The Women’s Health and Cancer Rights Act of 1998

The WHCRA offers the patient some protection when breast cancer necessitates a mastectomy. There is a guarantee that the insurance company will pay for any necessary post-mastectomy procedures, including breast reconstruction and anything else reasonably related to the mastectomy.

The WHRCA Provides Mastectomy-Related Rights

After a mastectomy, patients have specific rights and safeguards under the federal legislation of the Women’s Health and Cancer Rights Act (WHCRA). By virtue of this regulation, the majority of medical insurance policies that cover mastectomy procedures must also cover breast reconstruction, prosthetic breast implants, and any physical side effects of mastectomy, including lymphedema.

Group Health Plans for Plan Years Beginning On or After October 1, 1998, Are Covered by the WHCRA

Group health plans, health insurance providers, and HMOs are acceptable as long as the plan pays for the costs of the mastectomy procedure.

Despite the name, WHCRA benefits are not just for people with cancer. As long as the health insurer pays for the mastectomy, patients with risk-reducing, preventative mastectomies are also eligible for WHCRA benefits. Nothing in the statute also restricts the advantages of the WHCRA to women. The law applies to men as well.

While the WHCRA does not mandate that group health plans or health insurance providers cover mastectomies, if they do, they must typically follow its regulations. Some statutes offer additional protections in many states. To find out if you are entitled to additional mastectomy-related benefits, speak to your state’s surgeon or insurance department.

The WHRCA does not mandate complete insurance coverage; therefore, copays, coinsurance, and deductibles frequently apply.

Exceptions

The WHCRA exempts some short-term government health plans that are self-funded and promoted by religious organizations. The requirements of the statute also do not apply to Medicare or Medicaid. They follow their own set of rules.

How Can I Tell If the WHCRA Protects Me?

The WHCRA mandates that if you have a group health plan, insurance, or HMO policy that covers mastectomy surgery, the provider must also provide coverage for specific services connected to the operation in a way that is decided after consultation between a doctor and the patient.

What Medical Procedures Are Protected by the WHCRA?

If the WHCRA covers you, your provider is required to pay for any operations involving any of the following:

• Reconstructive surgery on the breast after mastectomy
• A reconstruction of the opposite breast to provide symmetry
• Prostheses
• Treatment of all physical side effects, including lymphedemas, at every stage of the mastectomy

Does the WHCRA Permit Insurers to Drop Members from their Plans so They Won’t Be Responsible for Paying Coverage for Breast Reconstruction?

No. The WHCRA prohibits health plans and insurance companies from disenrolling or preventing people from renewing their coverage under the plan in order to circumvent WHCRA regulations.

Does the WHCRA Permit Insurance Companies to Offer Incentives to Doctors So They Will Not Recommend Breast Reconstruction to Patients Who Have Undergone Mastectomy?

No. The WHCRA prohibits insurance companies and insurance issuers from punishing physicians or pressuring them to deliver treatment in a manner that is incompatible with the WHCRA.

Additionally, it prohibits insurance companies from rewarding medical professionals who do not suggest breast reconstruction to their patients.

Does My Insurance Company Have to Inform Me that the WHRCA Covers Breast Reconstruction?

Yes. Additionally, the law mandates that insurance companies inform you about this coverage when you sign up for their plan and then once a year after that.

What if Insurance Companies Are Required By Law to Pay for Breast Reconstruction in My State?

There are numerous jurisdictions with legislation requiring health insurance companies that cover mastectomy procedures to include reconstructive surgery after a mastectomy. Only the health plans that these state statutes cover an employer purchases from a commercial insurance company. State laws do not apply to self-insured employers; only federal laws do.

An employer, rather than a commercial insurance company, covers the insured person’s medical costs under a self-insured (or self-funded) plan. Even while the money for the payments still comes from the employer, some self-insured firms will use a commercial insurance company to draft the checks and manage the paperwork.

So, unless you specifically ask, it may be difficult to determine whether you are enrolled in a self-insured or a commercially insured plan.

Inquire with your employer’s benefits manager if you are unsure about the status of your plan.

As a Result of My Breast Cancer Diagnosis, I Want to Get a Mastectomy. How Will the WHCRA Change My Benefits?

Group health plans, insurance providers, and HMOs are required to fund reconstructive surgery following mastectomy under the WHCRA in addition to mastectomy. Breast prosthesis, treatment of physical problems at all phases of the mastectomy, including lymphedema, and reconstruction of the breast removed by the mastectomy are all covered under this insurance.

Even if individuals reside in states that do not mandate insurance companies to give this coverage, this federal statute establishes a minimum standard so that women can have breast reconstruction following mastectomy.

Does the WHCRA Mandate That All HMOs, Insurance Providers, and Group Plans Cover Reconstructive Surgery?

Yes, in the majority of situations, provided that the insurance policy also includes benefits for mastectomies’ medical and surgical costs. However, some government and church plans might not be compelled to cover reconstructive surgery.

Consult your plan administrator if you have health insurance via a church- or local government-sponsored program.

Can Insurance Companies Impose Deductibles or Co-Insurance Requirements for Reconstructive Surgery After a Mastectomy Under the WHRCA?

Yes. However, the deductibles and co-insurance must be the same as those that apply to other plans or coverage features. Breast reconstruction cannot be subject to a different deductible or copay from other types of surgery by the insurance provider.

Am I Also Eligible for the Minimum Hospital Stay that the State and WHCRA Require if I Have a Mastectomy and Breast Reconstruction?

It varies. You would be entitled to the minimum hospital stay mandated by state law if you have coverage via your work and your employer is insured. State law does not apply if you have coverage through your workplace, but it is not provided by an insurance provider or HMO (your employer “self-insures” your coverage).

In that situation, only the federal WHCRA is applicable, which has no minimum hospital stay requirements. Contact your plan administrator to learn whether your group health plan is insured or self-insured.

Ask your State Insurance Commissioner’s office if state law is relevant if you have coverage through a private health insurance policy (not through your employer).

Getting Legal Aid

Make sure you protest to the insurance company and learn the precise reason they are refusing to pay for those associated services. If you cannot settle the disagreement on your own, the best course of action is to speak with an insurance lawyer who has experience handling disagreements over insurance policies and even civil rights.

If your insurance company has broken the WHCRA, you may be entitled to monetary damages and compensation for any operations that should have been covered. Your attorney can advise you on your rights and the best course of action to safeguard them.