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| Women's Health and Cancer Rights Act | |
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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:
Under the WHCRA, mastectomy benefits must cover:
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:
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)
Health Insurance Info
National Association of Insurance Commissioners (NAIC)
US Department of Health and Human Services
US Department of Labor
*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 |