Breast reconstruction is surgery for women with all or part of a breast removed. A plastic surgeon rebuilds the breast to its previous size and shape during the surgery.
Most women who have had a mastectomy can have breast reconstruction surgery. The surgery can help rebuild the breast’s natural shape, create a more balanced look when wearing a bra or swimsuit, and eliminate the need for external prostheses worn in the bra. All stages of breast reconstruction after a mastectomy are covered under the law. If only one breast was affected by the mastectomy, surgery and reconstruction of the other breast are protected by the law, if needed, to create a symmetrical appearance.
There is no time limit regarding when the benefit is completed. It applies to women who have had a mastectomy years ago but now feel as if they are in a place – both emotionally and physically – to consider reconstruction.
Insurance Benefits And Products Available To Breast Reconstruction Patients
It is federally mandated insurance companies that cover breast reconstruction and prosthetics. In other words, insurance cannot legally deny coverage for prosthetics, mastectomy bras, and accessories that may or may not be needed after surgery. This is outlined in the Women’s Health and Cancer Rights Act of 1998.
- Many special post-operative garments are available and billable to insurance. These often include drain bulb holders, vitamin-infused cotton, padding for symmetry, front closures, and various degrees of compression and support.
- Semi-custom prosthetic nipples are a beneficial product for many women undergoing reconstruction. They can be adhered with water or silicone-based adhesives and may help decide size and color when considering nipple tattoos or reconstruction.
- Many pocketed bras help reconstruct, as they can hold a push-up pad to lift the unaffected healthy breast in place or smoothing pads to give a more round, natural breast shape bilaterally.
- Patients can call the customer service number on the back of their insurance card to ask a representative about the quantities of bras and prosthetics allowed under their specific coverage plan.
- Benefits for pocketed bras and breast prosthetics/partial prosthetics are available to a woman her entire life following a breast cancer diagnosis. Breast size and shape change over time, and new products may be needed as the body changes. Typically, insurance will cover other pocketed bras every year and prosthetics every two years.
Many special post-operative garments are available and billable to insurance. These often include drain bulb holders, vitamin-infused cotton, padding for symmetry, front closures, and various degrees of compression and support.
Treatment For Breast Cancer Re-Occurrences
Many women have no more problems after their original treatment for breast cancer. But sometimes, breast cancer returns after treatments. This is called recurrent or relapsed breast cancer.
It can be a shock to discover that your cancer has returned. You might need time to deal with the information your team gives you. Knowing what to expect and the treatment you might have can help you cope better.
Your breast cancer can come back in: (1)The same breast and (2) Areas close to the breast, such as the lymph nodes and chest wall.
Secondary Breast Cancer
Secondary breast cancer is also called advanced or metastatic breast cancer. Secondary breast cancer means that a cancer that began in your breast has spread to another part of the body. This includes the liver, lungs, brain, or bones.
Unfortunately, secondary breast cancer is incurable. Treatment aims to control the cancer, relieve the symptoms, and maintain quality of life. Many people can live an everyday life for several years.
What benefits are breast cancer patients entitled to?
If you develop breast cancer, you can apply for Social Security disability costs to help you pay for living expenses while you are too sick to work. The only requirement for applying for Social Security disability benefits is that you expect to be unable to work for at least a year.
What Payments Can You Get If You Have Cancer?
Among those benefits are Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, Medicaid, and nonprofit assistance. All these benefits can be helpful to an individual who is unable to work and earn a living because of cancer.
How much money do you get for breast cancer?
More than 275,000 women in the United States will be diagnosed with breast cancer this year. The average treatment will cost anywhere between $20,000 and $100,000.
Does Having Breast Cancer Qualify For Disability?
Social Security disability benefits are an option for women with breast cancer who need help. Because of the prevalence of breast cancer in the United States, the Social Security Administration (SSA) lists breast cancer as a disabling condition and a potentially qualifying disability.
How Long Do You Have Off Work With Breast Cancer?
Most women with breast cancer took time off work (almost six months on average) after receiving the diagnosis.
What Happens If You Can’t Work Due To Cancer?
If you can’t work due to a cancer diagnosis, you may be eligible for financial support from two Social Security programs. Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) provide financial support to people with disabilities unable to work.
Does Breast Cancer Qualify For SSI?
To qualify for SSDI benefits or SSI based on breast cancer, you must be unable to work, and your breast cancer must have lasted for one year or more — or be expected to last a year or more. Breast cancer is a type of cancer that develops in the cells of the breast.
Can I Still Work With Breast Cancer?
Many people who work at the time of their breast cancer diagnosis continue to work during treatment or return to work soon after treatment ends. Your healthcare provider can help you decide when (and if) you can work (part-time or full-time).
Is Stage 1 Cancer A Disability?
