I just read the Women's Health and Cancer Rights Act of 1998, where it states that insurance providers that provide medical and surgical benefits for mastectomy now must provide coverage for reconstruction of the breast on which a mastectomy has been performed. My question is: Will the current insurance the patient carries cover reconstruction of the breast on a mastectomy that was performed before the patient was covered by the current insurance? She was not covered by insurance at all at the time of the mastectomy.

M.J.

At the very end of its 1998 session, Congress passed a massive budget bill affecting all levels of government spending. This was a "must-pass" bill and, as such, attracted several amendments containing popular legislative initiatives not necessarily related to the federal budget. A late addition to that bill was the Women's Health and Cancer Rights Act of 1998 (WHCRA), sponsored by Republican Senator Alfonse D'Amato of New York. This is the bill that expanded mastectomy treatment for people with health plans that included mastectomy benefits.

Your brief summary of the bill is only partially correct. Not only does the WHCRA provide for reconstruction of the breast on which a mastectomy has been performed, but it also covers, according to the law, "surgery and reconstruction of the other breast to produce a symmetrical appearance."

The WHCRA applies to all health plans, including self-funded employer plans, large and small group plans, and individual (non-group) coverage. The sections of federal law governing health insurance were amended by the WHCRA, in part, with the following:

"(a) IN GENERAL - A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for...

"(1) Reconstruction of the breast on which the mastectomy has been performed;

"(2) Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

"(3) Prostheses and physical complications at all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter."

This coverage was effective for all health plans following the date the bill was signed into law -- October 21, 1998. The coverage described in the law was in effect on a health plan renewal only after that date. This means that if a person were covered by a group health plan that renews every January 1, the new coverage did not go into effect until that date. In other words, the coverage was not retroactive to any surgeries performed before the effective date.

There is no requirement for an insurer to cover breast reconstruction for a mastectomy that was performed before the effective date of the law, before the current coverage was in effect, or while the person was uninsured. So, in a case where the mastectomy was performed before the effective date of the required coverage, the law does not apply. In a case where a person was not covered by insurance at the time of the mastectomy, or the person had health insurance that did not include benefits for a mastectomy, the law also does not apply.

The U.S. Department of Labor (DOL) has published a "question & answer" document covering several federal laws related to health insurance. It is available on the DOL website. Several states have also passed mastectomy requirements that may add to the benefits guaranteed by federal law. Call your state's Department of Insurance for more information.