The Women's Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy. 

This law may apply to three different types of coverage:

1)     Self-funded group health plans (CMS has jurisdiction over self-funded public sector (non federal governmental) plans while the Department of Labor 866-444-3272 has jurisdiction over private sector self-funded group health plans.);

2)     Fully insured group health plans; and

3)     Individual (non-employment based) health insurance policies.

Contact your state's insurance department to find out about whether additional protections apply to your coverage if you are in a fully insured group health plan or have individual market (non-employment based) health coverage.

Medicare and Medicaid are not issuers of health insurance.  They are public health plans through which individuals obtain health coverage.  Contact your specific Medicare or Medicaid contractor to discuss your level of benefits.

Employment related group health plans that provide benefits through insurance are known as fully insured group health plans. Employment related group health plans that pay for coverage directly, without purchasing health insurance from an issuer, are called self-funded group health plans.  Contact your plan administrator to find out if your group coverage is fully insured or self-funded.  Non-employment related individual health insurance policies are sold to individual policy holders.

WHCRA does not apply to State high risk pools since the pool is not an issuer of health insurance.  The pool is a means by which individuals obtain health coverage.

WHCRA does NOT require health plans or issuers to pay for mastectomies. If a group health plan or health insurance issuer chooses to cover mastectomies, then the plan or issuer is generally subject to WHCRA requirements.

If WHCRA applies to you and if you are receiving benefits in connection with a mastectomy and you elect breast reconstruction, coverage must be provided for:

• All stages of reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and physical complications of all stages of mastectomy, including lymphedema.

The WHCRA requires group health plans and health insurance issuers, including insurance companies and health maintenance organizations (HMOs), to notify individuals regarding coverage required under the law. There are three separate notification requirements:

1. An initial one-time notice requirement after the 1998 enactment of WHCRA;
2. Upon enrollment into a group  plan or individual (non-employment based) policy; and
3. Annual notification to group  and individual participants.

For additional information, you may e-mail us at phig@cms.hhs.gov.

Note: A non federal government employer that provides self-funded group health plan coverage to its employees (coverage that is not provided through an insurer) may elect to exempt its plan (opt-out) from most requirements of title XXVII of the Public Health Service (PHS) Act, with the exception of requirements of the Genetic Information Nondiscrimination Act (GINA) requirements pertaining to the certification and disclosure of an individual's creditable coverage under the plan, and the issuance of a notice of opt-out to enrollees at the time of enrollment and on an annual basis thereafter.

Downloads
WHCRA Statute (PDF, 9KB) WHCRA Helpful Tips (PDF, 54 KB)
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Page Last Modified: 01/13/2009 9:23:15 AM
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