Benefits Compliance

Women's Health and Cancer Rights Act (WHCRA)

The Women's Health and Cancer Rights Act (WHCRA), signed into law on October 21, 1998, includes important protections for individuals who elect breast reconstruction in connection with a mastectomy. WHCRA amended the Employee Retirement Income Security Act of 1974 (ERISA) and the Public Health Service Act (PHS Act) and is administered by the Departments of Labor (DOL) and Health and Human Services (HHS).

Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Coverage includes reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymph edemas.

All group health plans, and their insurance companies or HMOs that provide coverage for medical and surgical benefits with respect to a mastectomy are subject to the requirements of WHCRA.

 

FAQs

My state requires the coverage for breast reconstruction that is required by WHCRA and also requires minimum hospital stays in connection with a mastectomy that are not required by WHCRA. If a health plan participant has a mastectomy and breast reconstruction, are they also entitled to the minimum hospital stay?

It depends. The federal WHCRA permits state law protections to apply to certain health coverage. State law protections apply if the state law is in effect on October 21, 1998 (date of enactment of WHCRA) and the state law requires at least the coverage for reconstructive breast surgery that is required by the federal WHCRA.

If state law meets these requirements, then it applies to coverage provided by an insurance company or HMO ("insured" coverage). If the employer’s group health plan is insured, the participants would be entitled to the minimum hospital stay required by state law. If the group health plan is not provided by an insurance company or HMO (that is, the plan is self-insured), then state law does not apply. In that case, only the federal WHCRA applies and it does not require minimum hospital stays.

What are the notice requirements under WHCRA?

There are two separate notices required under WHCRA. The first notice is an annual requirement under which group health plans and their insurance companies or HMOs must furnish a written description of the benefits that WHCRA requires. The second notice must also describe the benefits required under WHCRA, but it must be provided upon enrollment in the plan. All group health plans and their insurance companies or HMOs that offer coverage for medical and surgical benefits with respect to a mastectomy are subject to the notice requirements under WHCRA. Failure to provide the notice may result in legal action brought by a participant and an ERISA $110 per day fine may be assessed.

How must these notices be delivered to participants and beneficiaries?

These notices must be delivered in accordance with the Department of Labor's disclosure regulations applicable to furnishing summary plan descriptions. For example, the notices may be provided by first class mail, electronic media, or any other means of delivery prescribed in the regulation. It is the view of the Department that a separate notice would be required to be furnished to a group health plan beneficiary where the last known address of the beneficiary is different than the last known address of the covered participant.

 

Additional Resources


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