WHCRA and ACA FAQs: Key Takeaways

On October 21, 2024, new FAQs on the Affordable Care Act (ACA) and the Women’s Health and Cancer Rights Act (WHCRA) were issued, providing critical updates for group health plans, particularly in relation to breast reconstruction following a mastectomy. These updates are essential for human resources (HR) professionals and insurance brokers who oversee health plan compliance and employee benefits. 

Here are the key takeaways to ensure compliance with the ACA and WHCRA while maintaining comprehensive healthcare coverage for employees. 

What is the Women’s Health and Cancer Rights Act (WHCRA)? 

The WHCRA is a federal law designed to protect individuals undergoing mastectomies by ensuring that their group health plans cover breast reconstruction and related services. If a plan covers mastectomies, it must also provide coverage for: 

• Breast reconstruction surgery on the breast where the mastectomy was performed. 

• Symmetry surgery on the opposite breast to ensure a symmetrical appearance. 

• Prostheses, which are artificial replacements for the breast. 

• Treatment of complications, such as lymphedema resulting from the surgery. 

• Aesthetic flat closure, if chosen by the patient in consultation with their physician. 

Coverage must be provided in consultation with the patient and attending physician. It is also important to note that sponsors of self-funded, non-Federal governmental plans may elect to exempt those plans from (opt out of) certain PHS Act requirements, including WHCRA. See PHS Act section 2722(a)(2) and 45 CFR 146.180. 

WHCRA Compliance: Key Considerations for HR Professionals 

Employee Education
Employees may not be fully aware of their rights under WHCRA. It is important to ensure they understand that group health plans must cover all stages of breast reconstruction and related procedures after a mastectomy. Providing employees with clear and accessible resources about these rights helps improve awareness and satisfaction. 

Physician-Patient Consultation
HR teams should remind employees that the coverage provided under WHCRA is determined in consultation with their physician. The plan must cover the treatments agreed upon by both the patient and their doctor, ensuring that no services related to breast reconstruction are denied. 

Group Health Plan Review
Regularly reviewing group health plans for compliance with WHCRA is essential. Even if a health plan covers mastectomies, it must also include reconstructive services and associated treatments, ensuring employees receive the comprehensive care required by law. 

Real-World WHCRA Compliance Scenarios 

• Scenario 1: Aesthetic Flat Closure (See FAQs: Q7 for additional details)
  An employee opts for chest wall reconstruction with aesthetic flat closure after a mastectomy. Under WHCRA, the group health plan is required to cover this surgery. Ensuring compliance with this requirement supports employee recovery and builds trust. 

• Scenario 2: Preventive Care Cost-Sharing (See FAQs: Q6 for additional details)
  During a routine preventive colonoscopy, a polyp is removed from a patient. Because the procedure is classified as preventive, the plan should cover it without cost-sharing. Understanding how preventive services are classified helps ensure that employees are not burdened by unexpected costs. 

Preventive Services and Group Health Plans 

The Affordable Care Act (ACA) mandates that non-grandfathered group health plans cover certain preventive services without cost-sharing. These services include routine immunizations, breast cancer screenings, and HIV prevention medications such as Pre-Exposure Prophylaxis (PrEP). 

Recent updates to the 2023 U.S. Preventive Services Task Force (USPSTF) recommendations require that group health plans cover both oral and injectable formulations (two oral and one injectible) of PrEP, along with monitoring services, without cost-sharing. These updates underscore the importance of staying informed about evolving preventive service requirements. 

Ensuring Compliance with WHCRA and ACA 

• Update Benefits Documentation:
  Group health plans and employee benefits guides should be regularly updated to reflect the latest changes in WHCRA and ACA coverage. Ensuring employees have accurate information about their healthcare options reduces confusion and improves compliance. 

• Collaborate with Insurance Providers:
  HR professionals and insurance brokers should work closely with insurance carriers to verify that plans adhere to federal regulations. This collaboration ensures that employees are fully covered for services like breast reconstruction and preventive care. 

• Employee Training:
  Regularly training HR teams and benefits administrators ensures that employees receive correct information about their healthcare rights and coverage options. 

Conclusion 

The latest updates to the Affordable Care Act and WHCRA emphasize the need for group health plans to provide comprehensive healthcare coverage for individuals, particularly for breast reconstruction following mastectomy. HR professionals and insurance brokers play a vital role in ensuring compliance with these regulations, educating employees about their benefits, and maintaining up-to-date health plan offerings. 

Understanding and implementing these updates is crucial for supporting employee health and maintaining compliance with federal laws.