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Determining Compliance with the WHCRA Provisions in Part 7 of ERISA

Four Required Coverages under WHCRA

Does the plan provide the four coverages required by WHCRA?

In the case of a participant or beneficiary who is receiving benefits in connection with a mastectomy, the plan shall provide coverage for the following benefits for individuals who elect them:

  • All stages of reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance;
  • Prostheses; and
  • Treatment of physical complications of mastectomy, including lymphedema, in a manner determined in consultation with the attending provider and the patient. See ERISA section 713(a).

These required coverages can be subject to annual deductibles and coinsurance provisions if consistent with those established for other medical/surgical benefits under the plan or coverage.

Tip: Plans that cover benefits for mastectomies cannot categorically exclude benefits for reconstructive surgery or certain post-mastectomy services. In addition, time limits for seeking treatment may run afoul of the general requirement to provide the four required coverages.