The Women's Health and Cancer Rights Act (WHCRA) of 1998 is a federal law that requires health insurance companies and self-insured group health plans that cover mastectomies to also provide benefits for mastectomy-related services, including breast reconstruction surgery. If you're receiving benefits in connection with a mastectomy and you elect breast reconstruction surgery, WHCRA states that the insurer also must cover:

• Reconstruction of the breast on which the mastectomy was performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Prostheses (breast implants).
• Treatment for physical complications of the mastectomy, including lymphedema (swelling caused by an accumulation of lymph fluid in the arm).

Janet's Law

WHCRA is also known as Janet's Law, named after Janet Franquet, who was denied reconstructive surgery after a mastectomy. The Long Island, N.Y., woman was diagnosed with an aggressive form of breast cancer in 1997. Her insurer denied her breast reconstruction because it considered the surgery cosmetic rather than medically necessary. During a lengthy appeals process, which Franquet eventually won, her doctor performed the surgery for free.

Meanwhile, Franquet's plight drew the support of former New York Sen. Alfonse M. D'Amato, who had targeted more than $900 million in federal money for breast cancer research between 1982 and 1998. D'Amato sponsored WHCRA in Congress and helped pushed through the legislation, which was signed into law on Oct. 21, 1998.

How WHCRA works

WHCRA amended the Public Health Service Act and the Employee Retirement Income Security Act of 1974 (ERISA). It is administered by the U.S. Department of Health and Human Services and the U.S. Department of Labor (DOL). It does not require group health plans and individual insurers to cover mastectomies. Instead, it requires those plans and insurers that have elected to provide coverage for mastectomies to also pay for breast reconstruction surgery in connection with a mastectomy.

WHCRA does not prohibit plans and insurers from imposing deductibles or co-payments for benefits relating to breast reconstruction surgery following mastectomy. However, these deductibles or co-payments must be consistent with those charged for other benefits under the health plan.

It's against federal law for an insurer to deny you a policy or fail to renew your health insurance coverage solely for the purpose of avoiding WHCRA's requirements. In addition, insurers must not penalize your doctor for complying with WHCRA or provide financial incentives to induce your doctor to furnish care that is not consistent with WHCRA rules.

Although WHCRA covers most women with group health plans and individual insurance, the law does not apply to everyone, according to the DOL. If your employer is a church or state or local school district, and the plan is self-insured, your employer is exempt from WHCRA. Although these plans may indeed cover mastectomies, they do not have to cover breast reconstruction or implants.

State breast reconstruction laws sometimes apply

Some states require the same coverage for breast reconstruction that is legislated by WHCRA, but they also mandate minimum hospital stays in connection with a mastectomy.

If you obtained your group health coverage through your employer and your coverage is fully insured, you're entitled to the minimum hospital stay required by state law. However, if your group health plan is self-insured (your employer rather than an insurance company or HMO assumes the group's risk), then state law does not apply. In this case, only WHCRA applies and it does not require minimum hospital stays. To find out if your group health coverage is fully insured or self-insured, check your Summary Plan Description (SPD) or contact your plan administrator at work.

If you have an individual health insurance policy (not obtained through your employer), the DOL advises you to check with your state's insurance department to learn if state law applies. To find the contact information for your state insurance department, select your state from the pull-down menu marked "Insurance in your state" from the top of this page.

WHCRA notice requirements

WHCRA requires insurance companies and self-insured group health plans to notify plan members regarding coverage under the law. This notification is required upon enrollment and annually thereafter. The annual notice may be sent by itself or may be included in:

• 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.

To avoid duplication of notices, a group health plan can satisfy WHCRA notice requirements by contracting with another party that provides the required notice. For example, a self-insured group health plan will satisfy WHCRA notice requirements if an insurance company or HMO provides the notice that includes the required WHCRA information.