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 anything 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 coverage language. No two plans are the same. It is perfectly fine to call the customer service number for your plan and ask questions.

This is the traditional form of major medical insurance that normally pays 80% of reasonable and customary charges with the policy holder being responsible for the remaining 20%. There is a deductible the policy holder must meet up until a set dollar amount (called out of pocket) is met. The plan then pays covered expenses at 100%. There is a predetermined lifetime maximum the plan will pay. Most, but not all, major medical policies cover prescription drugs, private duty nursing when medically necessary, durable medical equipment, physician and inpatient/outpatient hospital charges. This plan offers more choices in providers and facilities.

"Many women assume their insurance will cover anything only to find out later that they will be responsible for a great deal of the expense of treatment themselves."

Managed care plans are known as the HMO, PPO, IPA, or POS. They differ in small ways by the plan structure but all utilize the same principals. All managed care plans utilize networks as a way to keep costs down. Many a patient has expressed shock upon the realization that a laboratory or imaging center is out of network and the plan either pays substantially less or not at all. It is imperative that the consumer be aware of the network status of all of the members of the healthcare team. In these plans, the beneficiary is usually limited to network facilities and physicians with substantial decrease in coverage for using an out of network member. Some managed care plans also have deductibles and out of pocket amounts. Typically, the lower the deductible and out of pocket amounts, the higher the cost for coverage. Many of these managed care plans allow self-referral to specialists, however most HMOs do not. Most of these plans cover prescription drugs although some plans have a closed formulary of which drugs they will cover. Inpatient, outpatient and rehabilitation services are usually covered. For many people, managed care plans are a more affordable option for insurance coverage with low co-payments and deductibles.

The Women’s Health and Cancer Rights Act of 1998 requires insurers providing coverage for mastectomy surgery to 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
• Prostheses and physical complications for all stages of mastectomy, including lymphedema, in a manner determined in consultation with the attending physician and the patient.

Prohibits: (1) denying 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) penalizing or otherwise reducing or limiting the reimbursement of an attending provider, or providing 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.

If you have Medicare, you may be eligible to have a breast prosthesis and/or post-mastectomy bras covered entirely or in part by Medicare. Effective April 1, 2002 Medicare guidelines deem the useful lifetime expectancy of a silicone breast prosthesis as two (2) years, and a non-silicone form has an expected lifetime of six (6) months. If you have Medicare, the 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. They may request payment from you in full, and then bill Medicare on your behalf so that the reimbursement check comes to you. Or they may accept assignment. This will allow you to take the form without full payment, while the store files for direct reimbursement. Either way, you will be expected to make a 20% co-payment.