Your Rights After A Mastectomy...
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).
The 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.
I’ve been diagnosed with breast cancer and plan to have a mastectomy.
How will WHCRA affect my benefits?
I have not been diagnosed with cancer. However, due to other medical
reasons I must undergo a mastectomy. Does WHCRA apply to me?
Does WHCRA require all group health plans, insurance companies and HMOs to
provide reconstructive surgery benefits?
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.
May group health plans, insurance companies or HMOs impose
deductibles or coinsurance requirements on the coverage specified in WHCRA?
I just changed jobs and am enrolled under my new employer’s plan.
I underwent a mastectomy and chemotherapy treatment under my previous employer's
plan. Now I want reconstructive surgery.
Under WHCRA, is my new employer’s plan required to cover my reconstructive
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 applied.
Specifically, HIPAA provides that a plan may impose a preexisting condition exclusion only if:
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).
My employer’s group health plan provides coverage through an insurance
company. Following my mastectomy, my employer changed insurance companies.
The new insurance company is refusing to cover my reconstructive surgery.
Does WHCRA provide me with any protections?
I understand that my group health plan is required to provide me with
of my rights under WHCRA when I enroll in the plan. What information can I
expect to find in this notice?
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.
What can I expect to find in the annual WHCRA notice from my health plan?
“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.
My State requires health insurance issuers to cover the benefits required by
WHCRA and also requires health insurance issuers to cover minimum hospital stays
in connection with a mastectomy (which is not required by WHCRA). If I
have a mastectomy and breast reconstruction, am I also entitled to the minimum
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.
My health coverage is through an individual policy, not through an employer.
What rights, if any, do I have under WHCRA?
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: