One federal rule covers what follows a mastectomy, and employers have paperwork to match.
The Women’s Health and Cancer Rights Act requires group health plans that cover mastectomies to cover reconstruction and related care, and to tell participants about it every year. This guide covers what employers need to know.
Five Topics On One Federal Law.
General information, not legal advice. Each page cites the statute or Department of Labor source it relies on.
What WHCRA Requires a Plan to Cover After a Mastectomy
The four benefits a plan must cover and who can claim them.
WHCRA Enrollment and Annual Notice Requirements
What the enrollment notice and the annual notice must say, and how they are delivered.
WHCRA Deductibles, Coinsurance and Plan Limits
When a deductible or coinsurance can apply, and what the sources leave open.
WHCRA Language in the Plan Document, SPD and Certificate
A review list for the plan document, the SPD and the carrier certificate.
WHCRA for Insured and Self-Funded Plans and Enforcement
Who answers for compliance in each funding type and who can enforce.
Where Things Stand.
WHCRA became law in 1998 and 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 health insurance issuers. It is permanent law, not a proposal, and it applies to plan years beginning on or after October 21, 1998.
If a group health plan pays for a mastectomy, it must also cover all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications of the mastectomy, including lymphedema. Care is determined in consultation with the attending physician and the patient.
Plans may apply annual deductibles and coinsurance to those benefits, but only if they are consistent with the deductibles and coinsurance for other benefits under the plan. And the plan must give written notice of the coverage at enrollment and every year after.
The Employer Checklist.
There are three jobs. Confirm the plan’s coverage and cost-sharing match the rule, send or confirm the two notices, and keep the plan documents consistent with both. Each of the five pages above takes one of those jobs apart.
The Department of Labor supplies a model enrollment notice and a model annual notice in its compliance guide, so no one has to draft from scratch. The blanks to fill in are the actual deductibles and coinsurance and the plan administrator’s phone number.
How It Fits The Plan Year.
WHCRA has no filing with an agency and no form to submit. The work is internal and repeats: each new hire gets the enrollment notice, and every participant gets a notice once a year. Many employers send the annual notice with open enrollment materials, which keeps it on the calendar without a separate project.
When the carrier or the plan design changes at renewal, take a second look. A new carrier means a new certificate to read against the four required benefits, and a new deductible or coinsurance schedule means the figures in the enrollment notice need updating. The compliance calendar on our site lays out where this sits among the other dates in a plan year.
If a participant asks about mastectomy benefits, the model notices point the person to the plan administrator, so make sure the phone number printed in the notice reaches someone who can answer.
What The Law Does Not Say.
It is not limited to cancer patients or to women, according to the Department of Labor. It does not set a minimum hospital stay, though state law on insured coverage may. It does not require preventive screening coverage; mammography for women 40 and older is an Affordable Care Act benefit with its own no-cost-sharing rule.
And it does not stop at the employer’s door when the carrier sends the notice. The Department says an insured plan satisfies the notice duty if the issuer timely provides it, but the employer still benefits from confirming it happened.
Limits Of This Guide.
We read the statute, the Department of Labor fact sheet, FAQs, consumer publication and compliance guide. Those sources do not give a WHCRA penalty amount, a calendar date for the annual notice or rules on flat copayments or dollar limits, so we do not state any. We also did not verify any Michigan-specific rule, so this guide makes no Michigan claim. Where a plan has a specific design question, ask the carrier and benefits counsel.
Related Rules And Tools.
ERISA Part 7 Group Health Plan Requirements Checklist
The other federal health plan mandates that sit beside WHCRA.
Michelle’s Law and Dependent Student Coverage
Another Part 7 rule that employers administer alongside 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 EBSA, Women’s Health and Cancer Rights Act: The Department of Labor page with the fact sheet, the FAQs and the consumer publication.
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.
Brief answers to what employers ask about WHCRA, each linked to the fuller page.
Does WHCRA apply to our group health plan?
Yes if the plan pays medical and surgical benefits for mastectomies. It applies to group health plans and issuers under ERISA section 713 and PHSA section 2727. Certain church and governmental plans may be exempt.
What must we cover if the plan covers mastectomies?
All stages of reconstruction of the affected breast, surgery on the other breast for symmetry, prostheses and treatment of physical complications such as lymphedema, decided with the attending physician and the patient.
When do we have to send the WHCRA notice?
At enrollment and once each year after, in writing. The same notice can serve both purposes if it has the required content.
Can we apply a deductible to breast reconstruction?
Yes, if it is consistent with the deductibles and coinsurance that apply to other medical and surgical benefits under the plan.
What happens if a plan does not follow WHCRA?
The Secretary of Labor enforces ERISA for private-sector plans, and participants can sue plans and issuers. We did not find a WHCRA-specific penalty amount, so we do not state one.
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