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

The Women's Health and Cancer Rights Act (1998), or WHCRA, is a federal law that provides certain protections to breast cancer patients who want breast reconstruction surgery. Under the WHCRA, all group health plans that cover mastectomies must provide coverage for reconstructive surgery and any other post-mastectomy benefits.

The WHCRA does not require health insurers or group health plans to cover mastectomies, but if they do, they are subject to the WHCRA. The WHCRA covers mastectomy for any medical reason, not just to treat breast cancer.

The Women's Health and Cancer Rights Act amends the Employee Retirement Income Security Act (ERISA) of 1974. ERISA identifies administrative standards for employers who offer group plans. This includes health insurance or retirement plans.

This article explores the Women's Health and Cancer Rights Act.

The Women's Health and Cancer Rights Act

Congress passed the WHCRA after a health insurance company refused to cover reconstructive surgery for a breast cancer patient. This law covers health insurance companies, HMOs, and private group health plans. It does not cover state and local government health plans. According to the Centers for Medicare and Medicaid Services, group plans can be " insured " or "self-funded" plans.

Health Insurance Basics

Health insurance is a contract between you and a health insurer. In exchange for paying a premium, they cover your healthcare costs. The details of your health coverage-coinsurance, deductibles, and co-pays—depend on your contract or policy. Your policy also outlines the health benefits offered by your insurer. Health benefits include the healthcare items or services provided under a health insurance plan.

Mastectomies and Breast Reconstruction

A mastectomy is a surgical procedure that removes breast tissue to treat or prevent breast cancer. With some mastectomies -- called "simple" or "total" mastectomies -- a surgeon removes all the breast tissue.

Breast reconstruction is a surgery that rebuilds the breast to give an appearance like the breast pre-mastectomy. Reconstructive surgery can take place concurrently or at some point after surgery.

Women choose breast reconstruction for many reasons, including the following:

• To give their upper bodies a more balanced appearance
• To regain the breast shape lost after a mastectomy
• To get rid of the need for a prosthesis or synthetic breast part that fits inside a bra
• To maintain body image and self-esteem

ERISA and the WHCRA

ERISA covers health insurance plans provided by private employers. ERISA does not cover plans offered to employees of state and local governments. Since the Women's Health and Cancer Rights Act is an amendment to ERISA, this law covers those employed by private, non-governmental employers.

The Employee Benefits Security Administration (EBSA) oversees private health plans. The EBSA is a U.S. Department of Labor (USDOL) office. EBSA administers and enforces the "fiduciary, reporting, and disclosure provisions" of ERISA. The Centers for Medicare and Medicaid Services regulate state and local government plans for the WHCRA. State laws regulate individually purchased plans.

Your Rights Under The WHCRA

The Women's Health and Cancer Rights Act doesn't make health insurance plans cover mastectomies. The WHCRA's mandate is simple: if a health insurance plan offers mastectomy coverage, that plan must also cover surgical benefits. These surgical benefits include breast reconstruction.

Coverage includes all stages of the mastectomy and breast reconstruction surgery. Some of the rights covered by eligible plans under WHCRA include the following:

• Being informed by health insurance issuers about WHCRA benefits. Issuers must do this at enrollment and annual renewal
• Coverage for the reconstruction of a breast or breasts removed in a mastectomy
• Coverage for surgery and reconstruction of the other breast for a symmetrical appearance
• Coverage for all stages of reconstruction of the breast
• Coverage for breast prostheses (artificial breasts that fit into a bra) for use before or during breast reconstruction
• Complete coverage for post-surgical treatment of physical complications, such as lymphedema

Under the WHRCA, health insurance providers cannot deny coverage or continuation of coverage to avoid meeting its requirements. Health insurance companies cannot provide incentives to physicians to avoid these requirements either.

The WHCRA and the Affordable Care Act

While the Affordable Care Act (ACA) of 1998 did not change any provisions of the WHCRA, it did offer some new protections. Under the ACA, health insurers cannot deny insurance coverage based on a pre-existing condition. This includes breast cancer. The only exceptions are as follows:

• The health plan is a group health plan that started before October 1, 1998, or
• The plan does not offer mastectomy coverage.

Get Help

Healthcare law is complex because it often combines medicine and the law. The Women's Health and Cancer Rights Act is no exception. Speak to a local experienced health care law attorney to learn more.