The Women's Health and Cancer Rights Act (WHCRA)
The Women's Health and Cancer Rights Act (WHCRA) was signed into law on Oct. 21, 1998. This law requires group health plans to provide certain benefits regarding a mastectomy and to provide their plan participants notice of their rights with regard to mastectomies. There is nothing in the law that limits entitlement to WHCRA to members who are cancer patients and is not limited to only women.
Most employer-provided group health plans must comply with the terms of WHCRA. Plans which are considered excepted benefit plans do not have to comply.
There is a small plan exception which excludes plans with less than two current plan participants from compliance with WHCRA. This includes stand-alone retiree plans if there are no current employees participating in the plan.
WHCRA requires group health plans and issuers that provide medical and surgical benefits for a mastectomy to provide, in the case of a participant or beneficiary who is receiving benefits in connection with a mastectomy, and who elects breast reconstruction in connection with such mastectomy, coverage for:
- All stages of reconstruction of the breast on which a mastectomy has been performed;
- Surgery and reconstruction of the other breast "to produce a symmetrical appearance"; and
- Prostheses and physical complications of mastectomy, including lymphedemas.
The Department of Labor (DOL) has confirmed that plans which provide mastectomy benefits must cover reconstruction even if the mastectomy was previously paid by a prior health plan.
WHCRA does not require coverage for the detection of breast cancer as is required under the preventive services mandate.
Plans subject to WHCRA may not deny a member enrollment or renewal in their plan or penalize the member for the purpose of avoiding compliance.
Plans must provide participants and their beneficiaries with a notice of their rights under WHCRA when they enroll in the plan and thereafter on an annual basis. If the participant and beneficiaries reside in separate locations, the notices must be sent to each address.
Self-funded, non-federal governmental plans can opt out of WHCRA's requirements, provided that certain procedures are followed as outlined by CMS and the appropriate opt-out notices are provided to plan participants.
A penalty of $110.00 per day penalty applies to each individual who fails to receive the WHCRA notice. Excise taxes may also apply and shall be self-reported on IRS form 8928.
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.