Individual health policies are NOT covered under WHCRA

VJSL8

I found a loophole in the Women's Health and Cancer Rights Act of 1998. I have an individual policy and I've been fighting with Blue Cross about the last bill for my reconstruction which they denied. To make a very long story short, those of us with an individual policy (instead of a group policy through work) are NOT covered. In other words, insurance companies have the right to deny us coverage for reconstruction. This has become my soapbox issue now--to get WHCRA amended to cover ALL women.

Just curious if there are others who have run into this discrimination?  

peggy_j

Wow that's terrible. I see you live in Ca. Not sure if you know but the state of CA had sued these insurance companies a few yrs back (for rescinding policies) so if you think there's any monkey business you may want to check with the state. Last spring I found a state agency that is like a consumer info line on health insurance ( found it on the state's website.) the guy I talked to was smart and surprisingly helpful.

PinkHeart

I'm just curious -- Is it also denied under medicare?

I have good insurance right now and need revisions to my reconstruction.  My good insurance expires in June.  I saw my surgeon today and he has an ego problem and says my breasts are fine.  They are two different cup sizes and one is sewn down in such a way that I have pain.  The other has waves and several lumps in it because I had a massive hemotoma two days after surgery and had to be opened up again to have it surgically removed.  This is from a major institution.  This has been the worse part of having breast cancer -- a PS with no bedside or compassion.  They say they "might" be able to do something to help me in July -- a month after my insurance is gone.

scuttlers

Quoted from the: http://www.dol.gov/ebsa/publications/whcra.html





My health coverage is through an individual policy, not through an employer. What rights, if any, do I have under WHCRA?

Health insurance companies and HMOs are generally required to provide WHCRA benefits to individual policies too. These requirements are generally within the jurisdiction of the State insurance department. Call your State insurance department or the Department of Health and Human Services toll free at 1.877.267.2323, extension 61565, for further information.

VJSL8

Scuttlers-I have done all that and I have talked to an attorney at the Cancer Legal Resource Center and as crazy as it seems, individual policies are NOT covered by the WHCRA, only group policies. I have already sent letters to my representative, both senators, Kathleen Sebelius, President Obama (as well as every Federal and State regulatory agency I could think of).

copied from your link:  you may be entitled to special rights

The law says you may be covered, not that you will be. If you notice this was under the Dept of Labor--ie employment. If you actually read the Act--it omits the word "individual", this is just a small technicality but gives insurance companies the right to not have to cover these services for women like me. 

While my individual policy covered most of my reconstruction, by law, they did not have to. I will be working on getting this changed, it's just not right.  

PinkHeart

VJ~

May I ask what part of reconstruction they would not cover?  I would be asking why they approved and paid for your reconstruction all along the way and dinged you at the end. 

My heart goes out to you and all BC patients dealing with the insurance nightmare.  IMO the anxiety of fighting over insurance is damaging to a human's psychological health and healing -- so if the insurance company pays for counseling -- than I would go for it.  Even without insurance hassles, many BC patients seek help through counseling.  The insurance mess pushes me over the edge.  I shake when I get an EOB in the mail.  I appeal everything and usually win.  It's been very detrimental to my health doing this (I have heart probs, too.), but IMO the insurance company picks things to deny and hopes people just pay them, because many are too sick to understand or time and energy to appeal.

VJSL8

They wouldn't pay for the tattoos (affectionally known as my tit-tats) so we are not talking about a huge amount of money, $1200.

I agree PinkHeart. I go to the counseling groups at Gildas--(wonderful organization and I feel so lucky to have one in my community). I have heard some absolute horror stories from other cancer patients and you are right, most of the time, people are too sick to fight against the injustice, which is why I feel this is important enough for me to fight for those who can't. 

It's a long story and I have to give credit to the asst of my PS, Jeanni--she is the one that kept re-submitting it for coverage. Blue Cross denied it a couple of times, each time for different reasons but what it boiled down to was that even though it is a "covered" procedure, there are NO approved providers and they won't cover it if the provider isn't approved. Classic catch-22.  I have asked for a list of approved providers and I was told that I would have to supply a name and then blue cross would tell me if they were an approved provider or not--they refused to give me the names of who IS approved. Now blue cross is calling the tit-tats "surgery" which can only be done by a surgeon. 

