Women’s Health and the Cancer Rights Act

Many women who undergo a mastectomy are not aware that their HMO or group health insurance plan will cover reconstructive surgery, a procedure which is often referred to as plastic surgery.

The Women’s Health and Cancer Rights Act (WHCRA) helps protect women with breast cancer who choose to have reconstructive surgery. Established in 1998, the WHCR established standards for this benefit which previously varied from carrier to carrier. This federal law requires most group insurance plans that cover mastectomies (i.e., removing all or part of the breast) to also cover breast reconstruction, as determined by the attending physician’s consultation with the patient.

Under the WHCRA, benefits must cover:

  • Reconstruction of the breast on which the mastectomy was performed
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance
  • Any external breast prostheses that are needed before or during the reconstruction
  • Treatment of any physical complications that occur during any stage of the mastectomy, including Lymphedema (i.e., fluid build-up in the arm and chest on the side of the surgery)

This coverage is subject to the plan’s annual deductible and co-insurance provisions. The following are questions and answers posted on the American Cancer Society website:

I have been diagnosed with breast cancer and plan to have a mastectomy. How will the WHCRA affect my benefits?
Under the WHCRA, 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. This federal law sets a 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 WHCRA 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 WHCRA, can 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’s required by the WHCRA and also requires a minimum hospital stay 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 WHCRA applies and it does not require minimum hospital stays. To find out if your group health plan is insured or self-insured, 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 tell you about 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’s not consistent with WHCRA.

Does the new health care law affect the WHCRA?
No. The WHCRA was not changed by the Affordable Care Act and there are no provisions or regulations that affect it. Health insurance plans that offer mastectomy must continue to offer breast reconstruction.

Do the WHCRA requirements apply to Medicare or Medicaid?
No. The law does not apply to Medicare and Medicaid. Still, Medicare covers breast reconstruction if you had a mastectomy because of breast cancer. Medicaid coverage varies in each state, so you will have to get this information for your state.

Where can I get more information about my rights under the WHCRA?
If you have more questions or concerns, you can contact:

  • US Department of Labor, which has the WHCRA information on its website at dol.gov/agencies/ebsa/laws-and-regulations/laws/whcra, or you can call their toll-free number, 1-866-487-2365
  • Employee Benefits Security Administration, a special office of the Department of Labor, at 1-866-444-3272 for information about employer-based health insurance
  • Your health plan administrator (a number should be listed on your insurance card)
  • Your State Insurance Commissioner’s office (The number should be listed in your local phone book in the state government section, or you can find it at the National Association of Insurance Commissioners online at www.naic.org/state_web_map.htm. If you can’t find the number elsewhere, call 1-866-470-NAIC (1-866-470-6242)