Make your own free website on Tripod.com
Mikki630's Breast Cancer Chronicle
Women's Health & Cancer Rights Act of 1998
Home
About Me
About Breast Biopsies
Drains
Understanding your Pathology Report
Ports for Chemotherapy
Lymphedema
Our Experience
Attitude is EVERYTHING
Your Kids, Your Cancer
Women's Health & Cancer Rights Act of 1998
Paget's Disease of the Nipple
The Breast Self Exam (BSE)
Calcifications
Breast Cysts
Fibroadenomas
Nipple Discharge
Understanding Fibrocystic Breasts
My Journal
LINKS

Questions and Answers

The Women’s Health and Cancer Rights Act (Women’s Health Act) was signed into law on October 21, 1998. The law includes important new protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy. The Women’s Health Act 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 and Health and Human Services.

The following information is intended to provide general guidance on frequently asked questions about the Women’s Health Act provisions that amend ERISA .

I’ve been diagnosed with breast cancer and plan to have a mastectomy. How will the Women’s Health Act affect my benefits?

Under the Women’s Health Act, 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.

Will the Women’s Health Act require all group health plans, insurance companies, and HMOs to provide reconstructive surgery benefits?

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.

Under the Women’s Health Act, may group health plans, insurance companies or HMOs impose deductibles or coinsurance requirements for reconstructive surgery in connection with a mastectomy?

Yes, but only if the deductibles and coinsurance are consistent with those established for other benefits under the plan or coverage.

When do these requirements take effect?

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 PHS Act within the jurisdiction of the Department of Health and Human Services.

My State requires the coverage for breast reconstruction that is required by the Women’s Health Act and also requires minimum hospital stays in connection with a mastectomy that is not required by the Women’s Health Act. If I have a mastectomy and breast reconstruction, am I also entitled to the minimum hospital stay?

It depends. The federal Women’s Health Act permits State law protections to apply to certain health coverage. State law protections apply if the State law is in effect on October 21, 1998 (date of enactment of the Women’s Health Act) and the State law requires at least the coverage for reconstructive breast surgery that is required by the federal Women’s Health Act.

If State law meets these requirements, then it applies to coverage provided by an insurance company or HMO (“insured” coverage). If you obtained your coverage through your employer and your coverage is “insured,” you would be entitled to the minimum hospital stay required by State law. If you obtained your coverage through your employer but your coverage is not provided by an insurance company or HMO (that is, your employer “self-insures” your coverage), then State law does not apply. In that case, only the federal Women’s Health Act applies and it does not require minimum hospital stays. To find out if your group health coverage is “insured” or “self-insured,” check your Summary Plan Description (SPD) or contact your plan administrator.

If you obtained your coverage under a private individual health insurance policy (not through your employer), check with your State Insurance Commissioner’s office to learn if State law applies.

Notice Requirements under the Women’s Health Act

The Women’s Health Act also requires that group health plans, insurance companies, and HMOs provide two notices regarding the coverage required by the Women’s Health Act. The following information is intended to provide general guidance on frequently asked questions about these notice requirements under the provisions of the Women’s Health Act that amend ERISA.

Are all group health plans, and their insurance companies and HMOs, required to satisfy the notice requirements under the Women’s Health Act?

All group health plans, and their insurance companies or HMOs, that offer coverage for medical and surgical benefits with respect to a mastectomy are subject to the notice requirements under the Women’s Health Act.

What are the notice requirements under the Women’s Health Act?

There are two separate notices required under the Women’s Health Act. The first notice is a one-time requirement under which group health plans, and their insurance companies or HMOs, must furnish a written description of the benefits that the Women’s Health Act requires. The second notice must also describe the benefits required under the Women’s Health Act but it must be provided upon enrollment in the plan and it must be furnished annually thereafter.

How must these notices be delivered to participants and beneficiaries?

These notices must be delivered in accordance with the Department of Labor’s disclosure regulations applicable to furnishing summary plan descriptions. (29 CFR 2520.104b-1). For example, the notices may be provided by first class mail or any other means of delivery prescribed in the regulation. It is the view of the Department that a separate notice would be required to be furnished to a group health plan beneficiary where the last known address of the beneficiary is different than the last known address of the covered participant.

When must the initial one-time notice under the Women’s Health Act be furnished to participants and beneficiaries?

The one-time notice must be furnished as part of the next general mailing (made after October 21, 1998) by the group health plan and their insurance companies or HMOs, or in the yearly informational packet sent out regarding the plan, but in no event can the one-time notice be furnished later than January 1, 1999.

Does a group health plan that already provided the coverage required by the Women’s Health Act have to send out the initial one-time notice?

A group health plan that, prior to the date of enactment (October 21, 1998), already provided the coverage required by the Women’s Health Act (and continues to provide such coverage) will have satisfied the initial one-time notice requirement if the information required to be provided in the initial notice was previously furnished to participants and beneficiaries in accordance with the Department’s regulations on disclosure of information to participants and beneficiaries.

What information must be included in the Women’s Health Act notices?

The notices must describe the benefits that the Women’s Health Act requires the group health plan, and its insurance companies or HMOs, to cover. The notice must indicate that, in the case of a participant or beneficiary who is receiving benefits under the plan in connection with a mastectomy and who elects breast reconstruction, the coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

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.

The notice must also describe any deductibles and coinsurance limitations applicable to such coverage. Under the Women’s Health Act, coverage of breast reconstruction benefits may be subject only to deductibles and coinsurance limitations consistent with those established for other benefits under the plan or coverage.

Must a group health plan, and their insurance companies or HMOs, furnish separate notices under the Women’s Health Act?

No. To avoid duplication of notices, a group health plan or its insurance companies or HMOs, can satisfy the notice requirements of the Women’s Health Act by contracting with another party that provides the required notice. For example, in the case of a group health plan funded through an insurance policy, the group health plan will satisfy the notice requirements with respect to a participant or beneficiary if the insurance company or HMO actually provides the notice that includes the information required by the Women’s Health Act.