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Federal law
requires most group insurance plans that cover mastectomies to also
cover breast reconstruction.
The Women's Health and Cancer Rights Act (WHCRA) helps protect
many women with breast cancer who choose to have their breast rebuilt
(reconstructed) after a mastectomy. It was signed into law on October
21, 1998. The United States Departments of Labor and Health and Human
Services oversee this law.
The WHCRA:
- applies to group health plans for plan years starting on or
after October 1, 1998
- applies to group health plans, health insurance companies,
and HMOs, as long as the plan covers medical and surgical costs for
mastectomy
Under the WHCRA,
mastectomy benefits must cover:
- reconstruction of the breast that was removed by mastectomy
- surgery and reconstruction of the other breast to make the
breasts look symmetrical or balanced after mastectomy
- any external breast prostheses (breast forms that fit into
your bra) that are needed before or during the reconstruction
- any physical complications at all stages of mastectomy,
including lymphedema
Mastectomy benefits may have a yearly deductible and may
require that you pay co-insurance.
Co-insurance is when health costs are insured for less than the full
amount and the patient must pay the difference. For instance, the
company may cover 80% of your expenses after you pay the deductible,
leaving you to pay the other 20%. This 20% is also called a co-payment or co-pay. But any
required deductible and co-insurance must be like those the plan uses
for other conditions it covers. So, if a plan pays 80% for hospital and
surgery fees for an appendectomy, but only 70% of hospital and surgery
fees for breast reconstruction, that would violate the WHCRA.
Questions and answers about the WHCRA
Does the WHCRA allow insurers to take
people off their plans so that they don't have to pay breast
reconstruction benefits?
No. The WHCRA does not allow insurance plans and insurance
companies to kick people out of the plan or keep them from enrolling or
renewing their coverage under the plan to avoid WHCRA requirements.
Does the WHCRA let insurance plans give
doctors incentives to discourage women from having breast
reconstruction after mastectomy?
No. The WHCRA also does not allow insurance plans and
insurance issuers to penalize doctors and cause them to provide care in
a way that does not support the WHCRA. Nor does it allow insurance
plans to reward doctors who do not encourage their patients to look
into breast reconstruction.
Does my insurance provider have to tell me
that I'm covered for breast reconstruction under the WHRCA?
Yes. The law also requires insurance providers to notify you
of this coverage when you enroll in their plan, and every year after
that.
What if my state has laws that require
insurers to cover breast reconstruction?
Several states have their own laws requiring health plans that
cover mastectomies to provide coverage for reconstructive surgery after
a mastectomy. These state laws only apply to those health plans
purchased by an employer from a commercial insurance company. If an
employer is self-insured,
state laws do not apply but federal laws do. Federal laws (like the
WHCRA) are enforced by the US Department of Labor.
A self-insured (or self-funded)
plan is one in which the employer, rather than a commercial insurance
company, pays for the insured person's health expenses. Some employers
that self-insure will hire a commercial insurance company to write the
checks and do other paperwork, even though the money for the payments
still comes from the employer. So it can be hard to tell whether you
are in a self-insured or a commercially-insured plan unless you ask.
If you are unsure of your plan's status, ask your employer's
benefits manager. You can contact your state’s insurance
department to find out if your state provides extra protection that
will apply to your coverage if you are not in a self-insured plan. The
WHCRA applies to self-insured plans that aren't covered by state law
and sets a minimum standard to be sure this service is available for
all women in every state. This includes states with weaker or no laws
covering breast reconstruction.
I have been diagnosed with breast cancer
and plan to have a mastectomy. How will the Women's Health Act affect
my benefits?
Under the Women's Health Act, group health plans, insurance
companies, and HMOs that offer mastectomy coverage must also provide
coverage for reconstructive surgery after mastectomy. This coverage
includes reconstruction of the breast removed by mastectomy,
reconstruction of the other breast to give a more balanced look, breast
prostheses, and treatment of physical complications at all stages of
the mastectomy, including lymphedema (swelling that sometimes happens
after breast cancer treatment).
This law sets a federal floor (minimum requirement) so that
women can have breast reconstruction after mastectomy, even if they
live in states that do not make insurance companies provide this
coverage.
Does the Women's Health Act require all
group plans, insurance companies, and HMOs to provide reconstructive
surgery benefits?
In most cases, yes, as long as the insurance plan also covers
medical and surgical benefits for mastectomies. But certain church
plans and government plans may not be required to pay for
reconstructive surgery. If you are insured under a health plan
sponsored by a church or local government plan, check with your plan
administrator about it.
Under the Women's Health Act, may insurance
providers impose deductibles or co-insurance requirements for
reconstructive surgery in connection with a mastectomy?
Yes. But the deductibles and co-insurance must be like those
that are used for other benefits under the plan or coverage. The
company can't have you paying a higher deductible or co-pay for breast
rebuilding than you would pay for other types of surgery.
