. Jacobs helps patients understand both their surgical options and the insurance considerations involved, so you can move forward with clarity.
Breast reconstruction is usually covered by insurance
Breast reconstruction is typically covered by health insurance. Although plastic surgeons perform the procedure, it is not considered cosmetic surgery when it follows a mastectomy.
Federal protections help ensure access to reconstruction. The Women’s Health and Cancer Rights Act (WHCRA) requires most group health plans that cover mastectomies to also cover breast reconstruction and related procedures. This generally includes the initial reconstruction, surgery on the opposite breast to achieve symmetry, and revision procedures if needed.
However, the specifics of your coverage will depend on your insurance provider and plan.
You may still have some out-of-pocket expenses
Even with insurance, some out-of-pocket costs may still apply. These costs are usually determined by the structure of your insurance plan rather than the procedure itself. Common expenses may include:
- Your annual deductible
- Co-payments for surgical services
- Co-insurance after your deductible is met
- Fees associated with hospital or surgical facilities
Because insurance policies vary, your financial responsibility can differ significantly from that of another patient. Understanding your plan early can help you avoid unexpected expenses.
Choosing an in-network surgeon can reduce costs
The final cost is also determined by whether your surgeon is in-network with your insurance provider. When you choose an in-network surgeon, your insurance company typically covers a larger percentage of the procedure because negotiated rates already exist between the surgeon and the insurance provider. This usually leads to lower deductibles and co-insurance payments.
If you see an out-of-network surgeon, your insurance may cover less of the procedure, or in some cases, none at all. For this reason, you must find a highly experienced plastic surgeon who also participates in your insurance network.
Preventive reconstruction may also be covered
Breast reconstruction coverage is not limited to patients who have already developed breast cancer. Many insurance plans also cover reconstruction following preventive mastectomies.
If you carry certain genetic mutations, such as BRCA, or have a strong family history of breast cancer, your physician may recommend preventative surgery to reduce your risk. In these cases, insurance often covers the mastectomy and the reconstruction that follows.
Travel and logistical costs may affect your budget
While surgical costs are often covered by insurance, you may want to consider other financial factors related to your care. For example, some patients travel to receive treatment from plastic surgeons who specialize in advanced breast reconstruction and microsurgical techniques. If you are traveling for surgery, you may need to account for:
- Transportation expenses
- Temporary lodging near the surgical center
- Time away from work during recovery
Our surgical team can help navigate the finances
An experienced surgical team can help you verify insurance benefits, clarify your expected costs, and guide you through the process step by step. At the New York Group for Plastic Surgery, board-certified plastic and reconstructive surgeon Dr. Jordan M. S. Jacobs and the team work closely with patients to ensure they are supported throughout the process.
By helping you understand the medical and financial aspects of surgery, we strive to make breast reconstruction as accessible as possible. Please schedule your consultation in NYC with Dr. Jacobs at the New York Group for Plastic Surgery to explore your options.
