The purpose of this federal law is to require that group health plans, insurance companies and health maintenance organizations (HMOs) that provide mastectomy coverage provide coverage for reconstruction as well. By doing so women in all states will be able to receive reconstructive surgery even if the state law where they live does not require it.
All stages of reconstruction are covered under the WHCRA--reconstructive surgery of the breast upon which the mastectomy was performed is covered, as well as surgery of the other breast as needed to produce a symmetrical appearance. Also covered are prostheses and treatment of physical complications of the mastectomy, such as lymphedema.
Generally yes. Group health plans, insurance companies, and HMOs that provide coverage for mastectomies are required to follow the WHCRA. Some church and government plans may fall outside the scope of the law. If you believe that you are insured as part of a church or government plan, you should check with your plan administrator.
I am insured under an individual plan not a group plan through my employer. Does the WHCRA still apply to me?
Yes, the same requirements apply to individual plans as well as group plans.
I have changed jobs since I had my mastectomy and now have insurance coverage with my new employer. Is my new employer’s insurance company required to comply with WHCRA?
If your new employer’s plan covers mastectomies and you are receiving benefits under the plan, then your new employer’s plan will generally be required to cover your request for reconstructive surgery. However, you maybe subject to a pre-existing condition exclusion period under your new employer’s plan. HIPAA may provide you with protections from a pre-existing exclusion period if you had prior continuous coverage.
Do I still have to pay a deductible or co-pays for medical services which are required to be covered by the WHCRA?
Yes, as long as those deductibles and co-pays are consistent with other benefits under your plan.
No, WHCRA does not apply to Medicare or Medicaid.
If I feel I am covered by WHCRA, but my insurance company is denying me coverage for reconstruction, who can I contact for help?
In Minnesota, you can call the Department of Commerce, Insurance Division at (800) 657-3602 or (651) 296-2488 to file a complaint and begin the investigation process.
You can also contact the Department of Labor’s Employee Benefits Security Administration. This is the federal agency that oversees the WHCRA. Their Kansas City office handles questions from Minnesota & their number is 816-426-5131. The EBSA’s job is to provide guidance for “participants” (i.e. people insured under group health plans, insurance companies and HMOs). They will talk with you about your issue and in some instances may negotiate on your behalf with your employer or insurance company.