IF I had a HMO or a group policy, then my provider IS approved and this would have been covered. 

I know how incredible this sounds. And what's even more incredible is that I haven't met my deductible for last year, so even if blue cross approved it (and the provider), it would just go against my deductible. But now that I know about this loophole, I will continue to fight and advocate to get this law changed. 

I am a Legislative Ambassador for the American Cancer Society's Cancer Action Network and I've also talked to them. It is easier to get a law amended than to pass a new law, so hopefully this won't be too difficult. My representative, Mary Bono-Mack, her office has already called me and has forwarded my information to her legislative committee. Both of my Senators-Feinstein and Boxer are huge advocates for cancer patients (Boxer even sent a letter around congress to support NOT cutting cancer funding when the super committee was meeting). so I'm hoping for their support too. 

ibcmets

I also heard coverage was dependent on where you got the tats done.  I assumed the tatooing would not be covered because they consider this cosmetic.  Sometimes you can get it covered if it's in an approved medical setting.

Terri

VJSL8

The person who did the tats is an approved provider for Blue Cross but ONLY for HMO's and group policies, not for individual coverage. On my last EOB, Blue Cross considers it "surgery". 

LisaAlissa

You say they won't tell you who is an "approved provider?"  

Do you have that in writing?  If not, send a written request to your insurer for a list of approved providers.  If you don't get a list of providers within a reasonable distance within a reasonable time, get in touch with your state insurance department/commission.

You should be able to get help there.

HTH,

LisaAlissa 

VJSL8

I've already sent letters to the state insurance department and today I just got a letter from them: 

"We have closed your complaint with us because we have determined that your issue concerns a matter outside our jurisdiction" 

I want to thank everybody for their suggestions. This has been going on for 1 year and I've done my due diligence, I HAVE NO RIGHTS.  This is a FEDERAL law, not state. Blue Cross doesn't even have to pay for any reconstruction for any individual policies, they do but they don't have to. 

I've talked to cancer disability attorneys and this is a loophole and the law needs to be changed. Here is the list of people that I have contacted (if you think of someone else, please let me know):

 CC: President Barack Obama

Senator Diane Feinstein

Senator Barbara Boxer
Congresswoman Mary Bono-Mack
Kathleen Sebelius, Secretary of Health and Human Services
State of California, Department of Insurance
Department of Managed Health
Cancer Legal Resource Center, Disability Rights Legal Center
American Cancer Society - Cancer Action Network
Ms. Angela Braly, President of Blue Cross/CA
Ms. Pam Kehaly, President of WellPoint

PinkHeart

VJ ~

 I cannot thank you enough for your efforts not only for you, but all breast cancer patients!

I've done informal advocacy as a spokeswoman for the organization WomenHeart: The National Coalition for Women with Heart Disease.  Every May they take spokeswomen to DC who want to help with bills.  Every year I contemplate doing it, but I am either too busy working (so I can have insurance), having a heart attack, or getting diagnosed with breast cancer. 

Is there anyone at Komen who can add some muscle to changing this law?

LisaAlissa

Gail,

I'm not clear how you presented your issue to your state insurance department--if your focus was the one you presented in your initial post, I'm suggesting a different issue for you.  You said:

"Blue Cross denied it a couple of times, each time for different reasons but what it boiled down to was that even though it is a "covered" procedure, there are NO approved providers and they won't cover it if the provider isn't approved. Classic catch-22. I have asked for a list of approved providers and I was told that I would have to supply a name and then blue cross would tell me if they were an approved provider or not--they refused to give me the names of who IS approved. Now blue cross is calling the tit-tats "surgery" which can only be done by a surgeon.

IF I had a HMO or a group policy, then my provider IS approved and this would have been covered."  

Generally speaking, if a procedure is covered, and your insurance company wants to limit providers of that procedure (as PPOs do), it must identify approved providers to you.  That's the issue which I think you should be able to get your insurance department to help you with.

I apologize if you've already pursued this tack, but I wanted to offer it in case it might help.  I hope it does.

