The Women’s Health and Cancer Rights Act (WHCRA) of 1998 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 drew the support of former New York Sen. Alfonse M. D’Amato, who sponsored WHCRA in Congress and helped pushed through the legislation, which was signed into law on Oct. 21, 1998.
WHCRA is a federal law that requires all sponsored group health plans, insurance companies, individual policies and health maintenance organizations offering medical and surgical benefits with respect to a mastectomy must also offer coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. WHCRA ensures that your coverage includes:
1. Reconstruction of the breast on which the mastectomy was performed.
2. Surgery and reconstruction of the other breast to create a symmetrical appearance.
3. Prostheses (breast implants).
4. Treatment for physical complications of the mastectomy, including lymphedema (swelling caused by an accumulation of lymph fluid in the arm).
WHCRA applies to three types of health insurance coverage, according to the Department of Health and Human Services:
1. Self-funded group plans
2. Fully insured group plans
3. 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.
Some state laws provide more protections than WHCRA. To learn more, contact your state’s insurance department.
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