Each year in the United States, more than 100,000 women undergo mastectomy surgery. While mastectomy is one of the main ways to treat breast cancer, not everyone who undergoes this surgery has a cancer diagnosis. There are several types of mastectomies, including single mastectomies, where one breast is removed, and double mastectomies, where both breasts are removed. Show
Generally, Medicare will cover most of the treatments needed after you receive a cancer diagnosis, including a mastectomy. However, some mastectomies do not qualify for Medicare coverage if they aren’t deemed medically necessary for the situation. Read on to learn more about when Medicare will cover a mastectomy and when it won’t. 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 what’s involved in your particular surgery. Doctor’s visits and outpatient careMedicare Part B is the part of Medicare that covers outpatient procedures, doctor’s visits, and medical services. This part of the program will cover any doctor’s visits related to your mastectomy and cancer care, as well as outpatient surgery. Inpatient surgery and careMedicare Part A is the part of Medicare that covers inpatient hospital services. This part of the program will pay for your mastectomy surgery and related inpatient care. ReconstructionMedicare Part A will cover surgically implanted prostheses after your mastectomy, if you choose to have reconstruction. Medicare Part B will cover external prostheses after your mastectomy, as well as the special post-surgery bras you’ll need. If you have Medicare Part C, a Medicare Advantage plan, your coverage for parts A and B are the same. However, you may have additional prescription drug coverage and other added benefits, based on the specific plan you’ve chosen. MedicationsMedications given while you’re admitted as an inpatient are covered under Medicare Part A. Some oral chemotherapy medications are included under Part B when given in an outpatient setting. If other medications are prescribed in relation to your mastectomy, you’ll need to have a Medicare Part D plan or a Medicare Advantage plan with prescription coverage. Otherwise, you may have to pay out of pocket for these. If you have a Medicare Part D plan, medications for nausea, pain, or other issues after surgery should be covered. The exact amounts covered and the costs of your Part D plan will depend on your plan provider and location. Prophylactic mastectomy and genetic testingMedicare’s coverage of elective mastectomies are more difficult to navigate than those for treating cancer. Coverage for a prophylactic (preventative) mastectomy is not guaranteed by Medicare. However, it might be covered under your state’s Medicaid program. Surgery for cosmetic reasons is not covered by Medicare. You might want a mastectomy if you’re at high risk of developing breast cancer due to a genetic mutation or family history. If Medicare denies coverage in this situation, you can ask your doctor to provide more information and written documentation to support your claim. Genetic testing is not typically covered by Medicare, but tests for common gene mutations that lead to breast cancer – BRCA1 and BRCA2 – are an exception. Medicare will cover BRCA testing if you have a personal history of breast cancer and meet one or more of the following criteria:
Genetic testing must be carried out by a provider and facility that accept Medicare. Studies have shown that prophylactic mastectomies can lower the risk of developing breast cancer by more than 90% in women who have the BRCA1 or BRCA2 gene mutation. To make sure that Medicare will cover your mastectomy, you should take the following steps:
Medicare is required to cover both internally implanted breast prostheses, as well as external prostheses. These include surgical implants, exterior forms, and supportive garments like mastectomy bras and camisoles. To check on coverage for specific items, visit Medicare’s website. For both Medicare parts A and B, you will be responsible for each of these deductibles, as well as coinsurance and copayment costs associated with your mastectomy. With Part B, you’ll pay 20% of the Medicare-approved amount for doctor’s visits and external prostheses, once you’ve met the Part B deductible. If you have a Medicare supplement plan, also called Medigap, it can be used to help cover most of the out-of-pocket costs from your mastectomy. Medicare Part AIn 2020, there are a number of out-of-pocket costs that might be associated with Medicare Part A, depending on how long you need care. You will pay a deductible of $1,408 for each benefit period. A benefit period is tied to a hospitalization so you should meet your deductible from the mastectomy surgery alone. There is no limit to the number of benefit periods you are allowed each year or in your lifetime. Your share of out-of-pocket costs rises as you extend your benefit period. Here’s the breakdown of costs to expect during a single benefit period:
Medicare Part BFor Part B, you will pay a monthly premium based on your income, as well as out-of-pocket costs. The following list is an overview of costs with Medicare Part B:
Medicare Part CFor Part C, your costs will depend on the plan you choose. Medicare Part C is a private insurance plan that combines all the aspects of Medicare parts A and B, and sometimes prescription drug coverage as well. For all Medicare Part C plans, the annual out-of-pocket limit is $6,700. Your monthly premium, deductible, copayments, and coinsurance all count toward this out-of-pocket maximum. Medicare Part DMedicare Part D is the prescription drug plan under Medicare. Costs for this plan also depend on the plan and provider you choose, as well as your location. While Medicare sets guidance for private insurers that offer these products, pricing and offerings can vary. You can expect to pay a monthly premium, an annual deductible, and copayments for prescription medications based on each plan’s drug tier system. The maximum annual deductible for Part D plans in 2020 is $435. Copayments vary based on how much you spend in a year. There is also a coverage gap that can affect the amount you pay for your prescriptions. Eventually, you will reach the catastrophic coverage threshold. Once you do, you will only pay minimal costs for your prescriptions for the rest of the year. There are several kinds of breast cancer, and it can affect both men and women. Here are some recent statistics on the prevalence of breast cancer:
Mastectomy rates have increased in the United States from 12% in 1998 to 36% in 2011 while cancer rates have remained fairly stable. Improved surveillance and treatment options have been credited for an improvement in cancer rates. StagingHow your cancer is treated may depend on your type of cancer. Surgery is usually the first step in breast cancer management and can be helpful in staging (identifying the size and spread of breast cancer). Staging is a big factor in deciding the best surgical and follow-up treatment for breast cancer. During initial biopsies and microscopic studies, a doctor can determine if your cancer is invasive or non-invasive. Invasive cancers usually require surgery, but only some noninvasive breast cancers need surgery. If you have a type of breast cancer that requires surgery, the first step is tumor removal. Next, you might receive systemic treatments and undergo any additional surgeries. Surgical optionsThere are two main types of surgery to treat breast cancer:
Breast-conserving therapy (BCT) usually requires radiation treatment as well. Most women with early stage breast cancer can pursue BCT rather than a full mastectomy. A mastectomy may be required because of cancer stage, breast or tumor size or shape, personal preference, or as a preventive measure if you are at high risk due to a genetic mutation. There are several different types of mastectomies, including:
What to expect before and after surgeryA mastectomy is a major surgery that will require preparation, at least several days in the hospital, and an extensive recovery process. The type of cancer you have may also require systemic treatments or radiation therapy. Even prophylactic surgeries have long-term impact, both physically and emotionally.
The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance. What does Medicare cover after mastectomy?Part A covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an inpatient setting. Part B covers the surgery if it takes place in an outpatient setting. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid.
Does insurance have to pay for reconstruction after mastectomy?The Federal law
This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law.
Does insurance cover reconstruction after double mastectomy?The Women's Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. In addition, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state.
What is the recovery time for breast reconstruction after mastectomy?Average recovery time after mastectomy and reconstruction is about 3-4 weeks, but may be up to 6-8 weeks. During that time, there may be restrictions against driving and activities that involve lifting or raising the arms up over the head.
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