Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides
protections to patients who choose to have breast reconstruction in connection
with a mastectomy. 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.
a group health plan or health insurance issuer chooses to cover mastectomies,
then the plan or issuer is generally subject to WHCRA requirements.
applies to you and if you are receiving benefits in connection with a mastectomy
and you elect breast reconstruction, coverage must be provided for:
Reconstruction of the breast on which the mastectomy has been performed;,
Surgery and reconstruction of the other breast to produce a symmetrical
Prostheses (e.g., breast implant); and
Treatment for physical complications of the mastectomy, including lymphedema.
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.
Question: Under WHCRA, may group health plans
and health insurance issuers impose deductibles or coinsurance for reconstructive
surgery in connection with a mastectomy?
Answer: Yes, but only if the deductibles and coinsurance
are consistent with the cost-sharing arrangements that apply to other benefits
under the plan or coverage.
Question: Are health
plans required to give me notice of WHCRA benefits?
Answer: Yes. Both group health plans and health insurance
issuers are required to provide you notice of WHCRA benefits upon enrollment
and annually thereafter.
Question: Does WHCRA
affect the amount that my health plan will pay my doctors?
Answer: No. WHCRA does not prevent a plan or
health insurance issuer from negotiating the level and type of payment with
attending providers. However, the law prohibits plans and issuers from penalizing
attending providers or providing incentives that would induce a provider to
provide care that is inconsistent with WHCRA.