LisaAlissa 

VJSL8

Hi LisaAlissa, I've already had the tit-tat's done so I really don't need to find an approved provider. What Blue Cross said was that they could send me a list of doctors--(like my PS) but they wouldn't know if that doctor provided that particular service--so I would have to call every doctor and ask if they performed tit-tats. (Blue Cross has determined that tit-tats are "surgery").

And it has been my PS that has pursued all the claims with blue cross, so I'm sure they know how to present it. Jeanni said she has never had blue cross deny a claim like this before. I sent a letter to the office of the President of BlueCross/CA and they called me. I said that I wasn't sure if I got the verbiage right in my letter and I was told that they understood my grievance but that I have no rights under the WHCRA. 

At this point I'm finished dealing with Blue Cross, I've gone as far as I  can with their process, my goal is to get the law changed. It just really pissed me off every time I hear them say that I have no rights under WHRCA. 

VJSL8

Update--Individual health insurance policies are regulated by the states and not by the federal government--that is why I am not covered by the WHCRA. Congresswoman Mary Bono-Mack's office called me and suggested I get the state laws changed. 

PinkHeart

1998  Federal Breast Reconstruction Law

Signed into Law on  October 21, 1998 - ASPS is working with federal regulators as they draft  guidance on implementation of the new law.
SEC. 713. REQUIRED  COVERAGE FOR RECONSTRUCTIVE BREAST SURGERY FOLLOWING MASTECTOMIES.
(a) IN GENERAL.-A group health plan, and a health insurance issuer providing  health insurance coverage in connection with a group health plan, that provides  medical and surgical benefits with respect to a mastectomy shall provide, in a  case of a participant or beneficiary who is receiving benefits in connection  with a mastectomy and who elects reconstructive breast surgery in connection  with such mastectomy, coverage for-
(1) reconstruction of the breast on which the breast cancer surgery has been  performed;
(2) reconstructive breast surgery of the other breast to produce a symmetrical  appearance; and
(3) prostheses and physical complications all stages of mastectomy, including  lymphedemas; in a manner determined in consultation with the attending  physician and the patient. Such coverage may be subject to annual deductibles  and coinsurance provisions as may be deemed appropriate and as are consistent  with those established for other benefits under the plan or coverage. Written  notice of the availability of such coverage shall be delivered to the  participant upon enrollment and annually thereafter.
(b) NOTICE.-A group health plan, and a health insurance issuer providing health  insurance coverage in connection with a group health plan shall provide notice  to each participant and beneficiary under such plan regarding the coverage  required by this section in accordance 1078 with regulations promulgated by the  Secretary. Such notice shall be in writing and prominently positioned in any  literature or correspondence made available or distributed by the plan or  issuer and shall be transmitted-
(1) in the next mailing made by the plan or issuer to the participant or  beneficiary;
(2) as part of any yearly informational packet sent to the participant or  beneficiary; or
(3) not later than January 1, 1999; whichever is earlier.
(c) PROHIBITIONS.-A group health plan, and a health insurance issuer offering  group health insurance coverage in connection with a group health plan, may  not-
(1) deny to a patient eligibility, or continued eligibility, to enroll or to  renew coverage under the terms of the plan, solely for the purpose of avoiding  the requirements of this section; and
(2) penalize or otherwise reduce or limit the reimbursement of an attending  provider, or provide incentives (monetary or otherwise) to an attending  provider, to induce such provider to provide care to an individual participant  or beneficiary in a manner inconsistent with this section. 1079
(d) RULE OF CONSTRUCTION.-Nothing in this section shall be construed to prevent  a group health plan or a health insurance issuer offering group health  insurance coverage from negotiating the level and type of reimbursement with a  provider for care provided in accordance with this section.
(e) PREEMPTION, RELATION TO STATE LAWS.-
(1) IN GENERAL.-Nothing in this section shall be construed to preempt any State  law in effect on the date of enactment of this section with respect to health  insurance coverage that requires coverage of at least the coverage of  reconstructive breast surgery otherwise required under this section.
