From past experience myself as well as having talked with many breast cancer patients, there are some key questions that arise related to health insurance coverage that might be helpful for you to know. Concerns about what your health insurance does and doesn't cover can add unnecessary anxiety and worry to you at a time that you don't need it. By being proactive you can contact your insurance company and get information up front about what they do and don't cover. This information below will also help advise you how to optimize the coverage you do have.

Will my insurance company cover my mastectomy/ lumpectomy surgery if I am an inpatient?

Most insurance companies, including managed care organizations, will cover an overnight stay. However there has been a trend toward outpatient surgery unless you are having reconstruction done at the same time or you have other medical conditions warranting hospitalization. Depending in what state you live, there might be specific legislature related to ensuring coverage for overnight stays as well. The need to be an inpatient or an ambulatory surgery patient should be decided by you with input from your surgeon. Discuss this with your surgeon first then talk with your insurance company if you are planning to be hospitalized. (Johns Hopkins makes it the patient's choice to be an inpatient or outpatient for mastectomy surgery without reconstruction based on input from her surgeon. We are strong advocates that only hospitals who have developed comprehensive patient education programs which are conducted in advance of the patient's surgery should be performing mastectomies on an outpatient basis. We know from experience however that patients prefer going home the day of surgery 71% of the time and do very well. They score us high on patient satisfaction surveys and feel confident that they made the right choice in electing to have their surgery performed on an outpatient basis. It requires a commitment of time, effort, and resources to develop a program that works well however. Not many facilities have invested this time and energy unfortunately. So ask your doctor how many patients have been done on an outpatient basis if he is considering recommending to you to have your surgery done in this way. Pressure from insurance carriers should not dictate whether you are done on an inpatient or outpatient basis. Decisions about this must rest with you and your doctor.)

I don.t know if I want to have reconstruction yet. Will it still be covered if I choose to wait until a later time, or is it only covered if done as part of my breast cancer surgery now? Will my insurance cover any type of reconstruction, such as tr am flap, saline implant, or dorsal flap?

Most insurance companies will cover reconstruction of all types, but check to see if they place a time limit when you can have it done. There is active legislature now (Sept 1997) which, if passed, will require that all insurance companies cover recons truction of all types for an unlimited length of time after the initial mastectomy surgery. Presently, there are some insurance companies who require that the reconstruction be done within one year of the initial mastectomy surgery, if it is to be a cover ed benefit.

I've decided not to have reconstruction. I'd prefer to wear a breast prosthesis. How expensive are they, and how much will my insurance cover?

This is a tricky question. Breast Prostheses range in price from $50 (made of cloth with tiny pillows for fillers inside) to $1400 (made of silicone and created from a mold of the other breast), with the standard prosthesis costing about $350. Silicone prostheses usually come with a two year warranty. There are also breast prostheses designed for swimming; these range in price from $15 to $40. If an insurance company only covers one prosthesis, make sure you submit the sales receipt of the permanent silicone breast prosthesis to your insurance company, not the receipt of the swimmer's prosthesis or a less expensive model such as the cloth prosthesis. Since the insurance company will only cover one you need to submit the more expensive one to them, otherwise you will be stuck with a large bill and they will have technically paid for a prosthesis even if it is a swimmers.s model or cloth model. This can result in serious financial hardship which is avoidable if you know how to submit your insurance bills up front. Also make sure you get a prescription from your surgeon ordering that you be fitted for a breast prosthesis as well as mastectomy bra. Without the prescription you will probably have trouble getting fitted and definitely trouble getting your insurance company to pay the bill. Most insurance companies pay 80%-100% of the bill for prostheses. Some companies are rigid and only cover the purchase of one prosthesis for a lifetime. This is an important benefit to ask about. Other companies will cover reimbursement for a prosthesis every two years.

What happens if my body changes in size and my prosthesis no longer fits properly? Can I get a replacement, and is it covered by my insurance?

Most insurance companies will cover replacements for this reason, provided there is a prescription from a doctor stating the reason for the replacement.

Can I go anywhere to get a breast prosthesis, or are there only certain locations approved for me to go?

