Does Medicaid Cover Breast Reconstruction After Cancer

Form Tf0001 Notice Of Case Action

If eligible for MBCC-Presumptive or MBCC, Form TF0001 informs the client of:

• the date benefits begin,
• her right to appeal, and
• the address and phone number of free legal services available in the area.

If the woman is certified for MBCC-Presumptive, a separate Form H1020 is sent informing her of the additional information needed to determine her eligibility for MBCC.

If ineligible for MBCC-Presumptive or MBCC, Form TF0001 informs the client of:

• the date of denial,
• her right to appeal, and
• the address and phone number of free legal services available in the area.

Medicaid And Medicare Dual Eligibility

If you’re on Medicare and can’t afford your share of the cost of surgery and are eligible for Medicaid, your state’s plan may help you pay for:

• Coinsurance
• Deductibles
• Premiums

When you’re enrolled in both plans, Medicare usually pays first, and Medicaid then helps to pay for all or some of what’s not covered. For example, if you require a lengthy stay in a hospital following surgery, Medicaid Part A would pay the daily cost of your stay up to a preset limit. Then, Medicaid would usually cover all or some of the cost of the remaining days. Your Medicaid plan may also help you pay for the deductible and coinsurance associated with Medicare Part A.

Does Medicare Cover Breast Reduction Surgery

• Summary

Generally, Medicare does not cover breast reduction because doctors often categorize it as a cosmetic procedure rather than medically necessary surgery.

However, Medicare does cover breast reduction surgery, also known as reduction mammoplasty, when excessively large breasts cause chronic medical problems, such as pain or postural changes.

Both original Medicare and Medicare Advantage provide coverage for medically necessary breast surgeries. However, the deductibles, copays, and coinsurances differ between the two programs.

Below, we explain what breast reduction surgery is and when and how Medicare covers the costs.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:

• Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
• Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
• Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.

When the purpose of breast reduction surgery is purely cosmetic, such as when a person wants to reduce the size of their breasts only for aesthetic reasons, Medicare does not cover the procedure.

Some examples of medical circumstances in which Medicare may pay for reduction surgery include:

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Will My Insurance Cover Breast Reconstruction Surgery After A Mastectomy

For Houston women, facing a mastectomy can be a very scary and emotional time. While it can be a life-saving procedure, it also changes the look of a womans body forever. Not to mention, theres the added stress of medical bills from breast cancer treatments and loss of income due to time off of work for treatments. And for many Houston women who want breast reconstruction after their mastectomies, they are left wondering, and worrying Will my health insurance pay for my breast reconstruction?

X932 Other Medical Assistance

Revision 17-2 Effective April 1, 2017

An MBCC applicant is not eligible to receive benefits if she is currently receiving Medicaid, Medicare Part A or B, or coverage through CHIP. If an application is received for a woman who receives Medicaid, Medicare or CHIP, or if a Medicaid or CHIP application is certified before the MBCC application, deny the MBCC application.

Staff must verify via TIERS, the State Online Query or the Wire Third-Party Query system that an applicant is not currently enrolled in Medicaid, Medicare Part A or B, CHIP, or Healthy Texas Women before disposition. If a woman is eligible for MBCC and is currently receiving HTW, the HTW EDG must be denied.

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Final Look Of The Breast

It will take some time to see the final results of your reconstructed breast.

How you feel about the final results may depend on your expectations. A reconstructed breast will never look or feel the same as a natural breast.

Most of the scarring will fade and improve over time, but it doesnt go away completely.

As you age and the opposite breast changes shape, the reconstructed breast may look and feel less natural.

Louisiana Medicaid Adds New Coverage For Women With Breast Cancer Or At Risk For Breast Cancer

For the first time, women receiving health benefits from Louisiana Medicaid have access to coverage for breast reconstruction surgery of the contralateral breast following a mastectomy. In addition, they will have access to BRCA 1 and BRCA 2 mutation testing in cancer-affected individuals and those at high-risk for breast or ovarian cancer.

Breast cancer is the most common cancer among women in the United States, no matter her race or ethnicity. In addition, the CDC reports that breast cancer is the second leading cause of cancer death among women. Notably, October is National Breast Cancer Awareness Month. Louisiana Medicaid is committed to providing the women of our state with access to early diagnosis and quality treatment for breast cancer.

Five to 10 percent of all breast cancers diagnosed in the United States are due to inherited gene mutations. BRCA 1 and BRCA 2 are genes that protect a cell from one step on the path to cancer. When these genes mutate, the cell can progress to cancer.

Louisianas Medicaid expansion meets the most urgent health needs of our residents. The addition of this coverage helps to restore a womans sense of normalcy after breast cancer surgery, and genetic testing can offer peace of mind to some or it can ensure a plan of care led by a physician if genetic testing detects a mutation, said Rebekah Gee, MD, Secretary, Louisiana Department of Health.

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What Parts Of Medicare Cover Mastectomy

Medicare generally provides coverage for most cancer treatments. If you need a mastectomy to treat breast cancer, you will be covered under your Medicare benefits, with some out-of-pocket costs. Different parts of Medicare pay for different services based on whats involved in your particular surgery.

For Nc Breast Cancer Patients Insurance Type And Distance To Care Can Be Barriers To Breast Reconstruction

Women were less likely to have breast reconstruction surgery after mastectomy if they had Medicaid or Medicare rather than private insurance or if they lived 10 or more miles from a plastic surgeons office, a University of North Carolina Lineberger Comprehensive Cancer Center study has found.

Dr. Anne Marie Meyer

Anne Marie Meyer, PhD, research assistant professor of epidemiology at UNC Gillings School of Global Public Health and UNC Lineberger member, is a co-author of the study.

Researchers said the findings, published in the August issue of Plastic and Reconstructive Surgery, highlight additional barriers to breast reconstruction in addition to other obstacles that have been identified, including race, socio-economic class and age. The new data are concerning, researchers said, as the procedure can help with self-esteem, sexuality and body image after cancer treatment.

We know that breast cancer affects not only the physical well-being of the patient, but also her psychosocial well-being, and we know that breast reconstruction can help address those issues, said the studys first author Michelle Roughton, MD, assistant professor of surgery and program director for the UNC School of Medicines Division of Plastic and Reconstructive Surgery. These findings highlight the fact that there are more barriers to breast reconstruction access than we previously recognized.

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Getting A Second Opinion

Its always OK to get a second opinion. Your plastic surgeon should be comfortable with it.

Getting a second opinion from a plastic surgeon from a different hospital or group practice can:

• Instill confidence in the first plastic surgeon by confirming your reconstructive options
• Provide another perspective on your reconstructive options
• Give you a chance to meet with another plastic surgeon, who may be better suited to perform your surgery

However, getting a second opinion shouldnt delay your breast cancer treatment.

Under The Whcra Mastectomy Benefits Must Cover:

• Reconstruction of the breast that was removed by mastectomy
• Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy
• Any external breast prostheses that are needed before or during the reconstruction
• Any physical complications at all stages of mastectomy, including lymphedema

Mastectomy benefits may have a yearly deductible and may require that you pay some out-of-pocket costs.

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Basic Types Of Breast Reconstruction

The table below compares the basic types of breast reconstruction.

Specific types of reconstruction are discussed in more detail below.

How Do Surgeons Reconstruct The Nipple And Areola

After the chest heals from reconstruction surgery and the position of the breast mound on the chest wall has had time to stabilize, a surgeon can reconstruct the nipple and areola. Usually, the new nipple is created by cutting and moving small pieces of skin from the reconstructed breast to the nipple site and shaping them into a new nipple. A few months after nipple reconstruction, the surgeon can re-create the areola. This is usually done using tattoo ink. However, in some cases, skin grafts may be taken from the groin or abdomen and attached to the breast to create an areola at the time of the nipple reconstruction .

Some women who do not have surgical nipple reconstruction may consider getting a realistic picture of a nipple created on the reconstructed breast from a tattoo artist who specializes in 3-D nipple tattooing.

A mastectomy that preserves a woman’s own nipple and areola, called nipple-sparing mastectomy, may be an option for some women, depending on the size and location of the breast cancer and the shape and size of the breasts .

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Does Breast Reconstruction Affect The Ability To Check For Breast Cancer Recurrence

Studies have shown that breast reconstruction does not increase the chances of breast cancer coming back or make it harder to check for recurrence with mammography .

Women who have one breast removed by mastectomy will still have mammograms of the other breast. Women who have had a skin-sparing mastectomy or who are at high risk of breast cancer recurrence may have mammograms of the reconstructed breast if it was reconstructed using autologous tissue. However, mammograms are generally not performed on breasts that are reconstructed with an implant after mastectomy.

A woman with a breast implant should tell the radiology technician about her implant before she has a mammogram. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant.

We Are Your Patient Advocate

Our expert staff has many years of experience working with insurance carriers to help patients obtain maximum coverage and maximum benefits. We understand patient rights and we want to help you navigate the process. Please contact us with any questions or to discuss the specifics of your individual case and your insurance coverage. We are here to serve you.

