WOMEN’S HEALTH AND CANCER RIGHTS ACT AND HEALTH CARE COVERAGE
The American Cancer Association (ACS) states that “the Women’s Health and Cancer Rights Act (WHCRA) is meant to protect most women who opt for breast reconstruction after a mastectomy.” This Act signed into law on October 21, 1998, requires most group insurance plans that cover mastectomies to also cover breast reconstruction. In Ms. Jones’s case, her insurance company’s denial of coverage for the procedure does come as a surprise. One reason for this could be that Ms. Jones may not have asked for such a cover or would have been ignorant of this fact. However, it is mandatory that an insurance provider must notify their client under law, to reveal whether they are covered for breast reconstruction under the WHRCA when they enroll in their plan, year after year. Also, under the Act, all group health plans, insurance companies, and HMOs that offer mastectomy coverage must also provide coverage for reconstructive surgery after mastectomy. Therefore, as Ms. Jones is covered by an insurance provider that comes under the gambit of this Act, she has every right to seek legal compensation along with insurance coverage for this procedure.
However, there are a few exceptions to this law. “While most cases where people are insured and have protection under WHCRA, and as long as the insurance plan also covers medical and surgical benefits for mastectomies are there, they will be covered for such procedures. This law applies to those people who are covered under group health plans and persons with individual health insurance coverage” (HCFA, p.31). But WHCRA does not require health plans or issuers to pay for mastectomies. Also, if Ms. Jones was covered under certain church plans and government plans that does not cover for reconstructive surgery, she will have to pay for the procedure herself. The option open to Ms. Jones under WHCRA is to invoke the Health Insurance Portability and Accountability Act of 1996 (HIPAA), so that she does not lose her privileges under WHCRA to secure coverage. HIPAA helps people like Ms. Jones from being “discriminated from pre-existing condition exclusions, prohibits group health plans from discriminating by denying coverage or charging extra for coverage based on the past or present health issues, guarantees certain small employers and individuals who lose job-related coverage the right to purchase health insurance, and finally, guarantees in most cases, that employers or individuals who purchase health insurance can renew the coverage regardless of any health conditions of individuals covered under the insurance policy” (HCFA, p.2-3). .
When Mr. Roberts worked for a large health care organization, his health care insurance coverage for ten years must have been maintained by his employer under the group health plan, where the premium must have been 80% from employer, and the remaining 20% by him. However, when Mr. Roberts lost his job, the employer would have stopped paying the premium towards Mr. Robert’s health insurance, thereby putting his health care insurance coverage under threat. Given Mr. Robert’s condition, in addition to losing his position and with it his job-based health insurance coverage, it would be in his interest to “buy an individual plan through the Marketplace, or keeping his health insurance for a limited time through the COBRA continuation coverage” (HealthCare.gov, 2014). The reason for this is that once Mr. Robert lost his position in the company, his company would automatically stop paying the premium he was entitled to. While he was employed, his contribution may have been only 20% of the total premium payable to the insurance provider, and so once he lost his position, the company would stop further premium payments and he would have had to pay the entire premium had he chose to continue with it.
Under the individual Marketplace plan, should Mr. Robert lose his job and his job-based coverage, he could study various options available to him and learn whether he qualifies for a lower monthly premium. In addition to this, he could also understand whether “he qualifies for free or low-cost coverage from Medicaid or Children’s Health Insurance Program (CHIP)” (HealthCare.gov, 2014). The most important factor is that the COBRA coverage will allow Mr. Robert to keep his job-based plan through a continuous coverage option, as COBRA may allow Mr. Robert to keep his and his family’s employee health insurance for a limited time after his employment ends or lose coverage. However, if Mr. Robert continues with his COBRA continuation coverage, he will not be able to get a lower premium because of his status and this could be hard on his pocket.
However, Lee (2011), in Health, says that one should be guarded against any complacency as at the time of leaving a job for another, people tend to forget their health insurance cover, and end up in dir state when they need it. “If you’ve left your employer; whether voluntarily or involuntarily, take steps to stay covered by your insurer, especially if you have a chronic condition such as diabetes, heart disease, or cancer.” Such acts, she warns, “could break the coverage that could trigger a preexisting-condition exclusion, which could make all the difference in your ability to continue using the same doctors, especially if you are in the middle of receiving important treatment.”
References
ACS: American Cancer Association, (2014), Women’s Health and Cancer Rights Act, Web, Accessed January 3, 2014, from <http://www.cancer.org/treatment/findingandpayingfortreatment/managinginsuranceissues/womens-health-and-cancer-rights-act>
HCFA, (2000), Protecting your health insurance coverage: The Women’s Health and Cancer Rights Act (WHCRA), Web, Accessed January 3, 2014, from <http://www.cms.gov/Regulations-and-Guidance/Health-Insurance-reform/HealthInsReformforConsume/Downloads/protect.pdf>, p. 2-34
HealthCare.gov, (2014), What if I’m losing job-based insurance? Losing job-based coverage, Web, Accessed January 3, 2014, from <https://www.healthcare.gov/what-if-i-am-losing-job-based-insurance/>
Lee, J, (2011), Health: Stretch Your Healthcare Dollar, How to Keep Your Insurance Benefits When You Quit or Get Fired from Your Job, Web, Accessed on January 3, 2014, from <http://www.health.com/health/article/0,,20457013,00.html>