Can I Get Disability Benefits with Cancer? Yes, you can get a disability for cancer if you meet the medical and work Requirements Outlined By The SSA That Qualify For Disability.
Is Breast Cancer A Disability Under The ADA?
Thankfully, there are specific protections in place for situations like these. The Americans with Disabilities Act (ADA) provides certain safeguards for those in positions that make them vulnerable to discrimination in the workplace due to disability or, in the case of breast cancer, severe illness.
Legal Rights of Disability and FMLA
Under the ADA, cancer qualifies on a case-by-case basis. The act protects individuals from losing their jobs due to disability and sets guidelines for employers regarding required accommodations.4 The United States EEOC, which enforces the ADA, offers the following example of a woman with breast cancer who would qualify for job protection under the act.
“Following a lumpectomy and radiation for aggressive breast cancer, a computer sales representative experienced extreme nausea and constant fatigue for six months. She continued to work during her treatment, although she frequently had to come in later in the morning, work later in the evening to make up the time, and take breaks when she experienced nausea and vomiting. She was too exhausted when she came home to cook, shop, or do household chores and had to rely almost exclusively on her husband and children to do these tasks. This individual’s cancer is a disability because it substantially limits her ability to care for herself.”
Disability Pay
Many companies offer disability pay for seriously ill or injured employees, but often, these plans require an employee contribution. Talk to a human resources representative about disability pay and how to collect if your employer offers a program.
FMLA
The Family and Medical Leave Act (FMLA) also protects the jobs of cancer patients. However, not everyone qualifies for FMLA protection. To qualify, you must have: (1) Worked for the employer for at least 12 months before the FMLA request. (2) Performed more than 1,250 hours in that calendar year.
In addition, employers who have fewer than 50 employees do not have to follow FMLA regulations.
If protected by the FMLA, you can take up to 12 weeks of unpaid leave from work. The act allows employees with serious medical illnesses, such as breast cancer, to use their leave “intermittently.” That means you could take one day off each week or two weeks off to recover from surgery while saving the remaining weeks to use during radiation or chemotherapy treatments.
If you feel your rights have been violated or dismissed from a job due to your diagnosis, you must file a charge “within 180 calendar days from the day the discrimination took place,” according to the EEOC. The EEOC can contacted at (800) 669-4000.
Health Insurance Coverage For a Medical Wig
Whether you are experiencing hair loss, temporary or permanent, many insurances cover the need for a wig due to hair loss caused by alopecia, chemotherapy, or other medical conditions, and you can file an insurance claim for the full or partial cost of your cranial prosthesis.
What is a Cranial Prosthesis?
A cranial hair prosthesis is a custom hair system designed for patients who have lost their hair due to medical conditions. These conditions include chemotherapy, alopecia totalis, alopecia areata, trichotillomania, and other disorders resulting in hair loss.
Knowing the terminology when applying for medical insurance or tax deduction status is essential. Other standard terms to describe a medical wig include cranial hair prosthesis, hair prosthesis, and full cranial prosthesis.
Notification of Insurance Coverage
Whether or not your insurance company covers your medical wig depends on your plan. But it’s possible to receive full payment for your full cranial prosthesis. However, while some insurance companies will pay for your prosthesis upfront, others require you to pay upfront and then get reimbursed.
Insurance companies cover 80-100% of the cost for your full cranial prosthesis. They also allow one cranial prosthesis per year for medical hair loss. Deducting your prosthesis as a medical expense on your taxes is possible. However, the wig is tax deductible if medical bills exceed 7.5% of an individual’s income. It is recommended you discuss this with your CPA.
The Standard List of Exclusions in default policies prohibits wig coverage. Speak with your employer’s human resource department to renegotiate your contract to include your cranial prosthesis coverage. And if you have secondary insurance, you can contact your insurance broker to do the same.
The Steps You Should Take
Contact the benefits department for your health insurance and ask:
- Does your policy cover a cranial prosthesis?
- If it does, what type of prosthesis is covered (I.e., human hair wigs, synthetic wigs, etc.)
- How much of the cost do they cover?
- What specific terminology for a wig should the prescription contain?
- Is there required documentation they need to submit your claim? What is it?
Note: When reviewing your insurance policy and you don’t see cranial prosthesis listed, it doesn’t necessarily mean you don’t have coverage. We strongly recommend that you call your health insurance company and get pre-authorization.
What To Do If Your Insurance Won’t Cover Your Wig Cost
Option 1. If you’re paying for the wig, save your receipt for possible tax deductions. Remember, if your wig is tax deductible, your medical bills exceed 7.5% of your income.
Option 2. Speak to your social worker or doctor about local resources! Call your local division of the National Alopecia Areata Foundation, the American Cancer Society, and other foundations. Depending on their requirements, you may qualify for financial assistance toward a wig or hair system purchase.
