notice of post-mastectomy coverage

[Guest Linda P]

Recently (mid to late Oct), a new section 713 was added to ERISA. Group health plans have to cover reconstructive surgery after a mastectomy (if the plan covers mastectomies). There are a few notice rules with tight deadlines.

In particular, notice of this coverage has to be provided to each participant and beneficiary:

(1)in the next plan mailing to participants;

(2) as part of the yearly informational packet mailed to participants; or

(3) not later than 1/1/99

WHICHEVER IS EARLIER.

Oh, and this notice must be "in writing and prominently positioned in any literature or correspondence."

My question: how are people handling this? For lots of companies, it's coming in the middle of open enrollment.

Thanks.

[Guest Chuck Miller]

I've not heard of this new reg. I'll do some checking and get back to you. Please send me your email address.

[Guest Chuck Miller]

This is not a new part of ERISA yet. It's been proposed but not passed or signed into law.

To read the whole proposed act, go to the What's New page and scroll down to:

11/5/98: The text of the Women's Health and Cancer Rights Act of 1998

[Guest Kathleen Meagher]

I believe that this provision was part of the massive budget bill signed by the President in late October. Apparently it was added by the conference committee as a new provision and was not part of either the House or the Senate bill. But it was part of the bill that was eventually passed and signed, so it looks like it is now the law.

I've already had a question about these notices. What if a plan has covered reconstructive breast surgery for several years and mentions this in its SPD? Does the plan sponsor still have to send out the notice?

[Guest rsmelson]

I have been asked the same question - that is if the SPD contains a discussion about reconstructive surgery will this satisfy the notice requirement? Since no DOL regulations or guidance have been issued, this question is difficult to answer. However, the intent of the new legislation seems to be that a initial notice must go out

prior to 1-1-99 and simply saying that the participants already have an SPD doesn't seem to satisfy the intent of the law.

[Guest Chuck Miller]

On Wednesday, 11/18, I'll be attending a leslative update that should cover 713...I'll specifically ask the ERISA lawyers what should be done about this...what you should do to comply etc....

I'll post the answer on here...

[Guest Anne V]

We literally "stopped the presses" on some annual enrollment materials to incorporate notice of the post-mastectomy coverage.

While the health plans already covered mastectomy and post-mastectomy benefits -- and so complied with the new law -- we incorporated a simple 1-2 paragraph statement that informed employees of the passage of this bill, and that their medical plans indeed covered this. We wanted to make sure that employees didn't hear about this elsewhere -- or think they weren't covered if they didn't read about it in the annual enrollment materials.

Here's a sample of the update we included in the enrollment guide and in a new SPD that is effective January 1. This information was developed with the help of the insurance carrier:

"Special Update About Mastectomy Coverage

Effective January 1, 1999, federal law requires that group health plans covering mastectomy also provide specific reconstructive and prosthetic benefits. While your XYZ Company medical plan already provides these benefits, this update has been included to ensure you are informed of these benefits.

The XYZ medical plan covers:

-- Reconstruction of the breast on which the mastectomy has been performed,

-- Surgery and reconstruction of the other breast to produce a symmetrical appearance, and

-- Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas.

These benefits are available to each plan participant who has a mastectomy while covered by the plan and who elects breast reconstruction in connection with the mastetcomy.

These benefits are subject to the medical plan's annual deductibles and copayments."

Hope that's helpful. If your enrollment materials are already completed and distributed, I would recommend distributing this information by year's end -- perhaps with enrollment confirmations or other benefits information you have scheduled to distribute between now and January 1.

[Christine Roberts]

Is there any web link to the text of the reconstructive surgery provisions? I am wondering if the language re: prosthetics and lymphedemas are part of the legislation, or particular to the plan for which the notice was drafted.

[Guest Nell Hennessy]

In late November, the DOL issued a set of Q&As (http://www.dol.gov/dol/pwba/public/pubs/newq&a.htm) on the Women's Health and Cancer Act of 1998, which requires plans that cover masectomies to include breast reconstruction. Plans are required to provide notice to their participants by January 1. However, the Q&As provide that a plan that provided the coverage required by the Women's Health Act (and continues to provide such coverage) prior to the date of enactment (October 21, 1998) will have satisfied the initial one-time notice requirement if the information required to be provided in the initial notice was previously furnished to participants and beneficiaries in accordance with the Department's regulations on disclosure of information to participants and beneficiaries.

[Guest Anne V]

The sample text that I provided late last year was based on a particular plan.

However, so long as the plan covers mastestomy then, as I understand the federal law, the reconstructive surgeries as described here must also be covered by the plan.

In drafting the required notice, I'd recommend working directly with your insurance carrier -- to ensure you know what's in your plan (and what's not...)

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