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*Click here to access a form that serves as a sample notice of an employee's rights under the Women's Health and Cancer Rights Act. The Women’s Health and Cancer Rights Act (WHCRA) was signed into law on October 21, 1998. The law includes important new protections for mastectomy patients who elect breast reconstruction in connection with a mastectomy. WHCRA amended the Public Health Service Act (PHS Act) and the Employee Retirement Income Security Act of 1974 (ERISA) and is administered by the Department of Health and Human Services and the Department of Labor. This law applies generally both to persons covered under group health plans and persons with individual health insurance coverage. But WHCRA does NOT require health plans or issuers to pay for mastectomies. If a group health plan or health insurance issuer chooses to cover mastectomies, then the plan or issuer is generally subject to WHCRA requirements. If WHCRA applies to you and if you are receiving benefits in connection with a mastectomy and you elect breast reconstruction, coverage must be provided for:
Coverage under WHCRA Whether WHCRA or a State law that affords you the same coverage as WHCRA applies to your coverage will depend on your situation. Generally, WHCRA applies if you are in a self-insured plan. Your State law will determine whether WHCRA will apply to coverage under an insured group plan, or to individual health insurance coverage. Contact your State's insurance department to find out about whether WHCRA will apply to your coverage if you are NOT in a self-insured health plan. Among other things, WHCRA requires that group health plans and health insurance issuers, including insurance companies and health maintenance organizations (HMOs), notify individuals at three separate regarding the coverage required by WHCRA:
The one-time notification provision required plans and issuers to inform participants and beneficiaries no later than January 1, 1999 of the coverage required by WHCRA. The permanent notification provision requires plans and issuers to notify participants upon enrollment and annually thereafter of the benefits required under WHCRA. The Department of Health and Human Services (DHHS) and the Department of Labor (DOL) believe that the WHCRA notices distributed by plans and issuers (including insurance companies and HMOs) should educate participants and beneficiaries who had a mastectomy, or who will have a mastectomy, about the benefits available under their plan (or health coverage) for reconstructive surgery and for complications related to a mastectomy. Both the DOL and the DHHS are also targeting their own outreach efforts and utilizing their health benefits campaigns, in partnership with a diverse group of companies and other interested parties, to most effectively educate the population protected by WHCRA. To this end, employers, unions, and health insurance issuers play a key role in educating participants, beneficiaries, and covered individuals and should have some flexibility in determining how best to educate consumers about their rights under WHCRA. *Click here to access a form that serves as a sample notice of an employee's rights under the Women's Health and Cancer Rights Act. Q. Will the Women’s Health Act require all group health plans, insurance companies, and HMOs to provide reconstructive surgery benefits? A. All group health plans, and their insurance companies or HMOs, that provide coverage for medical and surgical benefits with respect to a mastectomy are subject to the requirements of the Women’s Health Act. Q. Under the Women’s Health Act, may group health plans, insurance companies or HMOs impose deductibles or coinsurance requirements for reconstructive surgery in connection with a mastectomy? A. Yes, but only if the deductibles and coinsurance are consistent with those established for other benefits under the plan or coverage. Q. When is the law effective? A. The reconstructive surgery 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) or contact your plan administrator. These requirements also apply to individual health insurance policies offered, sold, issued, renewed, in effect, or operated on or after October 21, 1998. These requirements were placed in the PHS Act within the jurisdiction of the Department of Health and Human Services. Q. What if my state of residence also has a law regarding breast reconstruction benefits? A. WHCRA does not obstruct any state law in effect on or before October 21, 1998 if the state law requires at least the level of coverage as provided by the Act. Q. What are the notice requirements under the Women’s Health Act? A. There are two separate notices required under the Women’s Health Act. The first notice 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 Women’s Health Act requires. The second notice must also describe the benefits required under the Women’s Health Act but it must be provided upon enrollment in the plan and it must be furnished annually thereafter. Q. When must the initial one-time notice under the Women’s Health Act be given to participants and beneficiaries? A. It must be given as part of the next general mailing (made after October 21, 1998) by the group health plan and their insurance companies or HMOs, or in the yearly informational packet sent out regarding the plan. However, in no event can the one-time notice be furnished later than January 1, 1999. Q. What information must be included in the Women’s Health Act notices? A. The notices must describe the benefits that the Women’s Health Act requires the group health plan, and its insurance companies or HMOs, to cover. The notice 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:
The notice must also describe any deductibles and coinsurance limitations applicable to such coverage. Under the Women’s Health Act, coverage of breast reconstruction benefits may be subject only to deductibles and coinsurance limitations consistent with those established for other benefits under the plan or coverage.
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