U.S. Code » Title 29 » Chapter CHAPTER 18— EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM › Subchapter SUBCHAPTER I— PROTECTION OF EMPLOYEE BENEFIT RIGHTS › Subtitle Subtitle B— Regulatory Provisions › Part part 7— group health plan requirements › Subpart Subpart B— Other Requirements

29 U.S.C. § 1185b

Required coverage for reconstructive surgery following mastectomies

Read at: OLRCuscode.house.gov CornellLII GovInfogovinfo.gov JustiaTitle 29 CasesGoogle Scholar
(a) In generalA 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 breast reconstruction in connection with such mastectomy, coverage for—(1) all stages of reconstruction of the breast on which the mastectomy has been performed;(2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and(3) prostheses and physical complications 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) NoticeA 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 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) ProhibitionsA 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.(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 October 21, 1998, 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 1144 of this title with respect to group health plans.

(Pub. L. 93–406, title I, § 713, as added Pub. L. 105–277, div. A, § 101(f) [title IX, § 902(a)], Oct. 21, 1998, 112 Stat. 2681–337, 2681–436.)Statutory Notes and Related SubsidiariesEffective Date

Pub. L. 105–277, div. A, § 101(f) [title IX, § 902(c)], Oct. 21, 1998, 112 Stat. 2681–337, 2681–438, provided that:“(1)In general.—The amendments made by this section [enacting this section] shall apply with respect to plan years beginning on or after the date of enactment of this Act [Oct. 21, 1998].“(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.”

