Insurance - Frequently Asked Questions

As a breast reconstruction patient you are about to encounter numerous doctor, hospital, pathology and anesthesia bills. Remember, breast reconstruction is a long and staged process. One of the most common questions among breast cancer patients is "Will my health insurance cover this?" In the vast majority of cases the answer is "yes".

While insurance coverage varies on a patient by patient basis there are some things that are pretty standard. Breast reconstruction is covered as long as the mastectomy is covered (the mastectomy is always covered if it is performed for breast cancer). Breast reconstruction after prophylactic (preventive) mastectomy is usually covered as long as the patient is deemed high risk for breast cancer (significant family history or BRCA gene positive).

See breast reconstruction insurance state laws.

What is a Deductible?

A deductible is the amount you (the patient) must pay for medical expenses prior to your insurance carrier paying benefits. Deductibles generally run on a calendar or fiscal year and are generally due annually.

What is a Co-Pay?

A co-pay is a fixed dollar amount that is to be paid by the patient each time the patient is seen for medical services. Co-pays do not apply towards a patient's deductible.

What is Co-Insurance?

Co-insurance is the amount shared by you and your insurance carrier for medical expenses. For example, in an 80% / 20% co-insurance plan, the insurance carrier pays 80% of the allowed charges and the patient pays 20% of the allowed charges. Please remember that your insurance company will not begin paying for medical expenses until your deductible has been met.

What is an Out-of-Pocket Maximum? And, how do I reach that?

An out of pocket maximum is a specific dollar amount that a patient is to pay per calendar year. Patients reach their out-of-pocket maximum through their co-insurance payments. For example, if you have a $1,000 out-of-pocket maximum and an 80%/20% plan you will pay 20% of all allowed charges until you have paid $1,000. Once you reach your out-of-pocket maximum your carrier will begin covering all services at 100%. Remember, co-pays are not included in out-of-pockets.

What is an Allowable?

An allowable is an agreed or contracted rate between your carrier and provider for a specific service. This is what the insurance company (carrier) pays the doctor.

What is Balance Billing?

Due to shrinking insurance reimbursements to physicians some DIEP surgeons set their fee and ask the patient to pay the remaining amount that the insurance company will not cover (ie the difference between the doctor's fee and the Allowable). This is known as "balance billing". This can add 10's of thousands of dollars to the patient's final bill and is in addition to the out-of-pocket expenses described above. PRMA does NOT balance bill.

What is a Global Period?

A global period is a specific period of time (generally 90 days after a surgery) that the patient receives follow-up care and post-operative visits without billing the insurance company. Patients must wait until their global period is complete prior to proceeding with the next stage of their breast reconstruction. Global periods are federally mandated and cannot be changed.

What is an In-Network or Out-of-Network Provider?

An In-Network provider is a physician or practice who has signed an agreement with your insurance carrier to accept a specific fee for services provided. An Out-of-Network provider is a physician or practice who does NOT have a signed agreement with your carrier. Out-of-Network providers are not required to "write-off" any monies for services rendered, and you may be responsible for any dollar amount not paid by your carrier. **It is important to know whether your physician is considered In-Network or Out-of-Network for your insurance plan. Please be sure to ask our office staff. All our physicians are In-Network for all major US carriers. 

What is NOT covered by my Insurance?

Typically the breast reconstruction process involves more than one surgery, including one "revision surgery" (performed as the second surgery). Most insurance plans cover all reconstructive stages. However, more than one revision surgery (i.e. secondary revisions) will not be covered by your insurance company as medically necessary. Furthermore, secondary revisions will be considered cosmetic and cosmetic fee quotes will be provided.