Women's Health and Cancer Rights Act (WHCRA)
The Women's Health and Cancer Rights Act of 1998 (WHCRA) [Pub. L. No. 105-277, 112 Stat. 2681-436] is an amendment to both ERISA and the Public Health Service Act that provides protections to women who choose to have breast reconstruction in connection with a mastectomy. Generally, this federal law applies to persons who have health insurance under a group health plan and to persons with individual health insurance coverage.
Businesses Subjected to WHCRA
Determining whether your health insurance coverage is subject to the provisions of the WHCRA depends on the answer to two questions:
Does your health insurance provide coverage for medical and surgical benefits in connection with a mastectomy; and
Is your health insurance an insured plan or a self-insured plan?
Keep in mind, WHCRA doesn't require that health insurance coverage be offered for mastectomies.
If your health insurance coverage provides benefits in connection with a mastectomy, then you must determine whether your plan purchases insurance from a health insurance provider (“insured plan”) or if the plan provides benefits without purchasing insurance (“self-insured plan”).
If the plan is a self-insured plan, it is always subject to the coverage requirements under WHCRA.
On the other hand, if the plan is an insured plan, then your state law will determine whether WHCRA applies to an insured group plan or to individual health insurance coverage.
The provisions of the WHCRA might not apply if your state has a law that provides for protections for coverage for medical and surgical benefits in connection with a mastectomy.
Basic Rules of WHCRA
According to the WHCRA, effective for plan years beginning on or after October 21, 1998, group health plans and insurers that provide medical and surgical benefits for mastectomies must also provide reconstruction, prostheses, and coverage of physical complications at all stages of the mastectomy. Insurers are allowed to charge deductibles and coinsurance premiums for reconstructive surgery as long as they're consistent with the cost-sharing arrangements that apply to other benefits under the plan or coverage.
Operating Under WHCRA
Group health pans and health insurance issuers, including insurance companies and HMOs, are required to notify individuals of their coverage under WHCRA at three different instances:
After enactment of the Act;
Upon participant enrollment; and
Annually.
After the enactment of the Act, plans and issuers were required to send notification of the coverage under WHCRA no later than January 1, 1999. The permanent notification provisions require plans and issuers to provide notification of the coverage under WHCRA at the time of a participant's enrollment and annually thereafter.
Enrollment Notice
The enrollment notice must describe the benefits that group health plans and insurance issuers must provide under WHCRA. The enrollment notice must affirm that in the event that a participant, policyholder, or beneficiary receives benefits in connection with a mastectomy that coverage will be provided in a manner determined in consultation with an attending physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Prosthesis and treatment of physical complications of the mastectomy, including lymph edema.
It also must describe any applicable deductibles and coinsurance limitations. Under WHCRA, coverage of breast reconstruction benefits may be subject only to the deductibles and coinsurance limitations consistent with those of other benefits offered under the plan.
Annual Notice
The annual notice may have the same content as the enrollment notice. It may be sent by itself or may be included in any of the following:
A summary plan description (SPD), a summary of material modifications (SMM), or a summary annual report (SAR);
A union or benefits newsletter;
Open enrollment materials;
A policy renewal notification letter; or
Any other written communication by the parties.
Instead of sending an annual notice with the same content as the enrollment notice, the plan or issuer may distribute a notice informing participants and policyholders of the following:
The availability of benefits for the treatment of mastectomy-related services, including reconstructive surgery, prosthesis, and physical complications (including lymph edema); and
Information (e.g., telephone number, web address, etc.) on how to obtain a detailed description of the mastectomy-related benefits available under the plan.
The model annual notice provided by the Health Care Financing Administration is, “Did 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 reconstruction and surgery to achieve symmetry between breasts, prostheses, and complications resulting from a mastectomy (including lymph edema). Call your health insurance issuer for more information.”
For a more information regarding COBRA and how it may affect your company contact
Almond Valley Insurance Services, Inc. or visit the
Health Care Financing Administration online.
