Each year, insurance companies are required by state and federal laws and national accreditation standards to inform plan participants about certain rights and services available to them. One of these requirements is regarding The Women’s Health and Cancer Rights Act (WHCRA), which provides protections for patients who elect breast reconstruction in connection with a mastectomy. The WHCRA:
- Applies to group health plans for plan years starting on or after October 21, 1998
- Applies to group health plans, health insurance companies or HMOs, if the plan or coverage provides medical and surgical benefits with respect to a mastectomy
- Requires coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient
Under WHCRA, mastectomy benefits must include coverage 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;
- Prostheses; and
- Treatment of physical complications of the mastectomy, including lymphedema
Under WHCRA, mastectomy benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage.
The law also contains prohibitions against:
- Plans and issuers denying patients eligibility or continued eligibility to enroll or renew coverage under the plan to avoid the requirements of WHCRA
- Plans and issuers providing incentives to, or penalizing, physicians to induce them to provide care in a manner inconsistent with the WHCRA
WHCRA benefits are not limited to cancer patients or to women exclusively. If an individual is receiving benefits in connection with a mastectomy and the group health plan covers mastectomies, then the individual should be entitled to WHCRA benefits.
Group health plans, health insurance companies and HMOs covered by the law must notify participants in a group health plan of the coverage required by WHCRA upon enrollment and annually thereafter. These notices must be delivered in accordance with the Department of Labor’s disclosure regulations applicable to furnishing summary plan descriptions.
This notice will be provided by your group health plan. HR Knowledge has provided this advisory to inform our valued clients of these requirements to ensure you are aware of these requirements and notices being distributed to your employees.
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