Following breast cancer surgery, you continue to make decisions about your body and create a healthy lifestyle. One of these involves whether to wear a custom prosthesis or, if medically eligible, to undergo breast reconstruction surgery. You might even consider what is covered by your health insurance plan before planning how to move forward and when.

Whatever health plan you have, it should provide in-depth information on what is covered following your breast cancer surgery. However, you may be confused by the terminology they use or the exclusions detailed in the policy regarding your post-mastectomy coverage, especially whether reconstructive surgery is fully covered.

Here is some important information to help you make informed decisions about your body and your health plan coverage.

When is Breast Reconstructive Surgery Covered Under a Health Plan?

Reconstruction of the breast is designated as cosmetic surgery and is usually not covered under most health plans. However, following a mastectomy or other breast cancer treatments, it is most likely covered due to federal law.

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) outlines specific guidelines requiring group insurance health plans that pay for your mastectomy to provide coverage for reconstructive procedures and breast prostheses. In other words, most insurance plans cover reconstructive surgery following a mastectomy as long as the plan includes coverage for medical and surgical benefits.

An exception to this is church or government-sponsored health plans. Under the Act, these plans are not necessarily required to provide coverage for breast reconstructive surgery but may still do so. If you have one of these health plans, check with the administrator to determine what is and isn’t covered so you can make an informed decision for your particular circumstances.

For cancer patients with coverage under Medicare, breast reconstruction is also covered. For Medicaid, however, the coverage may vary depending on what state you are in. You’ll need to consult with the provider to determine your options under specific state laws.

Other issues can come up when determining if you have adequate coverage for breast reconstruction procedures. These may include newer methods of reconstruction or preferred plastic surgeons being outside your health plan’s network.

If you would like more information on the Act and laws requiring coverage, which is overseen by the US Department of Labor and Health and Human Services administrators, you can read more online or contact them via toll-free number 1-866-487-2365.

Is There a Time Limitation on Coverage?

Breast reconstruction surgery coverage is not limited to a certain time frame; it is available right away, soon after your mastectomy, or years later. This allows you to decide what is best for your body and lifestyle immediately following surgery and gives you time to understand what your needs are now and in the future.

Are There Any Out-of-Pocket Expenses?

In most cases, deductibles, co-insurance, and other out-of-pocket expenses will apply, much like other health care procedures. The Women’s Health and Cancer Right Act further provides that the amounts of each of these must be comparable to any other types of benefits under your health plan. They cannot be higher due to the cosmetic nature of breast reconstruction.

Questions to Ask Your Health Plan Provider

When contacting your health plan insurance company, ask the following questions to help guide your decision-making.

  • Is full coverage provided for a mastectomy, including lymphedema? This will confirm whether your plan is required to cover breast reconstruction procedures as well in accordance with the Act.
  • Are breast prostheses, including custom breast forms, covered?
  • Are post-mastectomy garments, such as bras or camisoles covered under your health plan?
  • How much coverage is provided for breast reconstruction procedures?
  • Do I need pre-authorization for surgery, and if so, what steps are involved?
  • Are there any restrictions on coverage for breast reconstructive procedures?
  • Are you required to use in-network surgeons only, or can you choose your surgeon?
  • What is your deductible? This is the amount you’re responsible for before the provider pays your claim.
  • What are the co-pays? These are amounts not covered under your deductible and payable by you for routine services.
  • What is the total out-of-pocket maximum you are responsible for each calendar year?

Reduce your stress by understanding what your health plan covers before making decisions about your health. During this time, you can consult with a certified fitter to find the right prosthesis, whether permanent or temporary and also post-mastectomy garments you need to get on with your life in the meantime. Specialty shop, A Fitting Experience Mastectomy Shoppe can help you with this and guide you through the insurance claim process.

Contact A Fitting Experience Mastectomy Shoppe to Learn More

When it comes to undergoing breast cancer surgery and the healing time it takes to get back to your life, you often have overwhelming decisions. Factor in all the specifics and potential limitations of your health insurance coverage, and you have a lot to think about in your planning.

As you make these decisions, you’ll need professionals who understand your situation and are there to help you through it all, such as helping you choose the right prosthesis, finding the best fit for your mastectomy bras, and guiding you through the insurance claim process. Contact A Fitting Experience Mastectomy Shoppe at (954) 978-8287 and learn how we can help.

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