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If you have had a mastectomy or expect to have one, you may be entitled to
special rights under the Women’s Health and Cancer Rights Act of 1998 (WHCRA).
following questions and answers clarify your basic WHCRA rights.
Under WHCRA, if your group health plan covers mastectomies, the plan must
provide certain reconstructive surgery and other post-mastectomy benefits.
Your health plan or issuer is required to provide you with a notice
of your rights under WHCRA when you enroll in the health plan, and then
once each year.
Under WHCRA, group health plans, insurance companies and health maintenance
organizations (HMOs) offering mastectomy coverage also must provide coverage for
certain services relating to the mastectomy in a manner determined in
consultation with your attending physician and you. This required
coverage includes all stages of reconstruction of the breast on which the
mastectomy was performed, surgery and reconstruction of the other breast to
produce a symmetrical appearance, prostheses and treatment of physical
complications of the mastectomy, including lymphedema.
Yes, if your group health plan covers mastectomies and you are receiving benefits in connection with a mastectomy. Despite its name, nothing in the law limits WHCRA rights to cancer patients.
Generally, group health plans, as well as their insurance companies and HMOs,
that provide coverage for medical and surgical benefits with respect to a
mastectomy must comply with WHCRA.
However, if your coverage is provided by a "church plan" or "governmental plan", check with your plan administrator. Certain plans that are church plans or governmental plans may not be subject to this law.
Yes, but only if the deductibles and coinsurance are consistent with those
established for other benefits under the plan or coverage.
If your new employer’s plan provides coverage for mastectomies and if you
are receiving benefits under the plan that are related to your mastectomy, then
your new employer’s plan generally will be required to cover reconstructive
surgery if you request it. In addition, your new employer’s plan
generally is required to cover other benefits specified under WHCRA. It
does not matter that your mastectomy was not covered by your new employer's
However, a group health plan may limit benefits relating to a
health condition that was present before your enrollment date in your current
employer’s plan through a preexisting condition exclusion. A Federal law
known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
limits the circumstances under which a preexisting condition exclusion may be
Specifically, HIPAA provides that a plan may impose a preexisting condition
exclusion only if:
The exclusion relates to a
condition (whether physical or mental) for which medical
advice, diagnosis, care or treatment was recommended or received within the 6 month period ending on your enrollment date
The exclusion extends no
more than 12 months (or 18 months in the case of a late
enrollee in the new plan) after the enrollment date
The preexisting condition
exclusion period is reduced by the days of prior creditable
coverage (if any, which is defined in HIPAA as most health coverage).
The plan also must provide you with written notification of the
existence and terms of any preexisting condition exclusion under the plan and of
your rights to demonstrate prior creditable coverage.
For an explanation of HIPAA, request a copy of
Your Health Plan and HIPAA...Making The Law Work For
You (see Resources section).
Yes, as long as the new insurance company provides coverage for mastectomies,
you are receiving benefits under the plan related to your mastectomy, and you
elect to have reconstructive surgery. If these conditions apply, the new
insurance company is required to provide coverage for breast reconstruction as
well as the other benefits required under WHCRA. It does not matter that your
mastectomy was not covered by the new insurance company.
Plans must provide a notice to all employees when they enroll in the health plan describing the benefits that WHCRA requires the plan and its insurance companies or HMOs to cover. These benefits include coverage of all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast
to produce a symmetrical appearance, prostheses, and treatment of physical complications of the mastectomy, including lymphedema.
The enrollment notice also must state that for the covered employee or their family member who is receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient.
Finally, the enrollment notice must describe any deductibles and coinsurance limitations that apply to the coverage specified under WHCRA. Deductibles and coinsurance limitations may be imposed only if they are consistent with those established for other benefits under the plan or coverage.
Your annual notice should describe the four categories of coverage required
under WHCRA and information on how to obtain a detailed description of the
mastectomy-related benefits available under your plan. For example, an
annual notice might look something like this:
“Do you know that your plan, as required by the Women’s Health and Cancer
Rights Act of 1998, provides benefits for mastectomy-related services including
all stages of reconstruction and surgery to achieve symmetry between the
breasts, prostheses, and complications resulting from a mastectomy, including
lymphedema? Call your plan administrator [phone number here] for more information.”
Your annual notice may be the same notice provided when you enrolled in the plan if it contains the information described above.
If your employer's group health plan provides coverage through an insurance company or HMO, you are entitled to the minimum hospital stay required by the State law.
Many State laws provide more protections than WHCRA. Those additional protections apply to coverage provided by an insurance company or HMO (known as "insured" coverage).
If your employer’s plan does not provide coverage through an insurance
company or HMO (in other words, your employer “self-insures” your coverage),
then the State law does not apply. In that case, only the Federal law, WHCRA, applies, and it does not require minimum hospital stays. To find
out if your group health coverage is “insured” or “self-insured,” check
your health plan's Summary Plan Description or contact your plan administrator.
If your coverage is “insured” and you want to know if you have additional
State law protections, check with your State insurance department.
Health insurance companies and HMOs are generally required to provide WHCRA benefits to individual policies too. These requirements are generally within the jurisdiction of the State
insurance department. Call your State insurance department or the Department of Health and Human Services toll free at 1.877.267.2323 extension 61565, for further information.
WHCRA is administered by the U.S. Departments of Labor and Health and Human
Services. If you have questions regarding your WHCRA rights under an
employer-sponsored group health plan, contact the following: