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Your Rights After a Mastectomy

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Your Rights After a Mastectomy If you request reconstructive surgery, your new Your Rights After A Mastectomy employer’s plan generally must cover it if: n the plan provides coverage for mastectomies, If you have had a mastectomy or expect to have and one, you may be entitled to special rights under n you are receiving benefits under the plan that the Women’s Health and Cancer Rights Act of are related to your mastectomy. 1998 (WHCRA). The following questions and In addition, your new employer’s plan generally must cover the other benefits specified in answers clarify your basic WHCRA rights. WHCRA, even if you were not enrolled in your new employer’s plan when you had the I’ve been diagnosed with breast cancer Do all group health plans and health mastectomy. and plan to have a mastectomy, which insurance companies have to provide my plan covers. Will my health plan reconstructive surgery benefits? The Patient Protection and Affordable Care Act cover reconstructive surgery too? Generally, WHCRA applies to all group health includes additional protections. A group health If your group health plan or health insurance plans that provide coverage for medical and plan generally cannot limit or deny benefits company covers mastectomies, it must provide surgical benefits with respect to a mastectomy, relating to a health condition that existed certain reconstructive surgery and other benefits as well as their insurance companies. However, before you enrolled in your new employer’s related to the mastectomy, including: there are exceptions for some “church plans” and plan. For more information, visit dol.gov/ “government plans.” If your coverage is provided agencies/ebsa/laws-and-regulations/ n all stages of reconstruction of the breast on laws/affordable-care-act/for-workers-and- by a “church plan” or “governmental plan,” check which the mastectomy was performed, families or HealthCare.gov. with your plan administrator. n surgery and reconstruction of the other breast My employer’s group health plan provides to produce a symmetrical appearance, Will I have to pay a deductible or coverage through an insurance company. coinsurance? n prostheses, and After my mastectomy, my employer Possibly. Group health plans or health n changed insurance companies. The new treatment of physical complications of the insurance companies may impose deductibles insurance company refuses to cover my mastectomy, including lymphedema. or coinsurance requirements on mastectomies reconstructive surgery. Is that legal? The plan must consult with you and your and post-mastectomy treatment, but no more Not if: attending physician when determining how this than those established for other benefits. In coverage will be provided. other words, the deductible for post-mastectomy n the new insurance company provides coverage YOUR RIGHTS reconstructive surgery should be similar to the for mastectomies, I must have a mastectomy for medical deductible for any similar procedure covered by n you are receiving benefits under the plan reasons, although I have not been the plan. AFTER A diagnosed with cancer. Does WHCRA related to your mastectomy, and apply to me? Before I changed jobs, I had a n you elect to have reconstructive surgery. MASTECTOMY Yes, the law applies if your group health plan or mastectomy and chemotherapy which If these conditions apply, then the new insurance health insurance company covers mastectomies were covered under my previous company must provide coverage for breast and you are receiving benefits in connection with employer’s plan. Now I am enrolled reconstruction as well as the other benefits a mastectomy – whether or not you have cancer. under my new employer’s plan and required under WHCRA. It does not matter that EMPLOYEE BENEFITS SECURITY ADMINISTRATION Despite its name, nothing in the law limits want reconstructive surgery. Is my new UNITED STATES DEPARTMENT OF LABOR you were not covered by the new company when WHCRA rights to cancer patients. employer’s plan required to cover it? you had the mastectomy. I understand that my group health “Do you know that your plan, as required by If your coverage is “insured” and you want to plan must provide me with a notice of the Women’s Health and Cancer Rights Act of know if you have additional state law protections, Resources my WHCRA rights when I enroll in the 1998, provides benefits for mastectomy-related contact your state insurance department. WHCRA is administered by the U.S. plan. What information does this notice services including all stages of reconstruction I have health coverage through an Departments of Labor and Health and include? and surgery to achieve symmetry between the individual policy, not through an Human Services. Plans must provide a notice to all employees breasts, prostheses, and complications resulting employer. Am I covered under WHCRA? when they enroll in the health plan that: from a mastectomy, including lymphedema? Call Department of Labor your plan administrator [phone number here] for WHCRA rights apply to individual coverage as For more information about your WHCRA n describes the benefits thatWHCRA requires more information.” well. These requirements are generally within rights under an employer-sponsored group the plan and its insurance companies to cover, the jurisdiction of the state insurance department. health plan and other health coverage which includes: Your annual notice may be the same notice Call your state insurance department or the topics, visit dol.gov/agencies/ebsa. To provided when you enrolled in the plan if it • coverage of all stages of reconstruction of Department of Health and Human Services toll order publications, learn more about our contains the information described above. the breast on which the mastectomy was free at 1-877-267-2323, extension 6-1565, for programs and services, or discuss questions performed, more information. about your benefits, contact EBSA at My state also requires health insurance askebsa.dol.gov or call toll-free: 1-866- • surgery and reconstruction of the other companies to cover minimum hospital Can I get breast cancer screening or 444-3272. breast to produce a symmetrical appearance, stays in connection with a mastectomy similar preventive services for free? (which is not required by WHCRA). Department of Health and Human Services • prostheses, and Possibly. Under the Affordable Care Act, you For more information on WHCRA, visit If I have a mastectomy and breast may receive certain recommended preventive www.cms.gov/CCIIO/Programs-and- • treatment of physical complications of the reconstruction, am I also entitled to the mastectomy, including lymphedema; services, such as breast cancer mammography Initiatives/Other-Insurance-Protections/ minimum hospital stay? screenings for women aged 40 and older, with whcra_factsheet.html or call toll-free: n states that mastectomy-related benefits If your employer’s group health plan provides no copayment, coinsurance, deductible, or 1-877-267-2323, extension 6-1565. coverage will be provided in a manner coverage through an insurance company, you are other cost-sharing. For more information, visit National Association of Insurance determined in consultation with the attending entitled to the minimum hospital stay required HealthCare.gov/coverage/preventive-care- Commissioners by the state law. Many state laws provide more physician and the patient; benefits/. WHCRA does not require coverage To find the contact information for your protections than WHCRA for coverage provided n describes any applicable deductibles for preventive services related to the detection of state office, visitnaic.org/state_web_map. and coinsurance limitations that apply to by an insurance company or “insured coverage.” breast cancer. htm. the coverage specified under WHCRA. Deductibles and coinsurance limitations may If your employer’s be imposed only if they are consistent with group health plan You are entitled to… those established for other benefits under the provides… plan or coverage. Federal and state Coverage through an protections (in states What information does the annual insurance company WHCRA notice from my health plan that provide them) include? Self-insured coverage Federal protections only Your annual notice should describe the four categories of coverage required under WHCRA To find out if your group health coverage is and how to obtain a detailed description of the EMPLOYEE BENEFITS SECURITY ADMINISTRATION “insured” or “self-insured,” check your health UNITED STATES DEPARTMENT OF LABOR mastectomy-related benefits available under your plan’s Summary Plan Description (SPD) or plan. For example, an annual notice might look contact your plan administrator. like this: September 2018.
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