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Know your benefits – Women’s Health and Cancer Rights Act (WHCRA) of 1998

The benefits related to mastectomies changed quite a bit with the Women’s Health and Cancer Rights Act (WHCRA) of 1998. This article will answer some of the common questions patients have about the WHCRA.

What does WHCRA cover?

If you are enrolled in a health plan that covers the medical and surgical costs of a mastectomy, the WHCRA states that your plan must also cover the costs of certain reconstructive surgery and other post-mastectomy benefits, including:

  • All stages of reconstruction of the breast on which the mastectomy was performed
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance
  • External breast forms that fit into your bra for before or during reconstruction
  • Treatment of any physical complications of the mastectomy, including lymphedema

I had a mastectomy due to non-cancer related health issues. Am I covered under WHCRA?

Yes. These rights are not limited to cancer patients. If your plan covers mastectomies, WHCRA rights apply.

My job does not offer a group health plan. Does WHCRA apply to my individual health insurance policy?

Yes. WHCRA applies to group health plans that are provided by an employer or union as well as to individual health insurance policies that are not based on employment.

Your health plan must also cover the costs of certain reconstructive surgery and other post-mastectomy benefits.

I receive health benefits through my church. Am I still covered under WHCRA?

There are certain “church” and “governmental” plans that are not subject to this law. Generally, though, any plan that provides coverage for mastectomies must also comply with WHCRA. Check with your provider for information specific to your plan.

Will my co-pay for reconstructive surgery be more expensive than my co-pay for other health conditions?

No. If your health plan requires a co-payment for other health conditions, the co-pay for your mastectomy benefits must be the same. For example, it is a violation of WHCRA for your plan to cover 90 percent of hip replacement surgery but to only cover 70 percent of  breast reconstruction.

Is my health plan required to inform me of my rights under WHCRA?

Yes. Your health plan must provide you with a notice of your rights under WHCRA when you first enroll in the health plan, and then annually after that.

All insurance policies are different. Be sure to review your insurance policy for specific information about coverages available to you. Nothing in this post is meant to suggest a guarantee of coverage.