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Federal Women's Health
and Cancer Rights Act of 1998
The federal women's Health and Cancer
Rights Act of 1998 requires that benefits must be provided for:
Reconstruction of a surgically removed
breast;
Surgery and reconstruction of the other
breast to produce a symmetrical appearance; and
Prostheses and treatment for physical
complications from all stages of mastectomy, including lymphedemas.
These benefits are subject to applicable
terms and conditions under your health plan, including copayments,
deductible, and coinsurance provisions. They are also subject to
medical insurance limitations and exclusions.
This notification is a requirement of
the act.
*The following information was
collected from the Department of Labor Website at www.dol.gov/dol/pwba/public/pubs/womhlth.htm.
The Women’s Health and Cancer Rights Act of 1998:
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. term paper writing services
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. custom essay
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.
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