The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy. This law applies generally both to persons covered under group health plans and persons with individual health insurance coverage.

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 you and if you are receiving benefits in connection with a mastectomy and you elect 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 you the same coverage as WHCRA applies to your coverage will depend on your situation. Generally, WHCRA applies if you are in a self-insured plan. Your state law will determine whether WHCRA will apply to coverage under an insured group plan, or to individual health insurance coverage. Contact your medical care provider or state’s insurance department to find out about whether WHCRA will apply to your coverage if you are NOT in a self-insured health plan.

You group medical plan is allowed to impose the normal coinsurance, deductibles and copays for reconstructive surgery connected with a mastectomy, but only if the deductibles and coinsurance are consistent with the cost-sharing arrangements that apply to other benefits under the plan or coverage.

WHCRA does not prevent a plan or health insurance issuer from negotiating the level and type of payment with attending providers. However, the law prohibits plans and issuers from penalizing attending providers or providing incentives that would induce a provider to provide care that is inconsistent with WHCRA.