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The Women’s Health and Cancer Rights Act (WHCRA), signed into law on
October 21, 1998, contains protections for patients who elect breast
reconstruction in connection with a mastectomy. For plan participants and
beneficiaries receiving benefits in connection with a mastectomy, plans offering
coverage for a mastectomy must also cover reconstructive surgery and other
benefits related to a mastectomy.
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WHCRA:
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Applies to group health plans for plan years starting on or after
October 21, 1998
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Applies to group health plans, health insurance companies or HMOs, if
the plan or coverage provides medical and surgical benefits with respect
to a mastectomy
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Requires coverage for reconstructive surgery in a manner determined in
consultation with the attending physician and the patient
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Under WHCRA, mastectomy benefits must include coverage for:
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Reconstruction of the breast on which the mastectomy was
performed
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Surgery and reconstruction of the other breast to produce a
symmetrical appearance
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Prostheses and physical complications at all stages of mastectomy,
including lymphedemas
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Under WHCRA, mastectomy benefits may be subject to annual deductibles and
coinsurance consistent with those established for other benefits under the plan
or coverage.
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The law also contains prohibitions against:
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Plans and issuers denying patients eligibility or continued
eligibility to enroll or renew coverage under the plan to avoid the
requirements of WHCRA
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Plans and issuers providing incentives to, or penalizing, physicians
to induce them to provide care in a manner inconsistent with the WHCRA
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Group health plans, health insurance companies and HMOs covered by the law
must notify individuals of the coverage required by WHCRA upon enrollment
and annually thereafter.
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