October 22, 1998

After two years of Congressional lobbying and a handful of stalled bills, yesterday President Clinton signed into law a bill that includes a provision protecting breast cancer victims from arbitrary coverage denials for breast reconstruction. The breast reconstruction protection was included as a part of the omnibus budget bill negotiated over the past few weeks among Congressional leaders. The massive $520 billion spending bill includes language requiring insurance companies to cover the cost of reconstructive breast surgery for women who have undergone a mastectomy.

Sen. Alfonse D'Amato (R-N.Y.) and Rep. Sue Kelly (R-N.Y.) successfully included the provision in the bill after searching for several months to find a vehicle for the legislation. The new law states that the attending physician and patient are to be consulted in determining the appropriate type of surgery, with coverage including all stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the opposite breast and the cost of the prostheses and complications of mastectomy, including lymphedema. The law also requires health plans to provide notice to patients and prohibits limiting reimbursement to physicians for providing care in accordance with the statute.

The new federal statute does not preempt state laws providing at least the same level of coverage. In recent years, 29 states have passed laws requiring insurance coverage for breast reconstruction, although none is believed to be more comprehensive in coverage than the new federal law. Significantly, the statute extends the requirement to self-insured plans, which generally use the ERISA federal law to avoid state insurance regulation.

"This provision, championed by ASPRS and Sen. D'Amato, will enable women who have faced this terrible disease to complete the healing process without having to fight another battle, this time against their insurance company," says ASPRS President Paul Schnur, MD.

"We wish to thank Sen. D'Amato and Rep. Kelly for their hard work on this issue and for fighting to ensure complete treatment for victims of breast cancer," adds Jack Bruner, MD, Chair of the ASPRS Government Relations Committee. "This federal legislation will now provide protection for those women whose insurance plans fall outside the scope of the many state laws passed to guarantee coverage for these procedures."

In addition to Sen. D'Amato and Rep. Kelly, the other original sponsors of breast reconstruction bills in this Congress were Sen. Edward Kennedy (D-MA) and Rep. Anna Eshoo (D-CA). There were 43 co-sponsors in the Senate and 306 co-sponsors in the House.

The new law is a testament to the effective grassroots work by plastic surgeons, their families and office staff, other medical organizations and of course breast cancer patients and their support groups. Special recognition goes to ASPRS member Christine Horner-Taylor, MD, who championed the cause early, and founded the Breast Reconstruction Advocacy Project to advance this issue.

"This day is a dream come true," says Dr. Horner-Taylor. "We have worked very hard over the past three years passing legislation in the states and working federally to guarantee women the human dignity to be made whole again without insurance battles."

The ASPRS Government Relations Committee, Breast Reconstruction Coalition Advisory Group, FAST key contact network and PlastyPAC worked with other several organizations to advance this legislative effort, most notably American Cancer Society, Women Against Breast Cancer, National Breast Cancer Coalition, Susan G. Komen Foundation, Breast Cancer Early Detection, American Society of Plastic and Reconstructive Surgical Nurses, American College of Obstetricians & Gynecologists, American Medical Association and American College of Surgeons.

Patient Sandy Marron from Maryland and Mary McCarthy from New York made a powerful impact on members of Congress through their testimony at hearings.

This is a proud and historical moment for plastic surgery, as this is believed to be only the second instance of Congress requiring that a certain medical procedure be covered by health policies, the first being the 1996 law assuring a minimum hospital maternity stay.

 

Elkhart Office

RiverPointe Medical Building
500 Arcade Ave., Suite 300
Elkhart, IN 46514
Phone: 574-296-9100
FAX: 574-293-1511

Mishawaka Office

611 EAST DOUGLAS ROAD, SUITE 108
MISHAWAKA, IN 46545
PHONE: 574-968-9100
FAX: 574-243-1141

ASPS ASAPS AAAASF