The documents should match what the law says the plan covers.
A plan can follow WHCRA in practice and still have paperwork that says something else. This page is a review list for the plan document, the Summary Plan Description and the carrier certificate.
Where This Fits.
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.
WHCRA Enrollment and Annual Notice Requirements
The notice text that the documents should be consistent with.
WHCRA Deductibles, Coinsurance and Plan Limits
The cost-sharing rule your schedule of benefits has to respect.
Three Documents, One Story.
Employers usually have three places where benefits are described. The plan document is the governing text for the plan. The Summary Plan Description, or SPD, is the participant-facing summary. For insured coverage, the carrier’s certificate or evidence of coverage describes what the insurance company will pay.
We found no WHCRA rule in the sources we read that dictates the wording of any of these three. What the sources do give us is the substance of the benefit, the content of the notices and the model notice language. The checklist below measures the documents against that substance. It is our review approach, not a Department of Labor form.
Seven Things To Look For.
One: the medical benefit lists mastectomy as a covered surgery. Two: the covered services include all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast for a symmetrical appearance, prostheses, and treatment of physical complications including lymphedema.
Three: the services are described as provided in consultation with the attending physician and the patient. Four: the deductibles and coinsurance shown for those services match what the plan applies to other medical and surgical benefits. Five: no exclusion or limitation elsewhere in the document cuts across the four benefits.
Six: the notice duties have an owner, meaning someone named who sends the enrollment notice and the annual notice. Seven: the document says whether the plan is insured or self-insured, a point the Department of Labor says participants look to the SPD to learn.
Where Wording Tends To Conflict.
Our reading is that the most likely collision is a general exclusion. Cosmetic surgery exclusions, device exclusions and similar blanket carve-outs are common in medical documents. Reconstruction after a mastectomy and prostheses are required benefits under ERISA section 713, so an exclusion written broadly enough to catch them should be clarified with a WHCRA exception. That is a drafting suggestion based on the statute, not a quotation of any agency rule.
A second friction point is the schedule of benefits. If it lists a separate cost-sharing line for mastectomy-related care that differs from comparable surgery, the consistency rule is in play.
Insured Plans Have An Extra Step.
For an insured plan, the carrier’s certificate is the document that actually controls payment. Ask the carrier two things in writing: does the certificate carry the four WHCRA benefits without conflicting exclusions, and who sends the annual notice and when. The Department of Labor guide says an insured plan satisfies the notice duty for a participant if the issuer timely provides the required notice, so the answer to the second question matters.
Ask for the date the last notice went out and a copy of it. Put the response in the compliance file with the plan year.
Start From The Department’s Wording.
The Department of Labor compliance guide includes a model enrollment notice and a model annual notice that plans may use as a guide. Starting from that text and filling in the plan’s actual deductibles, coinsurance and administrator phone number is a low-risk path. Reviewing the final version against the checklist above takes minutes and closes the common gaps.
Related Rules And Tools.
ERISA Part 7 Group Health Plan Requirements Checklist
The other federal health plan mandates that sit beside WHCRA.
A Compliance Calendar for Your Plan Year
A plan-year view of the dates that matter.
Benefits Compliance
How we keep plan notices and deadlines on the calendar.
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 EBSA, Women’s Health and Cancer Rights Act: The Department of Labor page with the fact sheet, the FAQs and the consumer publication.
General information, not legal or tax advice.
Quick Answers.
Short replies on plan documents, each tied to a fuller page.
Does the SPD have to repeat the WHCRA benefits?
The sources we read do not say what an SPD must contain about WHCRA. What they require is the written notice at enrollment and each year. Putting the same information in the SPD is a sensible way to keep documents consistent.
What should we do if the carrier certificate has a cosmetic surgery exclusion?
Ask the carrier in writing how the exclusion applies to reconstruction after a mastectomy and prostheses, which ERISA section 713 requires the plan to cover. Escalate to counsel if the answer is unclear.
Is there a model notice we can paste into the plan documents?
The Department of Labor compliance guide provides model enrollment and annual notice language that plans may use as a guide, with blanks for the actual cost-sharing and the administrator phone number.
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 Deductibles, Coinsurance and Plan Limits
Deductibles, coinsurance and the limits that are not settled.
WHCRA for Insured and Self-Funded Plans and Enforcement
Who answers for compliance and who can enforce.
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