KNOW YOUR RIGHTS
Patients have rights concerning their medical care including surgery. Knowledge of these rights is very helpful in navigating the patient process. Women also have specific rights related to mastectomy and breast reconstruction surgery.
Here you will find the text of the federal mandate which delineates specific rights, followed by a listing of each state whereby a law has been enacted related to mastectomy and/or breast reconstruction. If you have any questions about your patient rights or how your insurance may be impacted by these rights. Please call us.
WE ARE YOUR PATIENT ADVOCATE
Our expert staff has many years of experience working with insurance carriers to help patients obtain maximum coverage and maximum benefits. We understand patient rights and we want to help you navigate the process. Please contact us with any questions or to discuss the specifics of your individual case and your insurance coverage. We are here to serve you.
FEDERAL LAW
The U.S. federal Women’s Health and Cancer Rights Act (WHCRA), also known as Janet’s Law, helps protect patients who elect breast reconstruction in connection with mastectomy. The law is overseen by United States Departments of Labor and Health and Human Services. The law states:
As passed in H.R. 4328, the Omnibus Appropriations bill FY 99 Conference Report 105-825; Public Law: 105-277 (10/21/98)
TITLE IX–WOMEN’S HEALTH AND CANCER RIGHTS SEC. 901. SHORT TITLE. This title may be cited as the “Women’s Health and Cancer Rights Act of 1998”.
SEC. 902. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.
(a) In General.–Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section:
SEC. 713. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES.
(a) In General.–A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for–
(1) all stages of 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 all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter.
(b) Notice.–A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan shall provide notice to each participant and beneficiary under such plan regarding the coverage required by this section in accordance with regulations promulgated by the Secretary. Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the plan or issuer and shall be transmitted–
(1) in the next mailing made by the plan or issuer to the participant or beneficiary;
(2) as part of any yearly informational packet sent to the participant or beneficiary; or (3) not later than January 1, 1999; whichever is earlier.
(c) Prohibitions.–A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not–
(1) deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; and
(2) penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.
(d) Rule of Construction.–Nothing in this section shall be construed to prevent a group health plan or a health insurance issuer offering group health insurance coverage from negotiating the level and type of reimbursement with a provider for care provided in accordance with this section.
(e) Preemption, Relation to State Laws.–
(1) In general.–Nothing in this section shall be construed to preempt any State law in effect on the date of enactment of this section with respect to health insurance coverage that requires coverage of at least the coverage of reconstructive breast surgery otherwise required under this section.
(2) Erisa.–Nothing in this section shall be construed to affect or modify the provisions of section 514 with respect to group health plans.”.
(b) Clerical Amendment.–The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 note) is amended by inserting after the item relating to section 712 the following new item:
Sec. 713. Required coverage reconstructive surgery following mastectomies.”.
(c) Effective Dates.–
(1) In general.–The amendments made by this section shall apply with respect to plan years beginning on or after the date of enactment of this Act.
(2) Special rule for collective bargaining agreements.– In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers, any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this section shall not be treated as a termination of such collective bargaining agreement.
SEC. 903. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
nbsp; (a) Group Market.–Subpart 2 of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-4 et seq.) is amended by adding at the end the following new section:
SEC. 2706. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES.
The provisions of section 713 of the Employee Retirement Income Security Act of 1974 shall apply to group health plans, and health insurance issuers providing health insurance coverage in connection with group health plans, as if included in this subpart.”.
(b) Individual Market.–Subpart 3 of part B of title XXVII of the Public Health Service
Act (42 U.S.C. 300gg-51 et seq.) is amended by adding at the end the following new section:
SEC. 2752. REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES.
The provisions of section 2706 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.”.
(c) Effective Dates.–
(1) Group plans.–
(A) In general.–The amendment made by subsection (a) shall apply to group health plans for plan years beginning on or after the date of enactment of this Act.
(B) Special rule for collective bargaining agreements.– In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers, any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by the amendment made by subsection (a) shall not be treated as a termination of such collective bargaining agreement.
(2) Individual plans.–The amendment made by subsection (b) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after the date of enactment of this Act.
This Act may be cited as the Department of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 1999”.
