Understanding WHCRA: Your Legal Right to Breast Cancer Coverage

The Women's Health and Cancer Rights Act guarantees your coverage. Here's what it means for you.

If you've had a mastectomy, federal law is on your side. The Women's Health and Cancer Rights Act, known as WHCRA, is one of the most important pieces of legislation for breast cancer survivors, yet many women don't know it exists. Understanding WHCRA coverage can save you thousands of dollars and ensure you get the products and care you're entitled to.

Let me explain what WHCRA means for you in plain language.

What Is WHCRA?

The Women's Health and Cancer Rights Act was signed into law in 1998. It applies to group health plans and health insurance companies that cover mastectomies. The law says that if your plan pays for mastectomy, it must also cover:

• Reconstruction of the breast on which the mastectomy was performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
• Prostheses (external breast forms)
• Treatment of physical complications of mastectomy, including lymphedema

This coverage must be provided in a manner determined in consultation with your attending physician and you. The insurance company cannot impose penalties or inconsistent coverage for choosing these benefits.

Who Does WHCRA Cover?

WHCRA applies to most women with health insurance. It covers group health plans offered through employers, individual health insurance plans purchased on the marketplace, COBRA continuation coverage, and state and local government employee plans.

WHCRA does not apply to church plans that have not opted into ERISA or certain government plans. However, many states have their own laws that provide similar or additional protections.

What Products Are Covered?

Under WHCRA, your insurance should cover external breast prostheses, which are silicone or lightweight breast forms. Coverage typically includes one prosthesis per side every one to two years, depending on your specific plan.

Mastectomy bras are covered as the garment needed to hold the prosthesis. Most plans cover two to six bras per year.

Post-surgical camisoles and bras worn immediately after surgery are usually covered as well.

Some plans also cover swim forms, adhesive forms, and sleep bras, though this varies by carrier.

WHCRA vs. Other Laws

WHCRA works alongside other federal and state protections. The Affordable Care Act (ACA) strengthened these protections by requiring all marketplace plans to cover mastectomy-related prostheses as essential health benefits.

Medicare Part B provides coverage for external breast prostheses and mastectomy bras with a valid prescription. Medicaid coverage varies by state, but most state Medicaid programs cover breast prostheses.

Many states have enacted their own mastectomy coverage laws that go beyond federal requirements. Florida, for example, requires coverage for breast prostheses and mandates that insurers cannot impose deductibles specific to mastectomy benefits.

How to Use Your WHCRA Benefits

Step 1: Get a Prescription

Your surgeon, oncologist, or primary care doctor needs to write a prescription for external breast prosthesis and mastectomy bras. The prescription should include a diagnosis code and a statement of medical necessity.

Step 2: Verify Your Coverage

Call your insurance company and ask specifically about your mastectomy product benefits under WHCRA. Ask how many prostheses and bras are covered, what your copay or coinsurance will be, whether you need pre-authorization, and whether there are in-network provider requirements.

Step 3: Visit a Certified Fitter

A board-certified mastectomy fitter like me can bill your insurance directly in most cases. This means you pay only your copay at the time of service, and we handle the rest.

Step 4: Keep Records

Save your prescription, receipts, EOB statements, and any correspondence with your insurance company. You'll need these for annual renewals and any appeals.

What If Your Insurance Denies Coverage?

Denials happen, but they're often wrong. If your claim is denied, first request the denial in writing with the specific reason. Then file a first-level appeal, citing WHCRA and including your prescription and any missing documentation.

If the first appeal fails, request an external review. You can also contact your state's department of insurance for assistance. The Department of Labor enforces WHCRA for employer-sponsored plans and can help if your employer's plan is not complying.

Common Misconceptions

"My insurance only covers reconstruction, not prostheses." This is incorrect. WHCRA explicitly covers both reconstruction and prostheses. If your plan covers mastectomy at all, it must cover prostheses.

"I can only get coverage if I choose not to have reconstruction." Wrong. You can use prosthesis benefits regardless of your reconstruction status. Many women use prostheses while waiting for reconstruction, between surgeries, or as an alternative.

"WHCRA only applies for a limited time after surgery." No. There is no time limit on WHCRA benefits. Whether your mastectomy was last month or twenty years ago, you're entitled to coverage.

Know Your Rights

You've been through enough. You shouldn't have to fight for coverage the law guarantees. If you're having trouble with insurance, reach out to me. I've helped hundreds of women navigate the system, and I'm happy to help you too.

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