WHCRA - Women's Health and Cancer Rights Act

Effective with benefits plan years beginning on October 21, 1998, the WHCRA requires health plans that cover mastectomies to pay for reconstructive surgery in connection with a mastectomy.

Coverage

The WHCRA applies to group health plans, health insurance companies, or health maintenance organizations (HMOs), if the plan or coverage provides medical and surgical benefits with respect to a mastectomy.

The WHCRA does not require all group health plans, insurance companies, and HMOs to provide reconstructive surgery benefits. Only those which provide coverage for medical and surgical benefits with respect to a mastectomy are subject to the requirements of the Act.

Requirements

Under the Act, reconstructive benefits must include coverage for:

• 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 at all stages of mastectomy, including lymphedemas.

Benefits under the WHCRA may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage.

The WHCRA prohibits plans from denying patients eligibility or continued eligibility to avoid the requirements of the Act; and providing incentives to, or penalizing, physicians to induce them to provide care in a manner inconsistent with the Act.

 

Record-Keeping Requirements

The WHCRA requires that group health plans, insurance companies, and HMOs provide two notices regarding the coverage required by the Act.  The first 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 the WHCRA requires.  The second notice must also describe the benefits required under the WHCRA, but it must be provided upon enrollment in the plan and must be furnished annually thereafter.

According to guidance on the WHCRA issued by the Department of Labor (DOL), the notices must describe the benefits that the WHCRA requires the group health plan, and its insurance companies or HMOs, to cover.  The notices must indicate that, in the case of a participant or beneficiary who is receiving benefits under the plan in connection with a mastectomy and who elects breast reconstruction, the coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• 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 lymphedemas.

The notices must also describe any deductibles and coinsurance limitations applicable to such coverage.

The notices must be sent by the same means that have been approved by the DOL for summary plan descriptions, such as first-class mail or other means of delivery spelled out in the summary plan description regulations.  According to the DOL, 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 from the last known address of the covered participant.

To avoid duplicating efforts, group health plans can let their insurance companies or HMOs send the notices, rather than doing it themselves.

 

 

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