The Women's Health and Cancer Rights Act

The Employee Retirement Income Security Act of 1974 (ERISA) was passed to regulate employee benefit plans, including employer-sponsored group health plans. In 1998, an amendment to ERISA was passed called the Women's Health and Cancer Rights Act (WHCRA), which applies to individual health plans as well as to employer-sponsored group health plans. The WHCRA establishes rights for women who are covered under health plans that cover mastectomies. It is important to note that the WHCRA does not require health plans to provide coverage for mastectomy; rather, it imposes requirements on plans that do offer such coverage.

Under the WHCRA, if a health plan covers mastectomies, it must also provide additional coverage. That coverage must include breast reconstruction of the breast upon which a mastectomy was performed, surgery and reconstruction of the other breast necessary to provide a uniform appearance, any necessary breast prostheses, and any treatment necessary for the physical complications of mastectomy, including lymphedema.

Health plans may require coinsurance and deductibles for reconstructive surgery in connection with a mastectomy as long as they are consistent with the cost-sharing provisions that apply to other health benefits under the plan. Persons covered by health plans offering such coverage must be notified of the coverage, including any applicable deductibles or coinsurance, upon enrollment in the plan and annually thereafter.

Copyright 2012 LexisNexis, a division of Reed Elsevier Inc.

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