DE PA RT M E N T O F L AB O R

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N I T E D S TA T E S O F AM E R I C

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U.S. Department of Labor

Employee Benefits Security Administration

YOUR RIGHTS

AFTER A

MASTECTOMY

DE PA RT M E N T O F L AB O R

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N I T E D S TA T E S O F AM E R I C

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YOUR RIGHTS

AFTER A

MASTECTOMY
f you have had a mastectomy or expect to

have one, you may be entitled to special rights

under the Women’s Health and Cancer Rights

Act of 1998 (WHCRA).

The following questions and answers

clarify your basic WHCRA rights. Under WHCRA,

if your group health plan covers mastectomies,

the plan must provide certain reconstructive

surgery and other post-mastectomy benefits.

Your health plan or issuer is required to

provide you with a notice of your rights under

WHCRA when you enroll in the health plan,

and then once each year.
The following information

provides answers to

frequently asked questions

about WHCRA.

I’ve been diagnosed with breast cancer and plan to have a

mastectomy. How will WHCRA affect my benefits?

Under WHCRA, group health plans, insurance companies and

health maintenance organizations (HMOs) offering

mastectomy coverage also must provide coverage for certain

services relating to the mastectomy in a manner determined

in consultation with your attending physician and you. This

required coverage includes 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, prostheses and treatment of physical

complications from the mastectomy, including lymphedema.

I have not been diagnosed with cancer. However, due to

other medical reasons I must undergo a mastectomy.

Does WHCRA apply to me?

Yes, if your group health plan covers mastectomies and you are

receiving benefits in connection with a mastectomy. Despite

its name, nothing in the law limits WHCRA rights to cancer

patients.

Does WHCRA require all group health plans, insurance

companies and HMOs to provide reconstructive surgery

benefits?

Generally, group health plans, as well as their insurance

companies and HMOs, that provide coverage for medical and

surgical benefits with respect to a mastectomy must comply

with WHCRA.

However, if your coverage is provided by a “church

plan” or “governmental plan”, check with your plan

administrator. Certain plans that are church plans or

governmental plans may not be subject to this law.

May group health plans, insurance companies or HMOs impose

deductibles or coinsurance requirements on the coverage

specified in WHCRA?

Yes, but only if the deductibles and coinsurance are consistent with

those established for other benefits under the plan or coverage.

I just changed jobs and am enrolled under my new employer’s

plan. I underwent a mastectomy and chemotherapy treatment

under my previous employer’s plan. Now I want reconstructive

surgery. Under WHCRA, is my new employer’s plan required to

cover my reconstructive surgery?

If your new employer’s plan provides coverage for mastectomies and

if you are receiving benefits under the plan that are related to your

mastectomy, then your new employer’s plan generally is required to

cover reconstructive surgery if you request it. In addition, your new

employer’s plan generally is required to cover the other benefits

specified in WHCRA. It does not matter that your mastectomy was not

covered by your new employer’s plan.

However, a group health plan may limit benefits relating to a

health condition that was present before your enrollment date in your

current employer’s plan through a preexisting condition exclusion. A

Federal law known as the Health Insurance Portability and

Accountability Act of 1996 (HIPAA) limits the circumstances under

which a preexisting condition exclusion may be applied.

Specifically, HIPAA provides that a plan may impose a

preexisting condition exclusion only if:

 • The exclusion relates to a condition (whether physical or mental)

 for which medical advice, diagnosis, care or treatment was

 recommended or received within the 6- month period ending on

 your enrollment date;

 • The exclusion extends no more than 12 months (or 18 months in

 the case of a late enrollee in the new plan) after the enrollment

 date; and

 • The preexisting condition exclusion period is reduced by the days

 of prior creditable coverage (if any, which is defined in HIPAA

 as most health coverage).

The plan also must provide you with written notification of

the existence and terms of any preexisting condition exclusion under

the plan and of your rights to demonstrate prior creditable coverage.
For an explanation of HIPAA, request a copy of Health

Coverage Portability (see resources below).

