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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).
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On
This Page
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The
following questions and answers clarify a woman’s basic WHCRA rights.
Under WHCRA, if a woman’s group health plan covers mastectomies, her plan must
provide certain benefits if she chooses reconstructive surgery.
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Your health plan or issuer is required to provide notice to you regarding
your coverage rights under WHCRA when you enroll in the health plan, and then
once each year.
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I’ve been diagnosed with breast cancer and plan to have a mastectomy.
How will WHCRA affect my benefits?
Under WHCRA, group health plans, insurance companies and health maintenance
organizations (HMOs) offering mastectomy coverage must also provide coverage for
certain services relating to the mastectomy in a manner determined in
consultation with the attending physician and the patient. 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.
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I have not been diagnosed with cancer. However, due to other medical
reasons I must undergo a mastectomy. Does WHCRA apply to me?
Despite the title of the Act, nothing in the statute appears to limit
entitlement to WHCRA benefits to cancer patients. If you are an individual
seeking reconstruction and receiving benefits in connection with a mastectomy
and your group health plan covers mastectomies, then you should be entitled to
WHCRA benefits.
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Does WHCRA require all group health plans, insurance companies and HMOs to
provide reconstructive surgery benefits?
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 are subject to the requirements of WHCRA.
However, certain plans that are “church plans” or “governmental
plans” may not be subject to this law. Therefore, if your coverage is
provided by a church plan or governmental plan, check with your plan
administrator about your coverage for these benefits.
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Under WHCRA, may group health plans, insurance companies or HMOs impose
deductibles or coinsurance requirements on the coverage specified in WHCRA?
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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I just changed jobs and am enrolled under my new employer’s plan.
Under my previous employer’s plan I underwent a mastectomy and chemotherapy
treatment, which are now completed. I want reconstructive surgery.
Under WHCRA, is my new employer’s plan required to cover my reconstructive
surgery?
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 new employer’s plan did not provide coverage for
your mastectomy.
However, a group health plan provision may limit benefits relating to a
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:
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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
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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
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The preexisting condition
exclusion period is reduced by the days of prior creditable
coverage (if any, as defined in HIPAA)
The plan must also provide participants with written notification of the
existence and terms of any preexisting condition exclusion under the plan and of
the rights of individuals to demonstrate prior creditable coverage.
For an explanation of HIPAA, request a copy of
Q&As: Recent
Changes in Health Care Law by calling EBSA's Toll-Free Employee & Employer
Hotline at: 1.866.444.EBSA (3272).
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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?
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 other required benefits under WHCRA. It does not matter that the
new insurance company did not provide coverage for your mastectomy.
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I understand that my group health plan is required to provide me with notice
of my rights under WHCRA when I enroll in the plan. What information can I
expect to find in my enrollment notice?
Yes, plans must provide a notice to all workers when they enroll in the plan.
Your enrollment notice must describe the benefits that WHCRA requires the plan
and its insurance companies or HMOs to cover. Also, the enrollment notice
must state that for the covered worker or 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, for:
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All stages of 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
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Treatment of physical complications at all stages of the mastectomy, including
lymphedema
The enrollment notice must also describe any deductibles and coinsurance
limitations applicable to such coverage. Under WHCRA, coverage of breast
reconstruction and other benefits specified in WHCRA may be subject only to
deductibles and coinsurance limitations consistent with those established for
other benefits under the plan or coverage.
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What can I expect to find in my annual notice?
Your annual notice should describe the four categories of coverage required
and should contain information on how to obtain a detailed description of the
mastectomy-related benefits available under the 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 plan may provide the same notice it provided when you enrolled in the
plan as the annual notice if it contains the appropriate information as
described above.
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When did the WHCRA requirements take effect?
The WHCRA 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), the document that outlines your
benefits and your rights under the plan. If you do not have a copy,
contact your plan administrator.
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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
hospital stay?
You may be entitled to the minimum hospital stay required under your 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). Thus, 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.
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 SPD 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.
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My health coverage is through an individual policy, not through an employer.
What rights, if any, do I have under WHCRA?
Health insurance issuers are required to provide benefits for certain
services relating to mastectomies for individual health insurance policies
offered, sold, issued, renewed, in effect, or operated on or after October 21,
1998. These requirements are generally within the jurisdiction of the
State insurance department. If you have further questions related to your
WHCRA rights under an individual health insurance policy, call your State
insurance department or the Department of Health and Human Services at
410.786.1565 (not a toll-free number).
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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:
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EBSAs Toll-Free Employee & Employer
Hotline at: 1.866.444.EBSA (3272). Ask for a copy of Q&As: Recent
Changes in Health Care Law and a list of all publications from the Employee Benefits Security Administration.
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EBSAs
Offices can assist you with
health-related questions.
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National
Association of Insurance Commissioners. Click on State Insurance Regulators, then the state of your
choice for the office in your state.
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Centers
for Medicare & Medicaid Services.
Click on HIPAA, then HIPAA Health Insurance Reform for more information on WHCRA
and HIPAA.
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