My state requires the coverage for breast
reconstruction that is required by the WHCRA and also requires minimum
hospital stays for my mastectomy. If I have a mastectomy and breast
reconstruction, am I also entitled to the minimum hospital stay?
It depends. If you have coverage through your employer and
your employer is insured, you would be entitled to the minimum hospital
stay required by the state law. If you have coverage through your
employer but your coverage is not provided by an insurance company or
HMO (that is, your employer "self-insures" your coverage), then state
law does not apply. In that case, only the federal Women’s
Health Act applies and it does not require minimum hospital stays. To
find out if your group health plan is insured or self-insured
(self-funded), contact your plan administrator.
If you have coverage under a private health insurance policy
(not through your employer), check with your State Insurance
Commissioner’s office to learn if state law applies.
Are health plans required to give me notice
of the WHCRA benefits?
Yes. Both health plans and health insurance issuers are
required to provide you notice of the WHCRA benefits. They must do this
when you enroll and every year after that. The annual notice may be
sent by itself or it may be included in almost any written
communication by the plan or insurer, such as newsletters, annual
reports, policy renewal letters, enrollment notices, and others.
Enrollment notices may even be a phone number or Web address from which
to get more information about coverage.
Does the WHCRA affect the amount that my
health plan will pay my doctors?
No. the WHCRA does not keep a plan or health insurance issuer
from bargaining about amounts and types of payment with doctors. But
the law does forbid insurance plans and issuers from penalizing doctors
or providing incentives that would cause a doctor to give care that is
not consistent with WHCRA.
Do the WHCRA requirements apply to Medicare
or Medicaid?
No. The law does not apply to Medicare and Medicaid.
Where can I get more information about my
rights under the WHCRA?
If you have more questions or concerns, you can contact:
- your health plan administrator (a number should be listed
on your insurance card)
- your State Insurance Commissioner's office [The number
should be listed in your local phone book in the state government
section, or you can find it at the National Association of Insurance
Commissioners on the Web at www.naic.org/state_web_map.htm.
If you can't find the number elsewhere, call 1-866-470-NAIC
(1-800-470-6242).]
You may also want to check the "National organizations and Web
sites" section for other sources of help.
Additional resources
More information from your American Cancer
Society
We have selected some related information that may also be
helpful to you. These materials may be viewed on our Web site or
ordered from our toll-free number, 1-800-ACS-2345 (1-800-227-2345).
The following books are available from the American Cancer
Society. Call us to ask about costs or to place your order.
National organizations and Web sites*
In addition to the American Cancer Society, other sources of
patient information and support include:
Cancer Legal Resource Center (CLRC)
Toll-free number: 1-866-843-2572 (may need to leave a number for a call
back)
Web site: www.disabilityrightslegalcenter.org
Health Insurance Info
Georgetown University Health Policy Institute
(Offers free online Consumer Guides for Getting and Keeping Health Insurance for each state)
Web site: http://healthinsuranceinfo.net
National Association of Insurance Commissioners (NAIC)
Toll-free number: 1-866-470-6242 (866-470-NAIC)
Web site: http://naic.org
For state insurance department phone numbers, visit: www.naic.org/state_web_map.htm
US Department of Health and Human Services
Toll-free number: 1-877-267-2323, ext. 61565 (you will need to dial "9"
before entering this extension)
Web site: www.cms.hhs.gov
US Department of Labor
Toll-free number: 1-866-4-USA-DOL (1-800-487-2365)
Web site: www.dol.gov.ebsa
*Inclusion on
this list does not imply endorsement by the American Cancer Society.
No matter who you are, we can help. Contact us anytime, day or
night, for information and support. Call us at 1-800-ACS-2345 or
visit www.cancer.org.
References
US Department of Health and Human Services. Centers for
Medicare and Medicaid Services. The Women’s Health &
Cancer Rights Act. Available at
http://www.cms.hhs.gov/HealthInsReformforConsume/06_TheWomen'sHealthandCancerRightsAct.asp.
Accessed July 2, 2008.
US Department of Health and Human Services, Centers for
Medicare and Medicaid Services.
The Women's Health and Cancer Rights Act (WHCRA) of
1998--Helpful Tips As of 06/27/2008. Available online at:
http://www.cms.hhs.gov/HealthInsReformforConsume/Downloads/WHCRA_Helpful_Tips.pdf.
Accessed July 2, 2008.
US Department of Labor, Employee Benefits Security
Administration. Fact Sheet: Women's Health and Cancer Rights Act.
Available online at: http://www.dol.gov/ebsa/newsroom/fswhcra.html.
Accessed July 2, 2008.
US Department of Labor, Employee Benefits Security
Administration. Your Rights After A Mastectomy: Women's Health
& Cancer Rights Act of 1998. Available at:
www.dol.gov/ebsa/Publications/whcra.html. Accessed July 2, 2008.
Last Medical Review: 08/11/2008
Last Revised: 08/11/2008
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