What is the Women's Health and Cancer Rights Act?

The Women's Health and Cancer Rights Act, or WHCRA, is a federal law that was passed in 1998 in order to provide certain protections and coverage to patients who choose to have breast reconstruction surgery following a mastectomy. The Women's Health and Cancer Rights Act requires all group health plans that cover mastectomies to also provide coverage for reconstructive surgery as well as other post-mastectomy benefits. The WHCRA covers women who undergo a mastectomy for any medical reason, not just to treat breast cancer.

The WHCRA is an amendment to the Employee Retirement Income Security Act of 1974, commonly called ERISA. Among other things, ERISA requires employers who offer group plans (such as health insurance or retirement plans) to adhere to certain minimum standards in administrating those plans. This article explains what you need to know about the essential provisions of ERISA and what rights the Women's Health and Cancer Rights Act grants to patients.

ERISA and the WHCRA

ERISA covers health insurance plans provided by private employers; plans offered to employees of state and local governments are not covered by ERISA. Since the Women's Health and Cancer Rights Act is an amendment to ERISA, this means that the WHCRA will cover only those women who are employed by private, non-governmental employers. It also means that the WHCRA doesn't cover women who buy health insurance on the individual market, that is, women who don't get health insurance through an employer.

Private health plans that are regulated by ERISA are overseen by the Department of Labor, a federal agency responsible for things like workplace safety and wage and salary standards. The WHRCA applies to those group plans that are in effect as of October 1998. For the purposes of the WHRCA, state and local government plans are regulated by the Centers for Medicare and Medicaid Services. Plans purchased individually are governed by the laws of the state in which the plan was purchased.

Mastectomies and Breast Reconstruction

A mastectomy is a surgical procedure that involves the removal of breast tissue in order to treat or prevent breast cancer. With some mastectomies -- called “simple” or “total” mastectomies -- all of the breast tissue is removed. Breast reconstruction is a type of surgery that rebuilds the breast to give an appearance similar to that of the breast before the mastectomy. Reconstructive surgery may be at the same time as the mastectomy, or it may be at some point after surgery.

Women may choose breast reconstruction for a number of reasons, including:

• To give their upper bodies a more balanced appearance, especially when wearing a bra or swimsuit
• To regain their breast shape that was lost after a mastectomy
• To eliminate the need for a prosthesis, or synthetic breast part that fits inside a bra
• To maintain body image and self-esteem.

Your Rights Under The Women's Health and Cancer Rights Act

The Women's Health and Cancer Rights Act doesn’t require health insurance plans to cover mastectomies. Instead, the WHCRA mandates that if a health insurance plan opts to cover mastectomies then that plan must also cover those procedures the Act requires, such as breast reconstruction surgery after a mastectomy. Some of the rights of women covered by eligible plans under WHCRA include:

• Being informed by health insurance issuers about WHCRA benefits; issuers must do this whenever you enroll in a plan as well as every year when the plan is renewed.
• Coverage for reconstruction of a breast or breasts removed in a mastectomy
• Coverage for breast prostheses (artificial breasts that fit into a bra) for use before or during breast reconstruction
• Full coverage for any complications that arise post-surgery such as lymphedema

Moreover, the WHRCA forbids health insurance providers from denying coverage or continuation of coverage just to avoid meeting the requirements of the Act. Insurance companies are also forbidden to provide incentives to doctors to avoid the requirements of the WHRCA or to penalize doctors for providing care consistent with the law's requirements.

The WHCRA and the Affordable Care Act

The Affordable Care Act (ACA) that went into effect in 2010 didn’t change any provisions of the Women's Health and Cancer Rights Act. The Affordable Care Act doesn’t require health insurance plans to offer mastectomy coverage. However, any plans that do offer such coverage must also continue to offer coverage for breast reconstruction surgery under the WHCRA.

Get Legal Help With Your WHCRA-Related Claim

Although insurers are well aware of their obligation to cover certain procedures as a requirement under the Women's Health and Cancer Rights Act, there may be times where you need to pursue a civil claim to ensure that your rights are protected. Get in touch with an experienced health care law attorney in your area today to learn more.