YOUR RIGHTS

AFTER A

MASTECTOMY

U.S. Department of Labor

Employee Benefits Security Administration

U.S. Department of Labor

Employee Benefits Security Administration

YOUR RIGHTS

AFTER A

MASTECTOMY

YOUR RIGHTS

AFTER A

MASTECTOMY
if 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 

clarifyyour 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 health insurance 

issuer (also commonly referred to as your 

health insurance company) 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 and health insurance 

companies offering mastectomy coverage also must provide 

coverage for certain services relating to the mastectomy 

in amanner 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 of 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 or health insurance company 

coversmastectomies and you are receiving benefits in 

connectionwith a mastectomy. Despite its name, nothing in the 

lawlimits WHCRA rights to cancer patients. 

Does WHCRA require all group health plans and health 

insurance companies to provide reconstructive surgery 

benefits? 

Generally, group health plans, as well as their insurance 

companies, that provide coverage for medical and surgical 

benefitswith respect to a mastectomy must comply 

withWHCRA. 

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 or health insurance companies 

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 

ifyou are receiving benefits under the plan that are related to your 

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

to coverreconstructive 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 you were not enrolled in 

your new employer’s plan at the time you had the mastectomy. 

There are additional protections under the Patient 

Protection and Affordable Care Act (ACA). A group health plan 

generally cannot limit or deny benefits relating to a health condition 

that was present before your enrollment date in your new employer’s 

plan (a preexisting condition). For more information, visit the 

ACA Web page of the Department of Labor’s Employee Benefits 

Security Administration (EBSA) at dol.gov/agencies/ebsa/laws-andregulations/laws/affordable-care-act/for-workers-and-families or the 

Department of Health and Human Services’ Website at 

healthcare.gov.

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 

yourmastectomy, 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 you were not 

covered by the new company at the time you had the mastectomy.

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 

healthplan describing the benefits that WHCRA requires the plan and 

itsinsurance companies 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 

onlyifthey 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 companies to cover the 

benefits required by WHCRA and also requires health insurance 

companies 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, 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 (known as “insured” coverage). 
If your employer’s plan does not provide coverage

through an insurance company (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 

notrequireminimum 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.

If your coverage is “insured” and you want to know if

youhave 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?

WHCRA rights apply to individual coverage as well. These 

requirements are generally within the jurisdiction of the state 

insurancedepartment. 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.

Do I have a right to preventive services related to the 

detection of breast cancer? 

Under the ACA, you may receive recommended preventive 

services, such as breast cancer mammography screenings 

for women 40 years of age and older, with no copayment, 

coinsurance or deductible (or other cost-sharing). 

For more information, visit 

healthcare.gov/coverage/preventive-care-benefits/.

WHCRA does not require coverage for preventive services 

related to the detection of breast cancer.
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 or wish to view 

publications on a variety of health coverage topics, visit the 

Website of the Department of Labor’s Employee Benefits 

Security Administration at dol.gov/agencies/ebsa. To 

order publications or request assistance from a benefits 

advisor, contact EBSA electronically at askebsa.dol.gov

or call toll free 1-866-444-3272. 

Department of Health and Human Services

For more information on WHCRA, visit the Website 

of the Department of Health and Human Services’ 

Centers for Medicare & Medicaid Services at 

cms.gov/CCIIO/Programs-and-Initiatives/OtherInsurance-Protections/whcra_factsheet.html

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

National Association of Insurance Commissioners 

Visit naic.org and click on “Map”, then the state of your 

choice for the office in your state.

August 2017