Do you know about your rights under the Women’s Health Care Act? You should. If you get breast cancer, you do have rights with the insurance company that was covering you at the time of mastectomy. These rights include paying for any complications that might come from a mastectomy.
Most of these things a normal person wouldn’t even think about, nor care until the time comes. Well the time came for me and now I am in the insurance battle. Being a paralegal (which I graduated from in 2011 but chose not to practice right now) has given me some knowledge in how to deal with and understand insurance coverage. Below follows information that I found on the American Cancer website and copied for your convenience. If you want to read more just search the Internet for the Womens Health Care Act of 1998. It has been updated since but that will always help you find it.
Women’s Health and Cancer Rights Act
The Federal law
The Women’s Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breasts rebuilt (reconstructed) after a mastectomy. This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law.
- Applies to group health plans for plan years starting on or after October 1, 1998
- Applies to group health plans, health insurance companies, and HMOs, as long as the plan covers medical and surgical costs for mastectomy
Under the WHCRA, mastectomy benefits must cover:
- Reconstruction of the breast that was removed by mastectomy
- Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy
- Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction
- Any physical complications at all stages of mastectomy, including lymphedema (This is the part I am fighting for).
Mastectomy benefits may have a yearly deductible and may require that you pay co-insurance. Co-insurance is when health costs are insured for less than the full amount and the patient must pay the difference.
For instance, the company may cover 80% of your expenses after you pay the deductible, leaving you to pay the other 20%. This 20% is also called a co-payment or co-pay. But any required deductible and co-insurance must be like those the plan uses for other conditions it covers. So, if a plan pays 80% for hospital and surgery fees for an appendectomy, but only 70% of hospital and surgery fees for breast reconstruction, that would violate the WHCRA.
Questions and answers about the WHCRA
Does the WHCRA allow insurers to take people off their plans so that they don’t have to pay breast reconstruction benefits?
No.The WHCRA does not allow insurance plans and insurance companies to kick people out of the plan or keep them from enrolling or renewing their coverage under the plan to avoid WHCRA requirements.
Does the WHCRA let insurance plans give doctors incentives to discourage women from having breast reconstruction after mastectomy?
No. The WHCRA also does not allow insurance plans and insurance issuers to penalize doctors or lead them to provide care in a way that does not support the WHCRA. Nor does it allow insurance plans to reward doctors who do not encourage their patients to look into breast reconstruction.
Does my insurance provider have to tell me that I’m covered for breast reconstruction under the WHRCA?
Yes. The law also requires that insurance providers notify you of this coverage when you enroll in their plan, and every year after that.
What if my state has laws that require insurers to cover breast reconstruction?
Several states have their own laws requiring health plans that cover mastectomies to provide coverage for reconstructive surgery after a mastectomy. These state laws only apply to those health plans purchased by an employer from a commercial insurance company. If an employer is self-insured, state laws do not apply but federal laws do. Federal laws (like the WHCRA) are enforced by the US Department of Labor.
A self-insured (or self-funded) plan is one in which the employer, rather than a commercial insurance company, pays for the insured person’s health expenses. Some employers that self-insure will hire a commercial insurance company to write the checks and track the paperwork, even though the money for the payments still comes from the employer. So it can be hard to tell whether you are in a self-insured or a commercially insured plan unless you ask.
If you are unsure of your plan’s status, ask your employer’s benefits manager. You can contact your state’s insurance department to find out if your state provides extra protection that will apply to your coverage if you are not in a self-insured plan. The WHCRA applies to self-insured plans that aren’t covered by state law and sets a minimum standard to be sure this service is available for all women in every state. This includes states with weaker or no laws covering breast reconstruction.
I have been diagnosed with breast cancer and plan to have a mastectomy. How will the WHCRA affect my benefits?
Under the Act, group health plans, insurance companies, and HMOs that offer mastectomy coverage must also provide coverage for reconstructive surgery after mastectomy. This coverage includes reconstruction of the breast removed by mastectomy, reconstruction of the other breast to give a more balanced look, breast prostheses, and treatment of physical complications at all stages of the mastectomy, including lymphedema (swelling in the arm that sometimes happens after breast cancer treatment).
This law sets a federal floor (minimum requirement) so that women can have breast reconstruction after mastectomy, even if they live in states that do not make insurance companies provide this coverage.
Does the WHCRA require all group plans, insurance companies, and HMOs to provide reconstructive surgery benefits?
In most cases, yes, as long as the insurance plan also covers medical and surgical benefits for mastectomies. But certain church plans and government plans may not be required to pay for reconstructive surgery. If you are insured under a health plan sponsored by a church or local government plan, check with your plan administrator about it.
Under the WHCRA, can insurance providers impose deductibles or co-insurance requirements for reconstructive surgery in connection with a mastectomy?
Yes. But the deductibles and co-insurance must be like those that are used for other benefits under the plan or coverage. The company can’t have you paying a higher deductible or co-pay for breast rebuilding than you would pay for other types of surgery.
My state requires the coverage for breast reconstruction that’s required by the WHCRA and also requires minimum hospital stays for my mastectomy. If I have a mastectomy and breast reconstruction, am I also entitled to the minimum hospital stay?
It depends. If you have coverage through your employer and your employer is insured, you would be entitled to the minimum hospital stay required by the state law. If you have coverage through your employer but your coverage is not provided by an insurance company or HMO (that is, your employer “self-insures” your coverage), then state law does not apply. In that case, only the federal WHCRA applies and it does not require minimum hospital stays. To find out if your group health plan is insured or self-insured (self-funded), contact your plan administrator.
If you have coverage under a private health insurance policy (not through your employer), check with your State Insurance Commissioner’s office to learn if state law applies.
Where can I get more information about my rights under the WHCRA?
If you have more questions or concerns, you can contact:
- The US Department of Labor, which has the WHCRA information on its Web site at www.dol.gov/ebsa/Publications/whcra.html, or you can call their toll-free number at 1-866-487-2365
- Your health plan administrator (a number should be listed on your insurance card)
- Your State Insurance Commissioner’s office [The number should be listed in your local phone book in the state government section, or you can find it at the National Association of Insurance Commissioners online at www.naic.org/state_web_map.htm. If you can’t find the number elsewhere, call 1-866-470-NAIC (1-800-470-6242).]
You may also want to check the “National organizations and Web sites” section for other sources of help.
Boy if you made it this far and I didn’t bore you to death that’s great. Because we as women are left out there to find our own way and our own path. In times of treatment …it is difficult. I am struggling with insurance payments and its awful!!
This can happen, unfortunately, to all of us.