(by Andres Rojas)
The Women’s Health and Cancer Rights Act (WHCRA) is a federal law administered by the Department of Labor that provides protections for women choosing to get breast reconstruction services after having a mastectomy.
The WHCRA requires that health insurance carriers – group health plans, insurance companies, and health maintenance organizations (HMOs) – provide coverage for breast cancer patients that goes beyond “drive-through” mastectomies. This means that carriers can no longer cut costs by limiting a cancer patient’s hospital stay but instead must provide adequate post-op reconstructive services.
Breast Cancer Coverage Is Critical to Women’s Health
Breast cancer remains one of the most common types of cancer among American women. According to the American Cancer Society (ACS), American women have a 13% risk of developing breast cancer sometime in their life.
Breast cancer is the second deadliest type of cancer among women, after lung cancer, with 1 in 39 women (2.6%) dying from it every year – the ACS estimates that 43,600 women will die from breast cancer in 2021.
The Women’s Health and Cancer Rights Act of 1998 addresses this health issue by giving women the ability to check themselves and get mastectomy treatments if needed.
The WHCRA Extends Breast Cancer Benefits Beyond Mastectomies
Despite improvements in care, breast cancer survivability still depends on the early detection and treatment of the disease. And, unfortunately, many women die of breast cancer because they lack the coverage to check themselves or get mastectomies if needed.
Moreover, since breast cancer treatments are so expensive, survivors may get into debt paying for breast cancer treatment and end up with no hopes of getting reconstructive surgery. And this is precisely why the WHCRA was passed.
The Women’s Health and Cancer Rights Act of 1998 addresses this issue by requiring that insurance carriers cover reconstructive surgery as part of their mastectomy benefits.
What Is Covered Under the WHCRA?
The WHCRA applies to group health plans, health insurance companies, and HMOs with plans covering the medical costs for mastectomy surgery. According to the law, carriers must cover:
- Breast reconstruction services to offset the changes made by the mastectomy.
- Surgery costs for the other breast to ensure both look symmetrical and balanced.
- The costs of external breast prostheses used before or during the reconstruction process.
- Any complication that may arise during all the stages of the mastectomy – such as lymphedema, seromas, or infections.
Mastectomy benefits aren’t exclusive to breast cancer patients, though, so individuals who must undergo a mastectomy without having the disease are still covered under the WHCRA.
What Isn’t Covered Under the WHCRA?
The law itself doesn’t require group health plans to cover mastectomies but the reconstruction services that follow the procedure. Unfortunately, this means that the WHCRA is far from perfect and still has coverage gaps – which many nonprofits are working to reduce.
Some carriers might resist covering the costs of medical tattooing, which creates realistic-looking areolas that help survivors feel better about themselves. Worse yet, women who would prefer “going flat” and opt out of reconstruction after their mastectomy to lower the risks of surgery complications aren’t given the same coverage under the act.
Whatever the case may be, carriers and self-insured employers have a responsibility of informing plan members about the benefits covered under the WHCRA.
Carriers’ Have a Duty of Notice Under the WHCRA
The WHCRA requires that healthcare insurance carriers notify their plan members about their post-mastectomy benefits. According to the law, notice must be given to:
- Participants and beneficiaries of a group health plan during open enrollment – as well as to policyholders when an individual health insurance policy is issued.
- Group health plan members and beneficiaries, as well as individual policyholders, once a year.
As for the information included, the notice must include a detailed description of all the mastectomy-related employee benefits that are covered under the plan. Furthermore, the enrollment notice should also describe the deductibles and coinsurance limits of the plan.
The Women’s Health and Cancer Rights Act of 1998 plays a key role in helping breast cancer survivors on their way to a full recovery. Moreover, it outlines what responsibilities carriers and employers have toward plan participants in terms of coverage as well as the duty of giving them notice.
Contact us today if you want more information about the WHCRA, as well as your plan’s compliance with it.