Mastectomy benefits can carry a deductible, but only the one the plan already uses.
WHCRA lets a plan apply annual deductibles and coinsurance to mastectomy-related benefits, with one condition. This page explains the condition, a way to test it and the questions the sources leave open.
Keep The Series Close.
General information, not legal advice. Each page cites the statute or Department of Labor source it relies on.
WHCRA: Women’s Health and Cancer Rights Act Guide
The overview of the law and the five topics around it.
What WHCRA Requires a Plan to Cover After a Mastectomy
The four benefits that cost-sharing applies to.
WHCRA Language in the Plan Document, SPD and Certificate
Where the cost-sharing statement belongs in the documents.
Consistent With Everything Else.
The statute, ERISA section 713(a), 29 U.S.C. 1185b(a), says required mastectomy-related benefits may be subject to annual deductibles and coinsurance, provided they are consistent with those established for other benefits under the plan. The Department of Labor guide puts it in plainer terms: yes, but only if the deductibles and coinsurance are consistent with those established for other medical and surgical benefits.
So the law does not ban cost-sharing and does not guarantee free reconstruction. What it bans is a heavier burden placed on these particular services than on comparable medical and surgical care.
How To Compare.
The Department’s consumer publication gives one example: the deductible for reconstructive surgery should be similar to the deductible for comparable procedures. We suggest a simple review for any plan.
List the four WHCRA benefits. Next to each, write the cost-sharing the plan applies: the deductible, the coinsurance percentage and where it sits in the schedule of benefits. Then find a comparable inpatient or outpatient surgery or a comparable device benefit and write down its cost-sharing. If the two columns match, the plan passes the plain reading of the rule. If a mastectomy-related line carries a separate, higher deductible or a higher coinsurance rate, raise it with the carrier before the next notice goes out.
What The Sources Do Not Settle.
The statute names deductibles and coinsurance. The sources we read do not discuss flat copayments, out-of-pocket maximums, visit or dollar limits on prostheses, or network rules for these benefits. We are not saying those are allowed or barred; we are saying we did not find a source that answers it, and we will not guess.
For those design questions, ask the carrier for its written position and consider asking benefits counsel. The answer can depend on the plan’s wording and the plan’s own other benefits.
Say It In The Notice.
The enrollment notice must describe any deductibles and coinsurance limitations that apply to this coverage. The Department’s model language states that the benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits under the plan, with a blank to insert the actual amounts.
That connects the notice to the plan design. If you change the deductible or coinsurance next plan year, the notice amounts change with them, and the annual notice should still point readers to the detailed description.
Screening Is A Different Rule.
Plan members sometimes expect all breast care to cost nothing. The Department of Labor notes that recommended screenings such as mammography for women 40 and older must be covered under the Affordable Care Act without copayment, coinsurance or deductible, and that WHCRA itself does not require preventive screening coverage. Reconstruction after a mastectomy is a treatment benefit and follows the cost-sharing rule above.
Related Rules And Tools.
ERISA Part 7 Group Health Plan Requirements Checklist
The other federal health plan mandates that sit beside WHCRA.
Affordable Care Act for Employers
The employer mandate, reporting and the other ACA duties in one place.
A Compliance Calendar for Your Plan Year
A plan-year view of the dates that matter.
Laws And Sources
ERISA section 713, 29 U.S.C. 1185b: The statute: required coverage, notice, prohibited practices and the state-law savings clause.
DOL, Health Benefits Coverage Under Federal Law: The compliance guide with the WHCRA questions and answers, the model enrollment notice, the model annual notice and the Part 7 enforcement discussion.
DOL, FAQs About Women’s Health and Cancer Rights: Plain answers on notice content, cost-sharing, insured and self-insured plans and exempt plans.
DOL, Your Rights After a Mastectomy: The participant-facing publication on what the law covers and where to get help.
General information, not legal or tax advice.
Quick Answers.
Short replies on cost-sharing, each tied to a fuller page.
Can a plan apply a deductible to breast reconstruction?
Yes, if the deductible is consistent with those established for other medical and surgical benefits under the plan, according to ERISA section 713(a) and the Department of Labor guide.
Can we charge a higher coinsurance rate for mastectomy-related benefits than for other surgery?
Not under the plain reading of the rule, which requires consistency with the plan’s other medical and surgical benefits. Check the plan wording with the carrier or counsel.
Does the enrollment notice have to list the dollar amounts?
It must describe any deductibles and coinsurance limitations that apply to this coverage. The Department’s model notice has a blank for them.
The Rest Of This Series.
WHCRA: Women’s Health and Cancer Rights Act Guide
The overview of the law and where each topic lives.
What WHCRA Requires a Plan to Cover After a Mastectomy
The four required benefits and who can claim them.
WHCRA Enrollment and Annual Notice Requirements
What the enrollment notice and annual notice must say.
WHCRA for Insured and Self-Funded Plans and Enforcement
Who answers for compliance and who can enforce.
An independent employee benefits consulting firm. We look at the entire benefits program — cost, plan performance, risk and administration.
Switch to CFH. Unhappy with your broker? Your employees won’t notice. You will. →
Cookies on This Site
We use cookies to keep the site working properly and to understand how it is used. You can decline anything that is not essential. See our Privacy Policy for the detail.
- Essential — needed for the site to load and for you to move around it. These cannot be switched off.
- Analytics — tell us which pages get read, so we know what is worth writing more of.
- Advertising — set by third parties such as ad and social platforms to measure and target campaigns.