(g) For programs, projects or activities in the Department of Transportation and Related Agencies Appropriations Act, 1999, provided as follows, to be effective as if it had been enacted into law as the regular appropriations Act: AN ACT Making appropriations for the Department of Transportation and related agencies for the fiscal year ending September 30, 1999, and for other purposes.
STATE LAWS
Alabama
Provides that federally funded and publicly funded state programs that provide coverage for mastectomy surgery shall also provide coverage for reconstruction of the breast. http://alisdb.legislature.state.al.us/ Conforms state law to federal standards. Provides that health care insurers providing medical and surgical benefits for mastectomies must comply with 42 U.S.C. 300gg-52 regarding coverage for reconstructive surgery following mastectomies. [Sec. 21.42.400] Conforms state law to federal standards. Provides that health care insurers providing medical and surgical benefits for mastectomies must comply with 42 U.S.C. 300gg-52 regarding coverage for reconstructive surgery following mastectomies. Provides that every health benefit plan that provides coverage for mastectomy surgery shall also provide coverage for reconstruction of the breast. [23-99-405] http://www.arkleg.state.ar.us/ Treatment for breast cancer shall include coverage for prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. [10123.8.(d)] http://www.leginfo.ca.gov/calaw.html Provides benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a non-diseased breast to produce asymmetrical appearance. [Sec. 38a-504(c)] http://www.cga.ct.gov/2007/rpt/2007-R-0703.htm Coverage available for (1) all stages of reconstruction of the breast on which the mastectomy was performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and physical complications of mastectomy, including lymphedemas. [§3563] http://delcode.delaware.gov/title18/c033/index.shtml Covers prosthetic devices and reconstructive surgery incident to mastectomy, including surgery to reestablish symmetry; surgery must be in a manner chosen by the treating physician. [627.6417] Coverage for breast reconstruction in connection with a mastectomy shall include (1) reconstruction of the breast upon which the mastectomy was performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and treatment for physical complications at all stages of mastectomy, including lymphedemas. [215 ILCS 5/356g] Covers prosthetic devices and all stages of reconstructive surgery, in the manner determined by the attending physician and patient, including reconstruction of the other breast to produce symmetry. [27-13-7-14] Covers breast reconstruction, including surgery of the other breast to produce a symmetrical appearance, prostheses and physical complications, in a manner determined in consultation with the attending physician and the patient. [40-2,166] http://www.kslegislature.org/ Provides coverage for breast reconstruction, including surgery of the other breast to produce asymmetrical appearance, prostheses and physical complications, in a manner determined in consultation with the attending physician and the patient. [304.18-0983] Includes coverage for reconstruction of the breast on which the mastectomy has been performed, coverage for surgery and reconstruction of the other breast to produce a symmetrical appearance, and coverage for prostheses and physical complications, all stages of mastectomy, including lymphedemas and such coverage shall be in a manner determined in consultation with the attending physician and the patient. [22:1077] http://www.legis.state.la.us/lss/lss.asp?doc=507910 Provides coverage for reconstruction of the breast on which surgery has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance if the patient elects reconstruction and in the manner chosen by the patient and the physician. [§2837-C(2)] http://janus.state.me.us/legis/ Requires coverage for reconstructive surgery resulting from a mastectomy, including surgery performed on a non-diseased breast to establish symmetry. [§15-815] [31.11.06.03] http://www.dsd.state.md.us/comar/31/31.11.06.03.htm Covers breast cancer rehabilitative services, delivered on an inpatient or outpatient basis, including reconstructive plastic surgery and physical therapy. [500.3616] Reconstructive surgery and prosthetic devices are covered after the attending physician has certified medical necessity. [500.3613] http://www.legislature.mi.gov/ Covers all reconstructive surgery incidental to or following injury, sickness or other diseases of the involved part, or congenital defect for a child. Specifically includes benefits for all stages of reconstruction following mastectomy, including surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses. Also specifies that limitations on reconstructive surgery do not apply to reconstructive breast surgery following medically necessary mastectomy. [62A.25] https://www.revisor.leg.state.mn.us/statutes/?id=62A.25 Covers prosthetic devices and reconstructive surgery necessary to achieve symmetry, as recommended by the oncologist