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What You Need to Know About Insurance for Breast Care

Many women aren't aware of what's covered for breast cancer

Women facing a diagnosis of breast cancer have enough on their minds without having to worry about insurance coverage. Many women assume the insurance will cover all procedures and supplies that are associated with breast cancer treatment, only to find out later that they will be responsible for a great deal of the expense of treatment themselves. The best thing anyone can do for themselves is to be aware of their own benefit coverage. No two plans are the same. And insurance for breast care can be particularly confusing. It is perfectly fine to call the customer service number for your plan and ask questions.

What type of insurance plan do you have?

PPO

A Preferred Provider Organization, or PPO plan, is the traditional form of major medical insurance that contracts with healthcare providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that are part of the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

HMO

A Health Maintenance Organization (HMO) is a type of health insurance plan that typically limits coverage to doctors who work for or contract with the HMO. It may not cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

POS

 A Point of Service plan lets you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans usually do require you to get a referral from your primary care physician in order to see a specialist.

There are other types of plans and terminologies you may need to be familiar with. If you don't have coverage through your employer or a spouse or partner's employer, visit Healthcare.gov for more information about types of insurance  plans.

How the lawmakers have helped

The Women’s Health and Cancer Rights Act (WHCRA) of 1998 requires insurers providing coverage for mastectomy surgery to also provide to the insured receiving benefits in connection with a mastectomy, coverage for:

  • Reconstruction of the breast on which the mastectomy was performed
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance
  • Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction
  • Any physical complications at all stages of mastectomy, including lymphedema (fluid build-up in the arm and chest on the side of the surgery)

You can find more information about the WHCRA here.

Medicare

If you have Medicare, you may be eligible to receive a breast prosthesis and/or post-mastectomy bras coverage entirely or in part by Medicare. Medicare guidelines deem the useful lifetime expectancy of a silicone breast prosthesis as two (2) years, and a non-silicone breast form has an expected lifetime of six (6) months. If you have Medicare, your first step is to find a retailer who has a Medicare Supplier Number. These stores may choose to handle your purchase in one of two ways. 

  1. They may not take Medicare assignment, which means they may request payment from you in full, and then bill Medicare on your behalf so that the reimbursement check comes to you. 
  2. Or they may accept assignment, which allows you to take the breast prosthesis and mastectomy bras without full payment, while the store files for direct reimbursement. Please be prepared to pay any applicable deductible and/or coinsurance responsibility at the time of service. 

It is always important to ask the retailer if they accept assignment for Medicare. This will assist you as the member in being prepared for the financial responsibility you may be expected to pay at the time of service.

Pre-Existing Conditions and Preventive Care

Under the Affordable Care Act in the U.S., all marketplace health plans (and thus, other health insurers) must cover pre-existing conditions like asthma, diabetes and cancer. Preventive care like mammography is also a covered service. For more information, visit Healthcare.gov or the U.S. Department of Health and Human Services.