• Federal law does not require individual or group health plans to pay for mastectomies or elective breast reconstruction but if covered then the plan or issuer is subject to the requirements of WHCRA.
• The mastectomy coverage, if provided, must include reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses (e.g., breast implant), and treatment for physical complications of the mastectomy (including lymphedema).
• Group health plans and health insurance issuers, including insurance companies and HMOs, are required to notify individuals regarding coverage upon enrollment, and annually thereafter.

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections to individuals who have had a mastectomy and who elect breast reconstruction in connection with the mastectomy.

The Act (P.L. 105-277) amended the Public Health Service Act (PHS Act) and the Employee Retirement Income Security Act of 1974. The law is administered by the Department of Health and Human Services and the Department of Labor.

This law applies generally both to persons covered under group health plans and persons with individual health insurance coverage. But WHCRA does NOT require health plans or issuers to pay for mastectomies. If a group health plan or health insurance issuer chooses to cover mastectomies, then the plan or issuer is generally subject to WHCRA requirements.

If WHCRA applies to someone, and if that person is receiving benefits in connection with a mastectomy, and that person elects breast reconstruction, coverage must be provided for:

• Reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses (e.g., breast implant); and
• Treatment for physical complications of the mastectomy, including lymphedema.

Coverage under WHCRA

Whether WHCRA or a state law that affords the same coverage as WHCRA applies to someone’s coverage will depend on the situation. Generally, WHCRA applies to most group health plans. However, certain plans, such as “church plans” or “governmental plans” may not be subject to this law.

Notice

The WHCRA requires group health plans and health insurance issuers, including insurance companies and health maintenance organizations (HMOs), to notify individuals regarding coverage required under the law. Notification is required upon enrollment, and annually thereafter.