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Cancer.org Hero Banner Women?s Health and Cancer Rights Act

Posted by Colorado Massage Therapy on September 12, 2013 at 11:00 PM

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 Women’s Health and Cancer Rights Act

The Federal law

The Women’s Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breasts rebuilt (reconstructed) after a mastectomy. This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law.

The WHCRA:

·  Applies to group health plans for plan years starting on or after October 1, 1998

·  Applies to group health plans, health insurance companies, and HMOs, as long as the plan covers medical and surgical costs for mastectomy

Under the WHCRA, mastectomy benefits must cover:

·  Reconstruction of the breast that was removed by mastectomy

·  Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy

·  Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction

·  Any physical complications at all stages of mastectomy, including lymphedema

Questions and answers about the WHCRA

Does my insurance provider have to tell me that I’m covered for breast reconstruction under the WHRCA?

Yes. The law also requires that insurance providers notify you of this coverage when you enroll in their plan, and every year after that.

What if my state has laws that require insurers to cover breast reconstruction?

Several states have their own laws requiring health plans that cover mastectomies to provide coverage for reconstructive surgery after a mastectomy. These state laws only apply to those health plans purchased by an employer from a commercial insurance company. If an employer is self-insured, state laws do not apply but federal laws do. Federal laws (like the WHCRA) are enforced by the US Department of Labor.

A self-insured (or self-funded) plan is one in which the employer, rather than a commercial insurance company, pays for the insured person’s health expenses. Some employers that self-insure will hire a commercial insurance company to write the checks and track the paperwork, even though the money for the payments still comes from the employer. So it can be hard to tell whether you are in a self-insured or a commercially insured plan unless you ask.

If you are unsure of your plan’s status, ask your employer’s benefits manager. You can contact your state’s insurance department to find out if your state provides extra protection that will apply to your coverage if you are not in a self-insured plan. The WHCRA applies to self-insured plans that aren’t covered by state law and sets a minimum standard to be sure this service is available for all women in every state. This includes states with weaker or no laws covering breast reconstruction.

I have been diagnosed with breast cancer and plan to have a mastectomy. How will the WHCRA affect my benefits?

Under the Act, 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 (swelling in the arm that sometimes happens after breast cancer treatment).

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 is not consistent with WHCRA.

Did the 2010 passage of the Affordable Care Act (ACA) affect WHCRA?

No. The WHCRA was not changed by the ACA 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. (See the section called “To learn more” for contact information.)

Where can I get more information about my rights under the WHCRA?

If you have more questions or concerns, you can contact:

·  The US Department of Labor, which has the WHCRA information on its Web site at www.dol.gov/ebsa/Publications/whcra.html, or you can call their toll-free number at 1-866-487-2365

·  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 (1-800-470-6242).]

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