Women’s Health & Cancer Rights Act (WHCRA)

A federal law requires group health plans (HMOs and other insurers) providing coverage for mastectomies to also cover reconstructive surgery after a mastectomy. Prior to this law, the HMO plans generally already covered the services now mandated by the new law. The purpose of this section is to remind you and your covered spouse of the following:

Under federal law, group health plans and health insurance issuers that provide medical and surgical benefits with respect to a mastectomy must, in the case of a covered individual who is receiving benefits in connection with a mastectomy, provide coverage for:

• Reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and physical complications in all stages of the mastectomy, including lymphedemas;
  ... In a manner determined in consultation with the attending physician and the patient.

Such coverage may be subject to annual deductibles and coinsurance provisions that are consistent with those established for other benefits under the plan or coverage.

If you have any questions, contact your HMO directly, or call the Administrative Office for assistance.

Frequently Asked Questions About the WHCRA

Q. I’ve been diagnosed with breast cancer and plan to have a mastectomy. How will WHCRA affect my benefits?
A. 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.

Q. Will WHCRA require all group health plans, insurance companies, and HMOs to provide reconstructive surgery benefits?
A. 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.

Q. Under WHCRA, may group health plans, insurance companies, or HMOs impose deductibles or coinsurance requirements for reconstructive surgery in connection with a mastectomy?
A. Yes, but only if the deductibles and coinsurance are consistent with those established for other benefits under the plan or coverage.