The Women’s Health and Cancer Rights Act protects reconstructive coverage.
Plans that cover mastectomies must also cover reconstruction and related services under this federal law.
The Basics for Employers.
A plain-English summary. This is general information, not legal advice, and the rules change, so check the current text.
What Must Be Covered
Plans that cover mastectomy must cover reconstruction of the affected breast and surgery on the other breast for symmetry.
Related Services
Prostheses and treatment of complications, including lymphedema, are included.
Notice
Plans notify participants of these benefits at enrollment and every year.
How it plays out.
The Women’s Health and Cancer Rights Act applies to group health plans that cover mastectomies. It requires coverage for reconstruction after the mastectomy, surgery on the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications such as lymphedema.
The coverage has to be subject to the same deductibles and coinsurance as other benefits under the plan, and it has to be determined in consultation between the patient and the attending physician.
Plans must also send participants a notice about these benefits when they enroll and each year after. The notice is often included in the summary plan description and a yearly mailing, so it is easy to miss if nobody owns it.
Where This Shows Up in Your Plan.
ERISA, ACA Reporting and Form 5500 Support
How we help with the filings, notices and plan documents.
Employer Benefits Guides: Eligibility, Plan Design, Life Events and Rules
Eligibility, plan design and life-event rules in one place.
The annual routine.
Confirm Coverage Terms
Check that the plan covers the required services.
Find the Notice
Locate the current notice text.
Schedule the Mailing
Send it each year to participants.
Keep Proof
Retain proof of when it went out.
Mistakes to avoid.
Treating It as Optional
Coverage is required where mastectomies are covered.
Different Cost Sharing
It has to match other medical benefits.
No Annual Notice
The notice is repeated each year.
Other Rules Employers Work With.
Affordable Care Act
Public Law 111-148
ACA Reporting
26 U.S.C. 6056
Employer Shared Responsibility
26 U.S.C. 4980H
Laws and Rules Referenced
Women’s Health and Cancer Rights Act (29 U.S.C. 1185b) — The statute or rule text from its official or public source.
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