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Frequently
Asked Questions
about
Women's
Health and Cancer Rights
What is the Women's
Health and Cancer Rights Act (WHCRA)?
The
Women's Health and Cancer Rights Act (WHCRA),
signed into law on October 21, 1998, includes
important protections for individuals who elect
breast reconstruction in connection with a mastectomy.
WHCRA amended the Employee Retirement Income
Security Act of 1974 (ERISA) and the Public
Health Service Act (PHS Act) and is administered
by the Departments of Labor and Health and Human
Services.
I have been diagnosed
with breast cancer and plan to have a mastectomy.
How will WHCRA affect my benefits?
Under
WHCRA, group health plans, insurance companies
and health maintenance organizations (HMOs)
offering mastectomy coverage must also provide
coverage for reconstructive surgery in a manner
determined in consultation with the attending
physician and the patient. Coverage includes
reconstruction of the breast on which the mastectomy
was performed, surgery and reconstruction of
the other breast to produce a symmetrical appearance,
and prostheses and treatment of physical complications
at all stages of the mastectomy, including lymph
edemas.
Will WHCRA require
all group health plans, insurance companies
and HMOs to provide reconstructive surgery benefits?
All
group health plans, and their insurance companies
or HMOs, that provide coverage for medical and
surgical benefits with respect to a mastectomy
are subject to the requirements of WHCRA.
Under WHCRA, may
group health plans, insurance companies and
HMOs impose deductibles or coinsurance requirements
for reconstructive surgery in connection with
a mastectomy?
Yes,
but only if the deductibles and coinsurance
are consistent with those established for other
benefits under the plan or coverage.
When do these
requirements take effect?
The
reconstructive surgery requirements apply to
group health plans for plan years beginning
on or after October 21, 1998. To find out when
your plan year begins, check your Summary Plan
Description (SPD) or contact your plan administrator.
These requirements also apply to individual
health insurance policies offered, sold, issued,
renewed, in effect, or operated on or after
October 21, 1998. These requirements were placed
in the PHS Act within the jurisdiction of the
Department of Health and Human Services.
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My
state requires the coverage for breast reconstruction that
is required by WHCRA and also requires minimum hospital stays
in connection with a mastectomy that are not required by WHCRA.
If I have a mastectomy and breast reconstruction, am I also
entitled to the minimum hospital stay?
It
depends. The federal WHCRA permits state law protections to
apply to certain health coverage. State law protections apply
if the state law is in effect on October 21, 1998 (date of
enactment of WHCRA) and the state law requires at least the
coverage for reconstructive breast surgery that is required
by the federal WHCRA.
If
state law meets these requirements, then it applies to coverage
provided by an insurance company or HMO ("insured"
coverage). If you obtained your coverage through your employer
and your coverage is "insured," you would be entitled
to the minimum hospital stay required by state law. If you
obtained your coverage through your employer but your coverage
is not provided by an insurance company of 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 coverage is "insured" or "self-insured,"
check your Summary Plan Description (SPD) or contact your
plan administrator.
If
you obtained your coverage under a private individual health
insurance policy (not through your employer), check with your
State Insurance Commissioner's Office to learn if state law
applies.
What are the notice requirements under WHCRA?
There
are two separate notices required under WHCRA. The first notice
is a one-time requirement under which group health plans,
and their insurance companies or HMOs, must furnish a written
description of the benefits that WHCRA requires. The second
notice must also describe the benefits required under WHCRA,
but it must be provided upon enrollment in the plan and it
must be furnished annually thereafter.
Are all group health plans,
and their insurance companies and HMOs, required to satisfy
the notice requirements under WHCRA?
All
group health plans, and their insurance companies or HMOs,
that offer coverage for medical and surgical benefits with
respect to a mastectomy are subject to the notice requirements
under WHCRA.
How must these notices be delivered
to participants and beneficiaries?
These
notices must be delivered in accordance with the Department
of Labor's disclosure regulations applicable to furnishing
summary plan descriptions. For example, the notices may be
provided by first class mail or any other means of delivery
prescribed in the regulation. It is the view of the Department
that a separate notice would be required to be furnished to
a group health plan beneficiary where the last known address
of the beneficiary is different than the last known address
of the covered participant.
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