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Health insurance coverage for breast reconstruction surgery after mastectomy

 

The Women's Health and Cancer Rights Act (WHCRA) of 1998 is a federal law that 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 health insurance benefits in connection with a mastectomy and you elect breast reconstruction surgery, WHCRA states that the insurer also must cover:

WHCRA is also known as Janet's Law, named after Janet Franquet, who was denied reconstructive surgery after a mastectomy in 1997.

  • Reconstruction of the breast on which the mastectomy was performed.
  • Surgery and reconstruction of the other breast to create 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 insurance company 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.

WHCRA applies to three types of health insurance coverage, according to the Department of Health and Human Services:

  • Self-funded group plans
  • Fully insured group plans
  • Individual health insurance plans

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 or individual health insurance companies to cover mastectomies. Instead, it requires those plans and insurers that already 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 a 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 a health insurance company 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. It does not apply to state high-risk pools either. Although these plans may indeed cover mastectomies, they do not have to cover breast reconstruction or implants.

State health insurance laws sometimes apply

Some states require the same coverage for breast reconstruction that is legislated by WHCRA and 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 (meaning 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 or contact your plan administrator at work.

Also, keep in mind that some state laws provide more protections than WHCRA. To learn more, contact your state's insurance department.

WHCRA requires insurance companies to notify plan members regarding coverage under the law. This notification is required upon enrollment and annually thereafter.

The Henry J. Kaiser Family Foundation provides the below list of states that require broader coverage than the requirements under WHCRA.

State

Breast
Reconstruction
Mandates?

Details:

Reconstructive surgery includes augmentation mammoplasty, reduction mammoplasty and mastopexy

Alabama No N/A
Alaska Yes WHCRA coverage applies to any policy that covers mastectomies
Arizona Yes Any policy that covers mastectomy must cover reconstruction
Arkansas Yes WHCRA coverage applies to any policy that covers mastectomies
California Yes Any policy that covers mastectomy must cover reconstruction
Colorado No N/A
Connecticut Yes Any policy that covers mastectomy must cover reconstruction
Delaware Yes Any policy that covers mastectomy must cover reconstruction
District of Columbia Yes Any policy that covers mastectomy must cover reconstruction
Florida Yes Any policy that covers mastectomy must cover reconstruction
Georgia No N/A
Hawaii No N/A
Idaho No N/A
Illinois Yes If no malignancy found, reconstruction must be performed within two years
Indiana Yes Any policy that covers mastectomy must cover reconstruction
Iowa No N/A
Kansas Yes Any policy that covers mastectomy must cover reconstruction
Kentucky Yes WHCRA
Louisiana Yes Any policy that covers mastectomy must cover reconstruction
Maine Yes Any policy that covers mastectomy must cover reconstruction
Maryland Yes Any policy that covers mastectomy must cover reconstruction
Massachusetts No N/A
Michigan Yes Any policy that covers mastectomy must cover reconstruction
Minnesota Yes Any policy that covers mastectomy must cover reconstruction
Mississippi No N/A
Missouri Yes Any policy that covers mastectomy must cover reconstruction
Montana Yes Any policy that covers mastectomy must cover reconstruction
Nebraska Yes Any policy that covers mastectomy must cover reconstruction
Nevada Yes Any policy that covers mastectomy must cover reconstruction
New Hampshire Yes Any policy that covers mastectomy must cover reconstruction
New Jersey Yes Any policy that covers mastectomy must cover reconstruction
New Mexico No N/A
New York Yes Any policy that covers mastectomy must cover reconstruction
North Carolina Yes Any policy that covers mastectomy must cover reconstruction
North Dakota Yes Women's Health and Cancer Rights Act coverage requirements apply to any policy that covers mastectomies
Ohio No N/A
Oklahoma Yes Any policy that covers mastectomy must cover reconstruction
Oregon Yes Any policy that covers mastectomy must cover reconstruction
Pennsylvania Yes Any policy that covers mastectomy must cover reconstruction
Rhode Island Yes Any policy that covers mastectomy must cover reconstruction
South Carolina Yes Any policy that covers mastectomy must cover reconstruction
South Dakota No N/A
Tennessee No N/A
Texas Yes Any policy that covers mastectomy must cover reconstruction
Utah Yes Any policy that covers mastectomy must cover reconstruction
Vermont No N/A
Virginia Yes Any policy that covers mastectomy must cover reconstruction
Washington No N/A
West Virginia Yes Any policy that covers mastectomy must cover reconstruction
Wisconsin Yes Any policy that covers mastectomy must cover reconstruction
Wyoming No N/A

Source: Kaiser State Health Facts, State Mandated Benefits, Reconstructive Surgery after Mastectomy, 2008, and Health Policy Tracking Service, Thomson West

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