or primary care physician. [376.1209] http://www.moga.mo.gov/statutes/c300-399/3760001209.htm Covers reconstructive surgery following a mastectomy resulting from breast cancer, including all stages of reconstructive surgery on the non-diseased breast to establish symmetry and costs of any prostheses. [33-22-135] http://data.opi.mt.gov/ Requires coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy. [44-797] http://www.unicam.state.ne.us/laws/statutes.php?statute=s4407097000 Covers at least two prosthetic devices and reconstructive surgery incident to mastectomy, including surgery to reestablish symmetry. [NRS 608.157] Covers breast reconstruction, including surgery and reconstruction of the other breast to produce asymmetrical appearance, in the manner chosen by the patient and physician. [417-D:2-b] http://www.gencourt.state.nh.us/ Covers reconstructive breast surgery, including coverage to achieve and restore symmetry, and provides benefits for prostheses. [ 17B:26-2.1a.] Covers breast reconstruction following mastectomy, including reconstruction on a healthy breast required to achieve reasonable symmetry, in the manner determined by the attending physician and the patient to be appropriate. [§3221] Provides coverage for reconstructive breast surgery, including all stages and revisions of surgery performed on a non-diseased breast to establish symmetry, and reconstruction of the nipple/areolar complex without regard to the lapse of time between mastectomy and reconstruction, as well as coverage for prostheses and physical complications in all stages of mastectomy, including lymphademas. [§58-51-62] Specifies that health insurance policies may not be issued or renewed in the state unless they provide the benefit provisions of the 1998 Federal Womens’ Health and Cancer Rights Act. [26.1-36-09.11] http://www.legis.nd.gov/ Covers reconstructive breast surgery performed as a result of a partial or total mastectomy, including all stages of reconstructive surgery performed within 2 years on a non-diseased breast to establish symmetry. [§36-6060.5.(D)] http://www2.lsb.state.ok.us/ Covers prosthetic devices and breast reconstruction, including surgery on the opposite breast to achieve symmetry, within six years of the mastectomy date. Additional legislation adds language consistent with federal law. Covers prosthetic devices and reconstructive surgery to restore and achieve symmetry incident to a mastectomy. Surgery must be performed within 18 months of the original mastectomy. [§27-18-39] Covers prosthetic devices and breast reconstruction, including the non-diseased breast, if determined medically necessary by the patient and attending physician with the approval of the insurer. [38-71-130] http://www.scstatehouse.net/code/t38c071.htm Covers all stages of reconstruction for the diseased breast, excluding lumpectomy, and procedures to restore and achieve symmetry between the breasts, in the manner chosen by the patient and physician, within 5 years of the reconstructive surgery on the diseased breast. [56-7-2507] Covers reconstruction of the breast incident to mastectomy, including procedures to restore and achieve symmetry, for contracts delivered, issued for delivery or renewed on or after Jan. 1, 1998. 1999 amendment conforms statute to federal law. [§1357.004] Follows the example of the federal statute by requiring coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy. [31A-22-630] http://le.utah.gov/~code/TITLE31A/htm/31A22_063000.htm Covers reconstructive breast surgery performed coincident with a mastectomy performed for breast cancer or following the mastectomy, and surgery performed to reestablish symmetry between the two breasts. [§ 38.2-3418.4] Covers reconstructive breast surgery if mastectomy resulted from disease, illness or injury, includes surgery to reestablish symmetry. [48.46.280] http://apps.leg.wa.gov/RCW/default.aspx?cite=48.46.280 Includes coverage for reconstruction of the breast on which mastectomy was performed and the opposite breast for symmetry; also provides coverage for prosthesis and complications as determined in consultation with attending physician and patient. [§33-15-4g] http://www.legis.state.wv.us/WVCODE/Code.cfm?chap=33&art=15#15 Covers breast reconstruction of the affected tissue incident to mastectomy and specifies that such surgery is not considered cosmetic. [632.895(13)(a)] http://www.legis.state.wi.us/statutes/Stat0632.pdf PATIENT BILL OF RIGHTS In addition to specific rights relating to mastectomy and breast reconstruction, patients have certain rights regarding medical care. Please see the Patient Bill of Rights as adopted by New York and New Jersey. Each medical center where we provide services may also provide their own copy of Patients Bill of Rights. Patient Bill of Rights for the State of New York State of New Jersey Rights of Patients LawAlaska
Arizona
Arkansas
California
Connecticut
Delaware
Florida
Illinois
Indiana
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Oklahoma
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Washington
West Virginia
Wisconsin