Why insurance must pay for breast implants.

Even though it’s been on the books for over 15  years, many companies and people are not aware of the law that mandates group health plans, insurance companies and HMO to pay for breast implants for women who are treated for breast cancer.  The Women’s Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breasts rebuilt (reconstructed) after a mastectomy.  WHCRA was signed into law on October 21, 1998.  WHCRA amended the Employee Retirement Income Security Act of 1974 (ERISA) and the Public Health Service Act (PHS Act) and is administered by the Departments of Labor (DOL) and Health and Human Services (HHS).

Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) that offer 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 and breast implants on the place which the mastectomy was performed.  WHCRA also provides the woman 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 lymph edemas.

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 WHCRA.  http://www.dol.gov/ebsa/publications/whcra.html

All applicable groups, insurance and HMO’s must provide and deliver (in the manners prescribed by the DOL) notices of women’s WHCRA rights under WHCRA. The WHCRA notice must be provided annually and at the time of enrollment in the plan.  Failure to provide the notice may result in legal action brought by a participant and an ERISA $110 per day fine may be assessed.  If you have not already done so, check your organization’s, insurance, or HMO’s plan for WHCRA compliance.

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