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Employee Benefits Security Administration

Fact Sheet

Women's Health and Cancer Rights Act

The Women’s Health and Cancer Rights Act (WHCRA), signed into law on October 21, 1998, contains protections for patients who elect breast reconstruction in connection with a mastectomy. For plan participants and beneficiaries receiving benefits in connection with a mastectomy, plans offering coverage for a mastectomy must also cover reconstructive surgery and other benefits related to a mastectomy.

WHCRA:

  • Applies to group health plans for plan years starting on or after October 21, 1998

  • Applies to group health plans, health insurance companies or HMOs, if the plan or coverage provides medical and surgical benefits with respect to a mastectomy

  • Requires coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient

Under WHCRA, mastectomy benefits must include coverage for:

  • Reconstruction of the breast on which the mastectomy was performed

  • Surgery and reconstruction of the other breast to produce a symmetrical appearance

  • Prostheses and physical complications at all stages of mastectomy, including lymphedemas

Under WHCRA, mastectomy benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage.

The law also contains prohibitions against:

  • Plans and issuers denying patients eligibility or continued eligibility to enroll or renew coverage under the plan to avoid the requirements of WHCRA

  • Plans and issuers providing incentives to, or penalizing, physicians to induce them to provide care in a manner inconsistent with the WHCRA

Group health plans, health insurance companies and HMOs covered by the law must notify individuals of the coverage required by WHCRA upon enrollment and annually thereafter.