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Answer: Insurance Is Required To Cover Breast Reconstruction

Thankfully, Congress has supported women’s right to pursue breast reconstruction by passing the Women’s Health and Cancer Rights Act in 1998 and, more recently, the Breast Cancer Patient Education Act. These acts ensure that all insurance companies cover breast reconstruction for women who have undergone mastectomies.

Get Help Understanding Insurance And Patient Financial Responsibility

Toni Conner is the contact person for patients of UPMC Western Maryland Plastic Surgery who have financial questions about their plastic or reconstructive surgical procedure. Her contact telephone number is 240-964-8931. While patients are responsible for understanding their insurance coverage, she can help to answer questions and provide additional resources for those who need to finance any part of their surgery.

Please note, the information provided throughout this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and video, on or available through this website is for general information purposes only. If you are experiencing relating symptoms, please visit your doctor or call 9-1-1 in an emergency.

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Does Insurance Cover A Boob Job After Breast Cancer

Breast enlargement surgery is usually not covered by insurance. In addition, it will cover breast implants for women who have had mastectomies as a result of breast cancer. It is also possible that your health insurance will not cover additional surgery later on. It is also possible that having breast implants will affect your insurance rates later.

Is Breast Reconstruction Covered By Insurance

When you have breast cancer, your first concern is doing whatever is necessary to survive the disease. This can include the removal of one or both of your breasts.

Some women are fine with having no breasts after surgery while others want to undergo reconstructive surgery as soon as possible. There is no right or wrong answer, only what feels like the best decision for you.

One thing that can make a difficult decision even more challenging is concerns about whether insurance will cover the cost of breast reconstruction surgery. The federal government mandates that your insurance provider pay for the costs under certain circumstances. The Cecil B. Highland, Jr. and Barbara B. Highland Cancer Center at UHC encourage you to learn whether this applies to your current situation.

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Copays And Coinsurance For Surgery Under Medicaid

Even if the surgery is covered by Medicaid, you may have to pay for part of the procedure. State programs can require a copay or coinsurance. For example, in Alabama, Medicaid recipients are assessed a flat fee of $50 every time they are admitted to the hospital, and in Georgia, enrollees pay a $12.50 copay for hospital stays, according to the Kaiser Family Foundation. Some states like Montana base copays on income.

Your Providers Credentials And Level Of Experience

Most plastic surgeons are trained to perform breast reconstruction surgery, but it’s worth the time to find a board-certified plastic surgeon who specializes in breast reconstruction to join your surgery team .

Many plastic surgeons who specialize in breast augmentation procedures perform breast reconstruction surgery only rarely, and they may not offer the technique that’s best suited to your needs.

The more advanced training and experience a provider has performing breast reconstruction surgery, the higher their surgeon’s fee is likely to be. For instance, microsurgery fellowships provide invaluable training for surgeons who go on to perform breast reconstruction with tissue flap grafting, using donor tissue from other areas of the body.

Choose a surgeon whose level of experience you feel comfortable with, who produces exceptional results with the reconstruction technique you’re considering on a regular basis.

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Latissimus Dorsi Muscle Flap Reconstruction

The latissimus dorsi muscle flap procedure removes a large muscle in the back along with skin and underlying fatty tissue. It uses these tissues to reconstruct the breast .

In most women, the amount of soft tissue available on the back is limited and the flap itself is only about an inch thick or less. So, an implant is usually needed to create enough volume for the reconstructed breast.

The fatty tissue of the latissimus flap goes over the implant so it mimics the look and feel of a natural breast better than an implant alone.

Do You Have More Questions About Medicare Coverage Of Breast Implants

If you have other questions about Medicare coverage of breast implants, Id be happy to help. To set up a time to talk one-on-one about your Medicare needs, click the link below. You can also request an email from me with personalized Medicare information youll find that link below as well. To start browsing on your own, click the Compare Plans button on this page.

New To Medicare?

Becoming eligible for Medicare can be daunting. But don’t worry, we’re here to help you understand Medicare in 15 minutes or less.

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Womens Health And Cancer Rights Act

The Womens Health and Cancer Rights Act of 1998 requires group health plans, insurance companies and health maintenance organizations that pay for mastectomy to also pay for :

• Reconstruction of the breast removed with mastectomy
• Surgery and reconstruction of the opposite breast to get a symmetrical look
• Breast prostheses
• Treatment of any complications of surgery, including lymphedema

The Womens Health and Cancer Rights Act doesnt apply to some church and government insurance plans.