Professional Musicians & Employer’s Health & Welfare Fund:
Reconstructive Surgery Fully Covered After Mastectomy
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
The Professional Musicians Local 47 and Employers Health & Welfare Fund (“the Fund”) provides you with this notice as required by the Women’s Health and Cancer Rights Act of 1988 (WHCRA).
In compliance with WHCRA, the insurers contracted with by the Fund (Kaiser and Blue Shield) provide benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and for complications resulting from a mastectomy, including lymph edemas.
Although reconstructive surgery after a mastectomy is generally a covered procedure, some procedures are, of course, classified as cosmetic and, therefore, not covered.
Under the WHCRA, and in the case of a participant or beneficiary who is enrolled with and receiving benefits from the Fund, in connection with a mastectomy and elects reconstruction, federal law requires coverage, in a manner determined in consultation with the attending physician and the patient, for:
- reconstruction of the breast on which the mastectomy is performed
- complications at all stages of a mastectomy, including lymphedemas
- all any necessary prostheses required as a result of the mastectomy
- surgery and reconstruction of the other breast to produce a symmetrical appearance
The above benefits are provided to all enrolled Participants and Beneficiaries subject to the same deductibles and co-insurance payments that are applicable to all other medical and surgical benefits provided by the Fund. For more information please call PacFed Benefit Administrators at (818) 243-0222.
NEWBORN AND MOTHERS HEALTH PROTECTION ACT OF 1996 (NMHPA)
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). The Fund, through the insurance benefits provided by Kaiser and Blue Shield, fully complies with the NMHPA.
