I'm looking for information on the Women's Health Act of October 1998. Does this law protect post-reconstruction breast cancer patients as well as new victims? I have complications from my original mastectomy and reconstruction. I suspect my insurance company is not following the law. Can you clarify for me just what the law says?

Lisa

During the final days of its 1998 session, Congress passed a massive budget bill to appropriate funds to nearly every component of government. Included in this mammoth piece of legislation was the Federal/mastectomy Women's Health and Cancer Rights Act of 1998 (WHCRA), a pet project of former Senator Alfonse D'Amato (R-NY). The WHCRA, effective for health plan years beginning on or after October 21, 1998, mandates broad coverage for breast reconstruction and complications of mastectomy surgery.

According to the WHCRA, all group and individual health insurance plans that include coverage for medical and surgical benefits for a mastectomy shall provide to those receiving benefits in connection with a mastectomy and who elect breast reconstruction the following:

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 in a manner determined in consultation with the attending physician and the patient.
   

Group health plans that fall under the Employee Retirement Income Security Act (ERISA) are regulated at the federal level by the U.S. Department of Labor (DoL). Following passage of the WHCRA, the Labor Department released guidance for employers, insurers and consumers regarding the requirements of the WHCRA. The following paragraphs are excerpted from a Q&A document published by the DOL:

"Under the [WHCRA], group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Coverage includes reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.

"All group health plans, and their insurance companies or HMOs, that provide coverage for medical and surgical benefits with respect to a mastectomy are subject to the requirements of the Women's Health Act.

"The reconstructive surgery requirements apply to group health plans for plan years beginning on or after October 21, 1998. To find out when your plan year begins, check your Summary Plan Description (SPD) or contact your plan administrator."

"These requirements also apply to individual health insurance policies offered, sold, issued, renewed, in effect, or operated on or after October 21, 1998. These requirements were placed in the Public Health Service Act within the jurisdiction of the Department of Health and Human Services."

The WHCRA does allow group health plans, insurance companies or HMOs to impose deductibles or coinsurance requirements for reconstructive surgery in connection with a mastectomy, but only if the deductibles and coinsurance are consistent with those established for other benefits under the plan or coverage.

You can find out more about the specific benefits of your health plan by reading the health plan description supplied by your employer or by consulting your employer's health plan administrator. If you have non-group coverage and your policy is unclear to you, call your insurance broker or the policy benefits department of your insurance company.