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Employers Must Tell Employees About Health-Plan Mastectomy Coverage

Here's a sample notice for you to use.

December 1, 1999
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Related Topics: Medical Benefits Law, Benefits
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Issue: Your company's health plan offers coverage for mastectomies. Last year, you heard about a new law that requires you to tell your employees about their rights relating to post-mastectomy coverage and you did so during open enrollment. What, if any, notice obligations do you have during open enrollment season this year?

Answer: Under recently issued guidance, the U.S. Departments of Labor and Health and Human Services (DOL/HHS) have clarified what type of annual notice group health plans need to provide for employees under the Women's Health and Cancer Rights Act of 1998 (WHCRA). Under WHCRA, health plans that offer mastectomy coverage must also offer coverage for post-mastectomy reconstructive surgery. The WHCRA also requires employers to notify employee participants of their rights under WHCRA at the time of enrollment in the plan as well as every subsequent year.

How to provide notice.
According to the DOL/HHS, when providing the annual notice, employers must use measures "reasonably calculated to ensure actual receipt of the annual notice by plan participants." Notice must be sent by a method, such as first-class mail or via e-mail, that is "likely to result in full distribution."

The annual notice under WHCRA may be sent by itself or it may be included in another plan mailing such as open enrollment materials, a union or benefits newsletter, or official plan documents (such as the summary plan description, summary of material modifications, or a summary annual report). Annual notice can be delivered to employees at any time during the plan year.

To avoid duplicate notices, an employer/group health plan can satisfy the annual notice requirements by contracting with another party, such as an insurance company or HMO, which then provides the required notice.

Contents of notice.
Although WHCRA does not require employers to use the same notice to meet its enrollment notice obligations and its annual notice obligations, they may satisfy the annual notice rule by using the enrollment notice and delivering it to participants annually. Instead of distributing the enrollment notice annually, however, employers may choose annually to distribute a notice informing participants of the following:

  • availability of benefits for the treatment of mastectomy-related services, including reconstructive surgery, prosthesis, and lymphedema under the plan; and
  • information (such as telephone number or Web URL address) on how to obtain a detailed description of the mastectomy-related benefits available under the plan.

Sample model annual notice under WHCRA.
Language such as the following may be used to alert employees annually to their rights under WHCRA.

IMPORTANT NOTICE ABOUT YOUR RIGHTS UNDER YOUR GROUP HEALTH PLAN
Did you know that your plan, as required by the Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema)? Keep this notice for your records and call your Plan Administrator [insert phone number] for more information.

Source: CCH Incorporated is a leading provider of information and software for human resources, legal, accounting, health-care and small-business professionals. CCH offers human resource management, payroll, employment, benefits, and worker-safety products and publications in print, CD, online and via the Internet. For more information and other updates on the latest HR news, check our Web site at http://hr.cch.com.

The information contained in this article is intended to provide useful information on the topic covered, but should not be construed as legal advice or a legal opinion.

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