Prophylactic Mastectomy Insurance Coverage: Who to Work With

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Deciding on a prophylactic mastectomy due to a heightened risk of breast cancer is scary. It’s a major surgery that can feel overwhelming both physically and emotionally. However, it’s essential to remember that this decision is about taking control of your health and minimizing potential risks. Those risks aren’t just physical; they’re financial. Prophylactic mastectomy insurance coverage is not easy to navigate, but know if you live in New York and have health insurance, it should cover your prophylactic mastectomy and reconstruction.

Prophylactic Mastectomy Insurance Coverage Basics

Not all states mandate comprehensive coverage for prophylactic mastectomies. Luckily, New York State does. In fact, the state has some pretty robust coverage requirements when it comes to breast cancer screening, treatment, and reconstruction.

The need for a prophylactic mastectomy is determined based on breast cancer screening. Individuals with significant family histories of breast cancer, who have tested positive for certain genetic markers that make breast cancer likely, or who have had a previous breast cancer diagnosis are typically considered good candidates for a prophylactic mastectomy.

Both the mastectomy and breast reconstruction insurance coverage are guaranteed under New York law. Specifically, the law defines coverage for;

Breast reconstruction following mastectomy or partial mastectomy, including prophylactic mastectomy. Coverage includes all stages of reconstruction of the breast which was removed as well as surgery and reconstruction of the other breast to produce a symmetrical appearance. The patient’s physician, in consultation with the patient, will determine which type of reconstruction is appropriate. The insurance company may not deny the surgery as “not medically necessary.”

That provision doesn’t leave much room for insurance companies to wiggle out of paying for your treatment. And that treatment applies to both your in and out-of-network options.

Expanding Your Options with Out-of-Network Providers

While finding a surgeon to complete your mastectomy is usually straightforward, finding a plastic surgeon isn’t. Many plastic surgeons don’t take insurance at all. The ones who do will fall into one of two categories: in-network and out-of-network.

In-network means that the provider has an existing agreement with your insurance carrier. They have a set fee schedule that they will follow when it comes to billing and payments. An out-of-network provider doesn’t have the same agreement, but they can still provide care. In fact, there are some benefits to choosing an out-of-network provider. Here are some pros and cons of each.

In Network

Out-of-Network

Pros

Cons

Pros

Cons

  • Cost savings
  • Predictable expenses
  • Smoother preapproval process
  • Limited options
  • Long wait times
  • Possible quality issues
  • Access to top providers
  • Freedom of choice
  • Tailored care
  • Better outcomes
  • Potentially higher costs
  • Complex billing
  • Preapproval processes

The disadvantages of choosing to work with an out-of-network healthcare provider are contingent upon the specific policies of that provider. It’s worth noting that many of these healthcare professionals are often willing to work with their patients to ensure minimum out-of-pocket costs. They will provide insurance coordination services to help guide the patient through the preapproval process to ensure no financial surprises along the way.

What Out of Pocket Costs Can You Expect?

Prophylactic mastectomy and reconstruction are typically considered medically necessary. However, any medical procedure, even when deemed necessary by insurance, will come with some out-of-pocket expenses. These will change depending on your insurance policy, the type of procedure, and your chosen medical team. Here are some specific costs you must contend with when getting a prophylactic mastectomy and reconstruction.

  • Copayments: Copayments are fixed amounts paid when services are rendered. They may also change based on the type of treatment you are receiving. A primary doctor’s visit might be $25, while a trip to a specialist might go as high as $100 (or even more). 
  • Deductible: Insurance companies rarely cover expenses at 100%. A deductible is the amount you will cover before the insurance kicks in. This amount is usually between $1,000 to $2,000, though you may see high deductible insurance plans where the deductible is higher in exchange for a lower premium. Once you meet this deductible, the insurance company covers 100% of the cost. Keep in mind that not all treatments are applied to the deductible. 
  • Coinsurance: Some treatments under your policy may have a coinsurance provision. That means the insurance company will pay a percentage of the maximum allowable amount, and you will be responsible for the rest. While these percentages can vary quite a bit, typically, you’ll see an 80/20 split, meaning the insurance company pays 80% of the cost, and you pay 20%.
  • Out-of-pocket maximum: The out-of-pocket maximum is the absolute highest amount that you will pay before your insurance takes over. It’s usually set on an annual basis. For example, your out-of-pocket maximum might be $2,000 during the year. Once you have paid $2,000 out of pocket, your insurance company will cover everything else.

These costs and financial factors will affect you as you consider prophylactic mastectomy insurance coverage and coverage for your subsequent reconstruction. It’s best to meet with the doctor or their insurance coordinator to understand how much you can expect to pay for surgery. They should be able to walk you through the financial aspects so you can recover without a high financial burden.

Bringing Patient Advocacy to Breast Reduction and Reconstruction

If you are considering reconstruction and need guidance on prophylactic mastectomy insurance coverage, Harris Plastic Surgery can help. Reach out to us for a consultation. 

Joanne Parrinello, Practice Manager

Joanne Parrinello is an expert patient care coordinator, with two decades of experience navigating the complex financial side of medically necessary breast reduction and reconstruction surgery. She acts as a guide to patients, helping them understand their options and their expected out-of-pocket expense. The insurance industry can be complex and filled with jargon that makes you feel like you need a translator. At Harris Plastic Surgery, Joanne is that translator.

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