How to Find Out If Your Insurance Covers Mastectomy

Before admission to the hospital for breast cancer surgery, the method of payment must be determined. If you have insurance, the hospital will call your insurance company to find out the benefits. Depending on your policy type, you may be asked about arrangements for paying any amount not covered by your insurance provider. HMOs (Health Maintenance Organizations), PPOs (Preferred Provider Organizations) and third-party payers all have a different amount and method of payment for services. Read on to learn how to find out if your insurance pays for a mastectomy.

Instructions

Difficulty: Moderate

1. Read your insurance policy carefully to find out if there are exclusions or limitations for cancer treatment. If you had a history of cancer when you obtained coverage, there may be a rider placed on the policy that either limits or excludes any payment for surgical intervention such as a mastectomy.
2. Look in the detailed description of procedures your insurance policy covers. Some policies are written so that it is difficult to interpret the precise coverage, so you may want to have an attorney look at your policy.
3. Pay attention to your policy cap or limit. Some policies cover only a minimal amount for hospitalization or extended illness. Other policies may have a high maximum coverage, such as several million dollars.
4. Call your insurance provider to discuss how your plan covers a mastectomy. Ask specifically about coverage for follow-up procedures and therapy. Be sure to write down the name or badge identification of the person giving you the information. That helps in negotiations when payment doesn't equate to the information given.
5. Understand that each state is regulated by the government regarding coverage of post-mastectomy breast reconstruction. Find your state through the Plastic Surgery website to learn what is required by your insurance carrier. See the Resources section below for a link.
6. Recognize the benefit of mediation if your insurance company refuses to pay for a mastectomy. If there are no exclusions in the policy that will prevent coverage for breast cancer surgery, read your rights for appeal.

Tips & Warnings

• If you and your doctor determine the mastectomy can be done on an outpatient basis, check with your insurance carrier to find out if your policy covers home health care.
• Many medical and cancer societies discourage having a mastectomy on an outpatient basis. If this is your preference, discuss it thoroughly with your surgeon prior to admission.
• Avoid changing insurance policies during the treatment process. This could result in a loss of benefits due to a pre-existing condition.