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Your Rights After A Mastectomy
Women's Health and Cancer Rights Act of 1998
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).
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.
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.
The following information provides answers to frequently asked questions about WHCRA.
I have 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 reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Coverage includes 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 lymph edemas.
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.
Does WHCRA require all group health plans, insurance companies and HMOs to provide reconstructive4 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.
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.
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 not 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:
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's and A's: Recent Changes in Health Care Law or view it on the PWBA Web site (see the Resources section).
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. If does not matter that the new insurance company did not provide coverage for your mastectomy.
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 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 wit the attending physician and the patient, for:
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 deductible and coinsurance limitations consistent with those established for other benefits under the plan or coverage.
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, and annual notice might read:
"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 lympohedema? Call your plan administrator [phone number here] for more information."
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.
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.
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).
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:
1-800-998-7542 - Ask for a copy of Questions and Answers: Recent Changes in Health Care Law and a list of all publications from the Pension and Welfare Benefits Administration.
www.dol.gov/ebsa/ - Click on Quick Guide, then Contact EBSA, for the addresses of the 15 regional or field offices that can assist you with health-related questions. Also view EBSA's publications on health.
www.naic.org - This is the address of the National Association of Insurance Commissioner. Click on State Insurance Regulators, then the state of your choice for the office in your state.
www.cms.hhs.gov - The address of the Centers for Medicare and Medicaid Services. Click on HIPAA, then HIPAA Health Insurance Reform for more information on WHCRA and HIPAA.
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