My employer’s group health plan provides coverage through an

insurance company. Following my mastectomy, my employer

changed insurance companies. The new insurance company is

refusing to cover my reconstructive surgery. Does WHCRA provide

me with any protections?

Yes, as long as the new insurance company provides coverage for

mastectomies, you are receiving benefits under the plan related to your

mastectomy, and you elect to have reconstructive surgery. If these

conditions apply, the new insurance company is required to provide

coverage for breast reconstruction as well as the other benefits

required under WHCRA. It does not matter that your mastectomy was

not covered by the new insurance company.

I understand that my group health plan is required to provide me

with a notice of my rights under WHCRA when I enroll in the plan.

What information can I expect to find in this notice?

Plans must provide a notice to all employees when they enroll in the

health plan describing the benefits that WHCRA requires the plan and

its insurance companies or HMOs to cover. These benefits include

coverage of 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, prostheses, and

treatment of physical complications of the mastectomy, including

lymphedema.

The enrollment notice also must state that for the covered

employee or their family member who is receiving mastectomy-related

benefits, coverage will be provided in a manner determined in

consultation with the attending physician and the patient.

Finally, the enrollment notice must describe any deductibles

and coinsurance limitations that apply to the coverage specified under

WHCRA. Deductibles and coinsurance limitations may be imposed

only if they are consistent with those established for other benefits

under the plan or coverage.

What can I expect to find in the annual WHCRA notice

from my health plan?

Your annual notice should describe the four categories of

coverage required under WHCRA and information on how to

obtain a detailed description of the mastectomy-related

benefits available under your plan. For example, an annual

notice might look like this:

“Do 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 all stages of

reconstruction and surgery to achieve symmetry between the

breasts, prostheses, and complications resulting from a

mastectomy, including lymphedema? Call your plan

administrator [phone number here] for more information.”

Your annual notice may be the same notice provided

when you enrolled in the plan if it contains the information

described above.

My State requires health insurance issuers to cover the

benefits required by WHCRA and also requires health

insurance issuers to cover minimum hospital stays in

connection with a mastectomy (which is not required by

WHCRA). If I have a mastectomy and breast reconstruction, am I also entitled to the minimum hospital stay?

If your employer’s group health plan provides coverage through

an insurance company or HMO, you are entitled to the

minimum hospital stay required by the State law. Many State

laws provide more protections than WHCRA. Those additional

protections apply to coverage provided by an insurance

company or HMO (known as “insured” coverage).

If your employer’s plan does not provide coverage

through an insurance company or HMO (in other words, your

employer “self-insures” your coverage), then the State law does

not apply. In that case, only the Federal law, WHCRA, applies,

and it does not require minimum hospital stays.

To find out if your group health coverage is “insured”

or “self-insured,” check your health plan’s Summary Plan

Description or contact your plan administrator.

(continued on next panel)
If your coverage is “insured” and you want to

know if you have additional State law protections, check

with your State insurance department.

My health coverage is through an individual policy,

not through an employer. What rights, if any, do I have

under WHCRA?

Health insurance companies and HMOs are generally

required to provide WHCRA benefits to individual policies

too. These requirements are generally within the

jurisdiction of the State insurance department. Call your

State insurance department or the Department of Health

and Human Services toll free at 1-877-267-2323, extension

61565, for further information.

Resources:

WHCRA is administered by the U.S. Departments of Labor

and Health and Human Services.

Department of Labor

If you have questions regarding your WHCRA rights under

an employer-sponsored group health plan, call the

Department of Labor’s Employee Benefits Security

Administration toll free at 1-866-444-EBSA (3272) or visit

www.dol.gov/ebsa and click on Contact Us for the

addresses of the 15 field offices that can assist you.

You also can request a copy of Health Coverage Portability

and a list of all publications from the Employee Benefits

Security Administration.

Centers for Medicare and Medicaid Services

Visit cms.hhs.gov and click on HIPAA, then HIPAA Health

Insurance Reform for more information on WHCRA and

HIPAA or call toll free at 1-877-267-2323, extension 61565.

National Association of Insurance Commissioners

Visit www.naic.org and click on State Insurance

Regulators, then the state of your choice for the office in

your state.

Updated: June 2006

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