The Women.s Health and Cancer Rights Act of 1998 (WHCRA) was signed into law on October 21, 1998. The law includes important new protections for individuals who elect breast reconstruction in connection with a mastectomy. WHCRA is subject to concurrent jurisdiction by the Department of Labor and the Department of Health and Human Services. It affects employment-based group health plans, and health insurance issuers who sell health insurance in connection with those group health plans. It also affects issuers who sell health insurance in the individual market (not in connection with employment). Health insurance issuers include insurance companies and health maintenance organizations.
WHCRA requires group health plans and health insurance issuers that are subject to the Act to provide notices to covered individuals regarding the protections provided by the Act.
The following information is intended to provide general guidance on frequently-asked questions about the notice requirements under WHCRA.
1. Who is required to satisfy the notice requirements under WHCRA?
Group health plans, and health insurance issuers that offer coverage either in connection with a group health plan or in the individual market, are subject to the notice requirements of WHCRA if they cover medical and surgical benefits in connection with a mastectomy.
2. What must be included in the notice?
The notices must be in writing, and must describe the benefits that WHCRA requires a plan or issuer to cover. Until the Departments issue regulations, nonfederal governmental plans and issuers in the individual market may use the following language to satisfy the requirement:
Patients who undergo a mastectomy, and who elect breast reconstruction in connection with the mastectomy, are entitled to coverage for
- 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 lymphedemas
in a manner determined in consultation with the attending physician and the patient. The coverage may be subject to coinsurance and deductibles consistent with those established for other benefits.
(A) Notice Upon Enrollment. Notice must be delivered to the participant under a plan, or the policyholder under an individual market policy, upon initial enrollment in the plan or policy.4. When a group health plan purchases insurance from an issuer, must the plan and issuer furnish separate notices?(B) Annual Notice. Notice must be delivered to participants, or policyholders, annually after the initial enrollment.
The statute imposes the notice requirements on both the plan and the issuer. If no notice is given, both the plan and issuer will be responsible. We anticipate that it is likely that regulations implementing WHCRA will permit plans and issuers to have an agreement that governs who will provide the notices. Until more specific guidance is provided in regulations, the notice requirements will be deemed to be met as long as each covered individual actually receives the required notices, whether it is from the plan, the issuer, or a third party on behalf of the plan or issuer.
Last Updated February 2, 1999