The following information is intended to provide general guidance on frequently-asked questions about WHCRA.
1. I've been diagnosed with breast cancer and will need to have a mastectomy. How will WHCRA affect me?
The general rule under WHCRA is that if you have coverage under a group health plan, or under an individual health insurance policy that covers medical and surgical benefits in connection with a mastectomy, the group health plan or issuer (an insurance company or HMO) must also provide coverage for reconstructive surgery in a manner determined in consultation with you and your attending physician. Coverage includes 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.
2. Under WHCRA, are all group health plans and issuers (insurance companies and HMOs) required to provide reconstructive surgery benefits in connection with a mastectomy?
Most plans and issuers that provide coverage for medical and surgical benefits in connection with a mastectomy are required to provide reconstructive surgery benefits.
3. Under WHCRA, may group health plans and issuers (insurance companies and HMOs) impose deductibles or coinsurance for reconstructive surgery in connection with a mastectomy?
Yes, but only if the deductibles and coinsurance are consistent with those established for other benefits under the plan or insurance coverage.
4. If WHCRA applies to my coverage, when do these requirements take effect?
If you have group health plan coverage, the requirements are effective for plan years beginning on or after October 21, 1998. To find out when your plan year begins, contact your plan administrator.
If you have individual market coverage (not through your employer), the requirements are effective on October 21, 1998.
Last Updated February 9, 1999