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FAQ
Frequently Asked Questions
General
No, the proposed Comprehensive Breast Reconstruction Coverage Act does not mandate additional coverage and therefore will not increase your premiums as your premiums and the state’s budget already account for provision of coverage. What the proposed legislation will do is ensure that you have access to what you already pay for through your existing premiums and/or taxes.
Similar legislation was ratified in Arkansas and the state saw no fiscal impact based on its enactment.
No, breast reconstruction is NOT a cosmetic procedure. Breast reconstruction restores the breast(s) after removal due to cancer or other medical conditions. The goal is to restore what was lost, not provide elective enhancement. Breast reconstruction is considered a medically necessary procedure, and its coverage as such has been federally protected in association with a mastectomy since the passage of the WHCRA in 1998.
A “free flap” is a type of reconstructive surgery where your own tissue (typically skin, fat, and blood supply) is completely removed from one part of your body (donor site), transplanted to another, and then the tiny blood vessels are reconnected under an operating microscope.
The DIEP flap is a free flap procedure where the abdominal skin and fat is used (without transferring muscle) to create a new breast(s).
Free flap procedures like DIEP are recognized as the gold standard of care for breast reconstruction in the setting of radiation, where implant-based reconstruction has up to 50 percent complication/failure rate.
No, the proposed legislation does NOT mandate a rate. Rather, it seeks to create an environment for facilities and physicians where they can actually negotiate with insurance companies so that offering these medically necessary services remains financially viable.
If a patient selects an out-of-network provider, the insurance company and the provider must engage in a single-case negotiation for that patient’s care. If they cannot reach an agreement within five days, then the insurance carrier will pay the lesser of 80 percent fair market value for the service as determined by an independent third party (20 percent discount on fair market rate) or billed charges. The “lesser of” scenario ensures the health plan will always receive the best available rate.
Network adequacy refers to whether a health insurance plan has a sufficient number and variety of healthcare providers to ensure members can access covered services without unreasonable delay, travel, or potential for unnecessary harm.
Under the Affordable Healthcare Act, health insurance plans must maintain network adequacy or in the event of an inadequate network, they must cover out-of-network providers as though they were in-network, with no additional cost sharing to its member(s).
Unfortunately, the burden to obtain a recognition of a network inadequacy is placed on the patient, and there is no reasonable recourse for a health plan not responding timely to-or at all- to a “gap in care” request for acknowledgement from a health plan.
In consideration of the high incidence of this disease and the limited number of specialists able to provide reconstructive services, along with surgeries requiring multi-specialty coordination, the proposed legislation recognizes the inherent gap in care for breast reconstruction and removes this administrative burden from the patient and her family.
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