Get Latest WorkWORLD

Women's Health and Cancer Rights Act of 1998 (WHCRA)

This topic provides information about the Women's Health and Cancer Rights Act of 1998 (WHCRA), one of the amendments to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

You can read this topic sequentially, or click one of the links below to jump to a specific section:

·               Summary Information

·               Questions and Answers

·               Notice Requirements

·               Model Annual Notice

·               Statutory Text

Summary Information

Overview

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. But WHCRA does NOT require health plans or issuers to pay for mastectomies. 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 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.

Answers to Commonly Asked Questions

General Questions and Answers on WHCRA

1) Under WHCRA, may group health plans and health insurance issuers impose deductibles or coinsurance for reconstructive surgery in connection with a mastectomy?

Yes, but only if the deductibles and coinsurance are consistent with the cost-sharing arrangements that apply to other benefits under the plan or coverage.

2) Are health plans required to give me notice of WHCRA benefits?

Yes. Both group health plans and health insurance issuers are required to provide you notice of WHCRA benefits upon enrollment and annually thereafter.

3) Does WHCRA affect the amount that my health plan will pay my doctors?

No. 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.

Questions & Answers on the Annual Notice Requirements

1) Are all group health plans, and their insurance companies or HMOs, required to satisfy the notice requirements under WHCRA?

All group health plans and health insurance issuers that offer coverage for medical and surgical benefits with respect to a mastectomy are subject to the notice requirements under WHCRA. This requirement applies to issuers in both the group and individual markets.

2) What are the notice requirements under WHCRA?

There are three separate notices required under WHCRA. The first notice is a one-time requirement under which group health plans and insurance issuers must have furnished a written description of the benefits that WHCRA requires to participants, policyholders in the individual market, and beneficiaries no later than January 1, 1999. The second notice must also describe the benefits required under WHCRA, but it must be provided to participants and policyholders in the individual market upon enrollment in the plan. The third notice is required to be furnished annually to participants under the plan and to individual policyholders.

3) When must the annual notice be delivered?

As mentioned above, WHCRA requires a written notice of the availability of such coverage to be delivered to the participant or policyholder upon enrollment and annually thereafter. A plan or health insurance issuer satisfies the annual requirement if the plan or issuer delivers the annual notice anytime during a plan year.

4) During a plan year, must both an annual notice and an enrollment notice be provided to participants or policyholders enrolling in the plan?

No. If a plan or health insurance issuer provides appropriate enrollment notice to a participant or policyholder upon enrollment in the plan, then the plan or issuer does not have to provide that participant or policyholder with an annual notice for the plan year during which that participant enrolled.

5) How must the annual notice be delivered?

The plan or health insurance issuer must use measures reasonably calculated to ensure actual receipt of the annual notice by plan participants and policyholders and the notice must be sent by a method or methods of delivery likely to result in full distribution.

6) Does WHCRA require plans to send the annual notice separately?

No. The annual notice may be sent by itself or may, for example, be included in any of the following:

·               A summary plan description (SPD), a summary of material modifications (SMM), or a summary annual report (SAR);

·               A union newsletter (or a benefits newsletter);

·               Open enrollment materials;

·               Policy renewal notification letter; or

·               Any other written communication by the plan or issuer.

7) Can a plan or issuer satisfy the annual notice requirement by using the same notice as the one used to satisfy the enrollment notice?

Yes. Although WHCRA does not require plans to use the same notice to fulfill the enrollment and annual notice requirements, plans and issuers may satisfy the annual notice requirement by using the enrollment notice and delivering it to participants or policyholders on an annual basis.

The enrollment notice must describe the benefits that group health plans and insurance issuers must cover under WHCRA. The enrollment notice must indicate that, in the case of a participant, policyholder, or beneficiary who is receiving benefits in connection with a mastectomy, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

·               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; and

·               Prostheses and treatment of physical complications of the mastectomy, including lymphedema.

The enrollment notice must also describe any deductibles and coinsurance limitations applicable to such coverage. Under WHCRA, coverage of breast reconstruction benefits may be subject only to deductibles and coinsurance limitations consistent with those established for other benefits under the plan or coverage.

8) If a plan or issuer does not use the enrollment notice to satisfy the annual notice requirement, is there another way to fulfill the annual notice requirement?

Yes. Instead of distributing the enrollment notice annually, a plan or issuer may choose to distribute annually a notice informing participants and policyholders of the following:

·               The availability of benefits for the treatment of mastectomy-related services, including reconstructive surgery, prosthesis, and physical complications, including lymphedema; and

·               Information (telephone number, web address, etc.) on how to obtain a detailed description of the mastectomy-related benefits available under the plan.

See the Model Annual Notice below that may be used to satisfy WHCRA's annual notice requirement.

9) Must a group health plan or health insurance issuer furnish separate notices under WHCRA?

No. To avoid duplication of notices, a group health plan or health insurance issuer can satisfy the notice requirements of WHCRA by contracting with another party to provide the required notice. For example, in the case of a group health plan funded through an insurance policy, the group health plan will satisfy the notice requirements with respect to a participant or beneficiary if the insurance company or HMO provides the notice that includes the information required by WHCRA.

10) Where can I obtain more information?

For additional information see the Department of Labor's website at:
http://www.dol.gov/ebsa/FAQs/faq_consumer_womenshealth.html

Another Department of Labor website is at:
http://www.dol.gov/ebsa/Publications/whcra.html

The second website offers a copy of the publication Q&As: Recent Changes in Health Care Law. It may be obtained by calling a Toll-Free Employee & Employer Hotline at: 1-866-444-3272. It may also be downloaded as a PDF file (requires Adobe Acrobat) from:
http://www.dol.gov/ebsa/pdf/hipaaemployer.pdf

Notice Requirements

The WHCRA requires group health plans and health insurance issuers, including insurance companies and HMOs, to notify individuals regarding coverage required under the law. Notification is required at three separate times:

·               After enactment of WHCRA

·               Upon enrollment

·               Annually.

Model Annual Notice

"Did you know that your plan, as required by the Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). Call your health insurance issuer [insert phone number] for more information."

Statutory Text

The Women's Health and Cancer Rights Act (P.L. 105-277), enacted October 21, 1998, which amended the Public Health Service Act (PHS Act) and the Employee Retirement Income Security Act of 1974 (ERISA). The law is administered by the Department of Health and Human Services (DHHS) and the Department of Labor.

See Also:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Overview

Source

Information in this topic was drawn from pages of the Centers for Medicare & Medicaid Services' Health Insurance Portability and Accountability Act of 1996 (HIPAA) website at:
http://www.cms.hhs.gov/HealthInsReformforConsume/06_TheWomen'sHealthandCancerRightsAct.asp

WorkWORLD™ Help/Information System

   Share/Save: Click the button or link at left to select your favorite bookmark service and add this page.

This is one topic from the thousands available in the WorkWORLD™ software Help/Information System.
Complete information about the software is available at: http://www.WorkWORLD.org