Reconstructive Surgery Fully Covered After Mastectomy
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
The Professional Musicians Local 47 and Employers Health and Welfare Fund (“the Fund”) purchases health insurance benefits through Health Net of California and provides you with this notice as required by the Women’s Health and Cancer Rights Act of 1988 (WHCRA).
In compliance with WHCRA, Health Net provides benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and for complications resulting from a mastectomy, including lymph edemas.
Although reconstructive surgery after a mastectomy is generally a covered procedure, some procedures are, of course, classified as cosmetic and, therefore, not covered.
Under the WHCRA, and in the case of a participant or beneficiary who is enrolled with and receiving benefits from the Fund, in connection with a mastectomy and elects reconstruction, federal law requires coverage, in a manner determined in consultation with the attending physician and the patient, for:
• reconstruction of the breast on which the mastectomy is performed;
• complications at all stages of a mastectomy, including lymphedemas;
• all any necessary prostheses required as a result of the mastectomy; and
• surgery and reconstruction of the other breast to produce a symmetrical appearance.
This coverage is subject to the Fund’s co-payments schedule or any applicable deductibles. For more information on this and other benefits please call PacFed Benefit Administrators at (818) 243-0222.
NEWBORN AND MOTHERS HEALTH PROTECTION ACT OF 1996 (NMHPA)
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). The Fund, through the insurance benefits provided by Health Net, fully complies with the NMHPA.
Keep an eye out for our next update, in which we will review the Health Care Reform Act, the various implementing regulations just issued by the Federal Government and how all of this will impact you and the Fund.