Notes of Decisions
Cited in 18 cases (6 in the last 5 years), 2001–2026 · leading case: Krauss v. Oxford Health Plans, Inc., 517 F.3d 614 (2d Cir. 2008).
Sort: Relevance Newest Treatment
Krauss v. Oxford Health Plans, Inc., 517 F.3d 614 (2d Cir. 2008). · cites it 3× “They allege that Oxford’s denial of full reimbursement for the bilateral surgery and private-duty nursing care violated the Women’s Health and Cancer Rights Act, 29 U.S.C. § 1185b (“WHCRA”), as well as various ERISA provisions.”
Davidson v. Wal-Mart Assocs. Health & Welfare Plan, 305 F. Supp. 2d 1059 (S.D. Iowa 2004). · cites it 3× “She contends that Plan language indicates Defendant interprets mastectomy and breast reconstruction claims in accordance with the Women’s Health and Cancer Rights Act of 1998, 29 U.S.C. § 1185b (“Women’s Health Act”).”
J.L.F. v. Arizona Health Care Cost Containment Sys., 91 P.3d 1002 (Ariz. Ct. App. 2004). · cites it 2× “She relied upon the federal Women’s Health and Cancer Rights Act of 1998 (“Act”), 29 U.S.C. § 1185b (Supp.2003), which provides that an individual receiving benefits for a medically necessary mastectomy who elects breast reconstruction will also receive coverage for “surgery and…”
Haag v. MVP Health Care, 866 F. Supp. 2d 137 (N.D.N.Y. 2012). “” 29 U.S.C. § 1185b(a). The insurer must also provide written notice to its participants of the above coverage required by the WHCRA.”
Krauss v. Oxford Health Plans, Inc., 418 F. Supp. 2d 416 (S.D.N.Y. 2005). “2681 (Í998) (codified at 29 U.S.C. § 1185b) (“the WHCRA”), mandates full reinfibursement for post-mastectomy breast reconstruction.”
Howard v. Coventry Health Care, of Iowa, Inc., 293 F.3d 442 (8th Cir. 2002). · cites it 3× “; and Principal Mutual a/k/a Principal Life Insurance Company for tortious breach of statute in violation of the Women’s Health and Cancer Rights Act (“WHCRA”), 29 U.S.C. § 1185b. She also filed pendent state claims of breach of contract, violation of public policy, and bad…”
Iwata v. Intel Corp., 349 F. Supp. 2d 135 (D. Mass. 2004). “See 29 U.S.C. § 1185b. The first thing to note is that none of these statutes appears to have a particu *153 larly close nexus with disability, much less with distinctions between mental and physical disabilities.”
Shaw v. McFarland Clinic, P.C., 231 F. Supp. 2d 924 (S.D. Iowa 2002). “Rather, McFarland maintains that the Plan covers breast reconstruction surgery following a mastectomy pursuant to “The Woman’s Health and Cancer Rights Act,” 29 U.S.C. § 1185b, and that no comparable statute covers Shaw’s claim.”
Howard v. Coventry Health Care of Iowa, Inc., 158 F. Supp. 2d 937 (S.D. Iowa 2001). · cites it 2× “Tortious Breach of Federal Statute Howard alleges in Count I that 29 U.S.C. § 1185b has been breached by defendants.”
Prestige Inst. for Plastic Surgery, P.C. v. Keystone Healthplan East (D.N.J. 2020). · cites it 3× “29 U.S.C. § 1185b(a). WHCRA also prohibits group health plans and health insurance issuers providing coverage in connection with a group health plan to (1) deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely…”
Rideau v. Lafayette Health Ventures Inc (W.D. La. 2019). · cites it 2× “” 29 U.S.C.A. § 1185b. Since Defendants are not health insurers and are in no position to approve or deny insurance coverage for procedures related to Dr.”
Tamburrino, M.D. v. Unitedhealth Grp. Inc. (D.N.J. 2023). · cites it 2× “2008)); see generally 29 U.S.C. § 1185b. However, “Congress did not mandate 100 percent coverage of [post-mastectomy breast reconstruction] surgeries, irrespective of the other generally applicable terms of the plan.”
Show all 18 citing cases →
— 29 U.S.C. § 1185b(a) — 7 cases
Krauss v. Oxford Health Plans, Inc., 517 F.3d 614 (2d Cir. 2008). “They allege that Oxford’s denial of full reimbursement for the bilateral surgery and private-duty nursing care violated the Women’s Health and Cancer Rights Act, 29 U.S.C. § 1185b (“WHCRA”), as well as various ERISA provisions.”
Haag v. MVP Health Care, 866 F. Supp. 2d 137 (N.D.N.Y. 2012). “” 29 U.S.C. § 1185b(a). The insurer must also provide written notice to its participants of the above coverage required by the WHCRA.”
Davidson v. Wal-Mart Assocs. Health & Welfare Plan, 305 F. Supp. 2d 1059 (S.D. Iowa 2004). “She contends that Plan language indicates Defendant interprets mastectomy and breast reconstruction claims in accordance with the Women’s Health and Cancer Rights Act of 1998, 29 U.S.C. § 1185b (“Women’s Health Act”).”
Prestige Inst. for Plastic Surgery, P.C. v. Keystone Healthplan East (D.N.J. 2020). “29 U.S.C. § 1185b(a). WHCRA also prohibits group health plans and health insurance issuers providing coverage in connection with a group health plan to (1) deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely…”
Tamburrino, M.D. v. Unitedhealth Grp. Inc. (D.N.J. 2023). “2008)); see generally 29 U.S.C. § 1185b. However, “Congress did not mandate 100 percent coverage of [post-mastectomy breast reconstruction] surgeries, irrespective of the other generally applicable terms of the plan.”
— 29 U.S.C. § 1185b(c) — 1 case
Prestige Inst. for Plastic Surgery, P.C. v. Keystone Healthplan East (D.N.J. 2020). “29 U.S.C. § 1185b(a). WHCRA also prohibits group health plans and health insurance issuers providing coverage in connection with a group health plan to (1) deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely…”
— 29 U.S.C. § 1185b(d) — 1 case
Prestige Inst. for Plastic Surgery, P.C. v. Keystone Healthplan East (D.N.J. 2020). “29 U.S.C. § 1185b(a). WHCRA also prohibits group health plans and health insurance issuers providing coverage in connection with a group health plan to (1) deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely…”
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.