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The Women's Health and Cancer Rights Act (WHCRA), signed into law on October 21,
1998, includes important
protections for individuals who elect breast reconstruction in connection
with a mastectomy. WHCRA amended the Employee Retirement Income
Security Act of 1974 (ERISA) and the Public Health Service Act (PHS Act)
and is administered by the Departments of Labor and Health and Human
Services.
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Under WHCRA, group health plans, insurance companies
and health maintenance organizations (HMOs) offering mastectomy coverage
must also provide coverage for reconstructive surgery in a manner
determined in consultation with the attending physician and the patient.
Coverage includes reconstruction of the breast on which the mastectomy was
performed, surgery and reconstruction of the other breast to produce a
symmetrical appearance, and prostheses and treatment of physical
complications at all stages of the mastectomy, including lymph edemas.
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All group health plans, and their insurance companies
or HMOs, that provide coverage for medical and surgical benefits with
respect to a mastectomy are subject to the requirements of WHCRA.
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Yes, but only if the deductibles and coinsurance are
consistent with those established for other benefits under the plan or
coverage.
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The reconstructive surgery requirements apply to group
health plans for plan years beginning on or after October 21, 1998.
To find out when your plan year begins, check your Summary Plan
Description (SPD) or contact your plan administrator. These
requirements also apply to individual health insurance policies offered,
sold, issued, renewed, in effect, or operated on or after October 21,
1998. These requirements were placed in the PHS Act within the
jurisdiction of the Department of Health and Human Services.
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It depends. The federal WHCRA permits state law
protections to apply to certain health coverage. State law
protections apply if the state law is in effect on October 21, 1998 (date
of enactment of WHCRA) and the state law requires at least the coverage
for reconstructive breast surgery that is required by the federal WHCRA.
If state law meets these requirements, then it applies
to coverage provided by an insurance company or HMO ("insured"
coverage). If you obtained your coverage through your employer and
your coverage is "insured," you would be entitled to the minimum
hospital stay required by state law. If you obtained your coverage
through your employer but your coverage is not provided by an insurance
company of HMO (that is, your employer "self-insures" your
coverage), then state law does not apply. In that case, only the
federal 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 Summary Plan Description (SPD) or
contact your plan administrator.
If you obtained your coverage under a private
individual health insurance policy (not through your employer), check with
your State Insurance Commissioner's Office to learn if state law applies.
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There are two separate notices required under WHCRA.
The first notice is a one-time requirement under which group health plans,
and their insurance companies or HMOs, must furnish a written description
of the benefits that WHCRA requires. The second notice must also
describe the benefits required under WHCRA, but it must be provided upon
enrollment in the plan and it must be furnished annually thereafter.
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All group health plans, and their insurance companies
or HMOs, that offer coverage for medical and surgical benefits with
respect to a mastectomy are subject to the notice requirements under WHCRA.
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These notices must be delivered in accordance with the
Department of Labor's disclosure regulations applicable to furnishing
summary plan descriptions. For example, the notices may be provided
by first class mail or any other means of delivery prescribed in the
regulation. It is the view of the Department that a separate notice
would be required to be furnished to a group health plan beneficiary where
the last known address of the beneficiary is different than the last known
address of the covered participant.
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