If you have had or are planning to have a mastectomy, you may have special rights under the Women ‘s Health and Cancer Rights Act of 1998 (WHCRA ). The following questions and answers explain your basic WHCRA rights.
I have been diagnosed with breast cancer and plan to have a mastectomy, which is covered by my plan. Does my health insurance plan also cover breast reconstruction surgery?
If your group health plan or health insurer covers mastectomy, it must provide certain breast reconstruction surgery and other benefits related to mastectomy, including:
- All stages of breast reconstruction with excisional surgery,
- Surgery and reconstruction of the other breast to create a symmetrical appearance,
- Prosthesis, and
- Treatment of physical complications after mastectomy, including lymphedema.
The plan must consult with you and your primary care physician when deciding how to provide this coverage.
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Although I have not been diagnosed with cancer, I must have a mastectomy for medical reasons. Does WHCRA apply to me?
Yes, if your group health plan or health insurer covers a mastectomy and you are receiving benefits related to your mastectomy, the law applies whether or not you have cancer. Despite its name, there is nothing in the act that limits WHCRA rights to only those with cancer.
Are all group health plans and health insurers required to provide benefits for reconstructive surgery?
Generally, the WHCRA applies to all group health plans and their insurers that provide coverage for medical and surgical benefits for mastectomy. However, there are exceptions for some “church insurance plans” and “government insurance plans.” If your coverage is provided by a “church insurance plan” or “government insurance plan,” please check with your insurance plan administrator.
Do I need to pay a deductible or coinsurance?
Possibly. A group health plan or health insurer may set a deductible or coinsurance requirement for mastectomy and post-mastectomy treatment, but it should not exceed the deductible or coinsurance set for other benefits. In other words, the deductible for post-mastectomy reconstructive surgery should be similar to the deductible for any similar surgery covered by the insurance plan.
I had a mastectomy and chemotherapy before I changed jobs, and both were covered by my previous employer’s plan. Now I am on my new employer’s plan and would like to have reconstructive surgery. Does my new employer’s plan have to cover it?
If you request reconstructive surgery, your new employer’s insurance plan generally must cover it if:
- This insurance plan provides coverage for mastectomy, and
- You are receiving benefits under this plan related to your mastectomy.
In addition, even if you are not enrolled in your new employer’s insurance plan when you have your mastectomy, your new employer’s insurance plan generally must cover the other benefits specified in the WHCRA .
The Patient Protection and Affordable Care Act contains additional protections. Group health plans generally cannot limit or deny benefits related to a health condition that existed before you joined your new employer’s plan.
My employer’s group health plan provides coverage through an insurance company. After my mastectomy, my employer switched insurance companies. The new insurance company refused to cover my reconstructive surgery. Is this legal?
No, if:
- New insurance company to cover mastectomy
- You are receiving benefits under a plan related to mastectomy, and
- You choose to undergo reconstructive surgery.
If these conditions apply, the new insurance company must provide coverage for breast reconstruction along with the other benefits required by the WHCRA . It does not matter that you were not covered by the new company when you had your mastectomy.
I understand that when I join a group health insurance plan, the plan must provide me with a notice of my WHCRA rights. What information does that notice contain?
Plans must provide notice to all employees when they join a health insurance plan:
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- Describe the benefits that WHCRA requires the plan and its insurer to cover, including:
- Coverage for all stages of breast reconstruction following a surgical excision.
- Surgery and reconstruction of the other breast to create a symmetrical appearance,
- Prosthesis, and
- treatment of physical complications following mastectomy, including lymphedema;
- Indicates that benefits related to mastectomy will be provided in a manner determined in consultation with the treating physician and the patient;
- State any applicable deductible and coinsurance limits that apply to coverage under the WHCRA . Such limits apply only if the deductible and coinsurance are consistent with those stated for other benefits under the plan or coverage.
What information should be included in my annual WHCRA notice for health insurance?
Your annual notice should describe the four categories of coverage required by the WHCRA , as well as detailed instructions on how to obtain mastectomy-related benefits under your health insurance plan. For example, your annual notice might look like this:
“Did you know that your insurance plan provides benefits for mastectomy-related services under the Women’s Health and Cancer Rights Act of 1998? This includes all stages of reconstruction and surgery to achieve symmetrical breasts, implants, and complications from mastectomy, including lymphedema. Please call your plan administrator at [phone number here] for more information.”
If your annual notice contains the information above, it may be the same notice as the one provided when you joined the plan.
My state also requires health insurers to cover minimum hospital stays associated with mastectomies (which the WHCRA does not require). If I had a mastectomy and breast reconstruction, would I also be entitled to minimum hospital stays?
If your employer’s group health plan provides coverage through an insurance company, you are entitled to the minimum length of stay required by state law . Many states provide more protection than the WHCRA regarding coverage provided by insurance companies, or “insured coverage laws.”
| If your employer’s group health insurance plan… | You have the right to… |
|---|---|
| Coverage provided by insurance companies | Federal and state protections (in states that offer protection) |
| Self-insurance | Federal protection only |
To find out whether your group health insurance is “exclusive” or “self-insured”, please review your health insurance plan’s Summary Plan Description (SPD ) or contact your plan administrator.
If your coverage is “other-insured” and you want to know whether you have other protections under state law, contact your state’s insurance regulator.