A plan that pays for a mastectomy has to cover what comes after it.
When a group health plan covers mastectomies, federal law attaches four benefits to that coverage. This page lists them, says who can use them and names what a plan may not do.
Start With The Overview.
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 whole law on one page: coverage, notices, cost-sharing, plan documents and enforcement.
WHCRA Enrollment and Annual Notice Requirements
The enrollment notice and the annual notice, and what each one has to say.
WHCRA Deductibles, Coinsurance and Plan Limits
When a deductible or coinsurance can apply to these benefits.
When The Law Switches On.
The Women’s Health and Cancer Rights Act of 1998, known as WHCRA, is section 713 of ERISA, codified at 29 U.S.C. 1185b. Section 2727 of the Public Health Service Act, 42 U.S.C. 300gg-27, applies the same rules to group health plans and to the insurance companies behind them. The rules apply to plan years beginning on or after October 21, 1998, so no employer is waiting on a start date.
The law is triggered by the plan’s own design. If a group health plan or its issuer pays medical and surgical benefits for a mastectomy, and a participant or beneficiary who is receiving those benefits chooses breast reconstruction, the plan must cover the items below. In practice that describes most medical plans. The statute does not require a plan to add mastectomy coverage; it governs what must go with that coverage once the plan has it.
What Must Be Covered.
First, all stages of reconstruction of the breast on which the mastectomy was performed. Reconstruction often happens in steps over months, and the statute says all stages, so a plan cannot stop at the first procedure.
Second, surgery and reconstruction of the other breast to produce a symmetrical appearance. Third, prostheses. Fourth, treatment of physical complications of the mastectomy, including lymphedema.
The statute adds that this care is provided in consultation with the attending physician and the patient. That wording matters for plan administration: the clinical decision about the sequence and type of reconstruction belongs to the patient and physician, not to a utilization rule written in advance.
Who Can Use These Benefits.
The Department of Labor says plainly that, despite the title, nothing in the law limits these benefits to cancer patients or to women. Anyone receiving benefits in connection with a mastectomy under a plan that covers mastectomies is entitled to them.
The Department also addresses a common claims question. If a participant had the mastectomy while covered by a different plan or a different insurance company, the current plan generally must still cover reconstruction on request once it is paying mastectomy-related benefits. Being outside the plan when the surgery happened does not defeat the claim.
What A Plan May Not Do.
Section 713(c) adds two prohibitions. A plan or issuer may not deny or limit a person’s eligibility, enrollment or renewal for the purpose of avoiding these requirements. It also may not penalize a provider, reduce a provider’s payment or offer incentives to push care in a way that conflicts with the section.
Section 713(d) keeps room for ordinary contracting: a plan may still negotiate the level and type of provider reimbursement for the care it covers.
Two things are not part of WHCRA. It does not set a minimum hospital stay, although state law for insured coverage may. And it does not require preventive breast cancer screening; mammography for women 40 and older is an Affordable Care Act preventive benefit with its own no-cost-sharing rule, according to the Department of Labor.
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.
PHSA section 2727, 42 U.S.C. 300gg-27: Applies the same rules to group health plans and to issuers in the group and individual markets.
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.
General information, not legal or tax advice.
Quick Answers.
Short replies on the coverage rules, each tied to a fuller page.
Does WHCRA require a plan to cover mastectomies at all?
No. It applies when the plan pays medical and surgical benefits for a mastectomy. Once it does, the four related benefits must be covered under ERISA section 713.
Does the person need a cancer diagnosis?
No. The Department of Labor states that the law does not limit these benefits to cancer patients, and it does not limit them to women.
Can a plan limit how many stages of reconstruction it will pay for?
The statute requires coverage of all stages of reconstruction on the affected breast, determined in consultation with the attending physician and the patient. Questions about a specific plan limit should go to the carrier or counsel.
The Rest Of This Series.
WHCRA: Women’s Health and Cancer Rights Act Guide
The overview of the law and where each topic lives.
WHCRA Enrollment and Annual Notice Requirements
Timing, content and delivery of the two required notices.
WHCRA Language in the Plan Document, SPD and Certificate
What the plan document, SPD and certificate should say.
WHCRA for Insured and Self-Funded Plans and Enforcement
Who is responsible under each funding type and who can enforce.
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