(2) ERISA.-Nothing in this section shall be construed to affect or modify the  provisions of section 514 with respect to group health plans.''
(b) CLERICAL AMENDMENT.-The table of contents in section 1 of the Employee  Retirement Income Security Act of 1974 (29 U.S.C. 1001 note) is amended by  inserting after the item relating to section 712 the following new item:
SEC. 713. REQUIRED COVERAGE RECONSTRUCTIVE BREAST SURGERY FOLLOWING BREAST  CANCER SURGERY.
(c) EFFECTIVE DATES.-
(1) IN GENERAL.-The amendments made by this section shall apply with respect to  plan years beginning on or after the date of enactment of this Act. 1080
(2) SPECIAL RULE FOR COLLECTIVE BARGAINING AGREEMENTS.-In the case of a group  health plan maintained pursuant to 1 or more collective bargaining agreements  between employee representatives and 1 or more employers, any plan amendment  made pursuant to a collective bargaining agreement relating to the plan which  amends the plan solely to conform to any requirement added by this section  shall not be treated as a termination of such collective bargaining agreement.
SEC. 903. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
(a) GROUP MARKET.-Subpart 2 of part A of title XXVII of the Public Health  Service Act (42 U.S.C. 300gg-4 et seq.) is amended by adding at the end the  following new section:
SEC. 2706. REQUIRED COVERAGE FOR BREAST CANCER RECONSTRUCTION SURGERY FOLLOWING  MASTECTOMIES.
''The provisions of section 713 of the Employee Retirement Income Security Act  of 1974 shall apply to group health plans, and health insurance issuers  providing health insurance coverage in connection with group health plans, as  if included in this subpart.''.
(b) INDIVIDUAL MARKET.-Subpart 3 of part B of title XXVII of the Public Health  Service Act (42 U.S.C. 1081 300gg-51 et seq.) is amended by adding at the end  the following new section: ''SEC. 2752. REQUIRED COVERAGE FOR RECONSTRUCTIVE  SURGERY FOLLOWING MASTECTOMIES. ''The provisions of section 2706 shall apply to  health insurance coverage offered by a health insurance issuer in the  individual market in the same manner as they apply to health insurance coverage  offered by a health insurance issuer in connection with a group health plan in  the small or large group market.''.
(c) EFFECTIVE DATES.-
(1) GROUP PLANS.-
(A) IN GENERAL.-The amendment made by subsection (a) shall apply to group  health plans for plan years beginning on or after the date of enactment of this  Act.
(B) SPECIAL RULE FOR COLLECTIVE BARGAINING AGREEMENTS.-In the case of a group  health plan maintained pursuant to 1 or more collective bargaining agreements  between employee representatives and 1 or more employers, any plan amendment  made pursuant to a collective bargaining agreement relating to the plan which amends  the plan solely to conform to any requirement added by the amendment made by  1082 subsection (a) shall not be treated as a termination of such collective  bargaining agreement.
(2) INDIVIDUAL PLANS.-The amendment made by subsection (b) shall apply with  respect to health insurance coverage offered, sold, issued, renewed, in effect,  or operated in the individual market on or after the date of enactment of this  Act.

Debi1956

STage IV CANCER.....Need help understanding ICHIA.org. Have current insurance, but will end soon. less than 2o emloyees will not qualify for cobra. Need insurance with no gap. I cannot stop treatments if I want to live! Any imput will be appreciated. Medicare no help have to be disabled for two yrs. no coverage. Which I think is crazy. Medicaid not an option, not poor enough yet. Spouse already on disabiliy due to bone spurs on spine. Any imput would be appeciated.

thanks!

pinkpolitico1

Unfortunately, it's more than a State issue.  Federal law always trumps State laws and your Representatives know that.  Furthermore, it doesn't apply to Medicare, Medicaid, self funded or non government plans. Federal Breast Reconstruction legislation is only one of 23 active bills that are trying to address these issues.  I am a member of an advocacy group that is trying to change several laws that would in essence override WHCRA loop holes as well as shore up the question about lymphedema and external breast prosthesis (non-reconstruction related) coverage. With so many companies looking for cost cutting measures, without action, this will get more difficult.  Let us know if we can help with your endeavor! 

Binney4

pinkpol, can you expand on what legislation you're talking about regarding lymphedema coverage? Thanks!
Binney