Handicap Parking Permit
Cancer patients undergoing chemotherapy may be eligible to receive a temporary handicapped parking permit for their vehicles during their treatment. The side effects of chemotherapy can make even a small trek across a parking lot to the hospital or pharmacy feel like mountain climbing. A handicapped parking permit allows for safer and more accessible mobility while helping with independence.
To obtain a parking pass, you must talk to your healthcare provider about your difficulties and the symptoms that limit your everyday mobility. Getting a parking pass can be as simple as having your healthcare provider sign an application and submit it to your state’s motor vehicle department. There are several different types of handicapped parking permits, some for short-term disabilities and others that are more long-term or permanent. Most temporary handicapped parking permits average about six months in duration. Some states are more flexible than others when issuing parking permits to people with cancer, and qualify regulations vary from state to state.
Free Prescription Programs for All Cancer Patients
Cancer is an expensive disease. Anyone who’s been through it knows it takes its toll physically, emotionally, and financially. But did you know many nonprofit programs available across the USA can help?
There are zero-cost medication programs, no application fees, and are sponsored by drug companies, doctors, patient advocacy organizations, government agencies, and civic groups to help you as a low-income or uninsured cancer patient receive no-cost access to essential medications and related professional services. https://www.cancer.org/cancer/financial-insurance-matters/managing-costs/prescription-drug-assistance-programs.html
INSURANCE COVERAGES
Most insurance companies will cover the cost of breast prostheses and post-mastectomy garments, including mastectomy camisoles. However, there may be some extenuating circumstances and clauses in your coverage that make obtaining that coverage a little bit more convoluted.
The following is a guide to help you determine what is covered, what isn’t covered, and what to look for, as well as where to look in your health insurance to find out which mastectomy garments are covered by your insurance company.
Medicare Coverage
Medicare coverage sets the guidelines for what is and is not covered by health insurance. These guidelines grant partial reimbursement for four to six mastectomy bras annually and three medically necessary camisoles monthly. Your doctor may prescribe additional bras or camisoles if you experience significant weight gain or loss after surgery.
Typically, your insurance is also required to cover these additional garment prescriptions. However, the mastectomy camisole must meet specific standards, including pockets for breast prostheses, to be covered by Medicare.
Private Insurance Coverage
Similar rules generally apply to private insurance, and the only significant difference may be the number of post-surgical bras or mastectomy camisoles covered by your plan and the amount reimbursed for each product.
It is essential to contact your insurance agent or company to verify your exact benefits before scheduling a fitting to ensure that you are looking at the correct products from the start of your fitting. Talk to your certified fitter about which products your policy covers, how many garments are permitted annually, and how much reimbursement for different pieces. With this information, a certified fitter can help you find and fit clothing in your price and product range that will round out your wardrobe and cater to your needs.
Physician Involvement
A prescription is needed from your doctor for your mastectomy garments to get reimbursement for your mastectomy wear costs. Check with your insurance provider before your fitting or purchases and determine what is covered. Some private insurances will only sell specific items under every mastectomy garment brand, which makes finding high-quality garments that fit you well and last all the more critical.
Your doctor’s office and certified fitter will be familiar with reimbursement procedures from different insurance providers, and they should be able to help and provide the information you need on your prescription.
Reimbursements
To obtain your reimbursement, you will likely have to provide most, if not all, of the following items to your insurance company:
- A written diagnosis from your physician.
- A prescription from your physician for post-surgery bras, breast prostheses, or mastectomy camisoles.
- A copy of your receipt from the mastectomy store.
- A printed copy of the reimbursement form from your insurance provider.
However, it may also be the case that your insurance requires per-authorization of products, so it is always best to check with an insurance agent before attending your fitting. Once your paperwork is submitted, your claim can take 30-120 days, though most companies process claims reasonably quickly.
How Much is Covered?
The reimbursed amount can vary drastically from plan to plan, as some insurers will offer full coverage while others will only compensate a percentage of your costs. Still, others even work on a lump-sum basis and provide a pre-determined sum that can be used at your discretion.
Looking into your plan is the best way to ensure your mastectomy camisole purchase is covered by your insurance. Keep in mind that if your doctor provides you with a prescription for mastectomy wear, it is likely that you are entitled to mastectomy camisoles as a necessary garment for the recovery process and never hesitate to call your insurance provider, your physician, or your certified fitter with any questions regarding what is covered by your specific insurance policy.
SUMMARY
Many women are still unaware that The Women’s Health and Cancer Rights Act (WHCRA) law exists. The law created in 1998 – requires that group health plans, insurance companies, and health maintenance organizations (HMOs) that offer mastectomy coverage must also provide coverage for other breast(s) removal services.
RESOURCES
American Cancer Society
National cancer.org
Premier Health
VeryWell Health