Most insurance companies will let a patient go anywhere she chooses. It is wise to choose a store that employs certified fitters who are specially trained to fit women for breast prostheses. Being fitted for a mastectomy bra and/or breast prosthesis is very intimidating, and can be degrading if not done by a highly professional staff dedicated to making the experience a nonstressful one. Ask the health care professionals if they have a list of stores who they recommend and who have certified fitters there. You will probably find that many of the mastectomy supply shops are owned by women who have had breast cancer themselves. These women have chosen to help others like you and I. These women know how you feel because they.ve been there themselves... Feel free to ask when you call to make a fitting appointment if any of the fitters are breast cancer survivors.

Are mastectomy bras covered by my insurance, and if so, how many will they cover per year?

There is some variance among insurance companies about this particular benefit. Most insurers will cover two bras a year, provided they are accompanied with a prescription from a doctor. During the month of October, National Breast Cancer Awareness Month, many mastectomy supply shops have sales on their mastectomy supply items. This is especially important if your insurance company doesn.t cover reimbursement for mastectomy bras beyond the initial coverage of two bras. Bras are expensive and take advantage of sales! (Mastectomy bathing suits, by the way, are not covered by insurance companies. These items are almost always on sale around Labor Day.)

I've been told I might need chemotherapy. Is it covered by my insurance? What if I choose to participate in a clinical trial? What drugs are and aren't covered?

This varies from company to company. Call and ask them specific questions. It is best to also ask the oncologist if a research grant will cover any drug and treatment costs if you do participate in a clinical trial. There is a positive trend developing now, which is good news, of insurance companies covering health expenses related to clinical trial participation.

I might need radiation therapy. Is this covered by my insurance?

Check to see what sites are covered for radiation therapy. Sometimes patients assume they will receive all medical care at the place they were diagnosed and initially treated, and are later surprised to discover that the site for radiation treatment is in a different location and will be provided by health care professionals who are not part of the patient's original treatment team. If this is the case, you need to know up front to prevent anxiety about it later.

Based on my understanding of the type of chemotherapy I'll be receiving, I might lose my hair. Will my insurance company cover the cost of a wig? How soon can I get one? Does my hair have to be completely gone in order to get one?

Many companies do cover this expense. However, it might require sending a letter to the insurance company from your doctor. If they don't cover it, check with the American Cancer Society or with the Breast Center where you are being treated; they might have access to wigs for you if this is a financial burden for you. There are various organizations and hospitals who have a supply for "recycling" to newly diagnosed patients who are in need of such an item. It is advisable to be fitted for a wig before you begin to lose your hair. This way, the wig will be easily matched to your hair color and hair style.

My doctor plans to do my procedure (mastectomy or lumpectomy with axillary node removal) as an outpatient procedure. Arrangements are going to be made by the Breast Center for a home health nurse to come to my home the night of my surgery and the next day. Is this expense covered by insurance?

Most insurance companies do cover home health care following this type of surgery. They usually cover two visits and there must be extenuating medical circumstances to warrant approval of additional visits. There are special forms that the doctor or nurse fill out for the insurance company and for the home health nurse to help assist with ensuring coverage. Insurance companies usually contract with specific home health care agencies too. Ideally the home health nurse caring for you is familiar with out patient mastectomy care. (Johns Hopkins has trained home health care nurses specifically for this purpose to ensure they know what is expected of them when conducting a home health visit. This better ensures continuity of care for you.)

I might be switching insurance companies in the middle of my treatment. Will my new insurance company cover the continuation of my current cancer treatments?

If at all possible it is best not to switch insurance companies in the midst of treatment. There can be serious problems with insurance coverage for continuation of your breast cancer care. If you are leaving your present place of employment you might want to strongly consider continuing your current insurance coverage by paying the monthly premiums yourself at least until your treatments are completed. You should also check with your new insurance company about their policies regarding "pre-existing conditions." Some companies picking you up as a new member will continue your coverage for breast cancer treatment and others may not for a specified period of time.

What can I do to influence changes in insurance coverage if I think that my insurance company is being unreasonable about my treatment benefits?

First talk with the member relations manager for your insurance company to see if you can come to some agreement about what is reasonable coverage and what is not. If you are

unsuccessful in getting satisfactory help, you may need your doctor to write a letter on your behalf explaining the medical need for certain treatments and such. If the problem is one related to your insurance company not providing a specific benefit at all or a limited benefit (for example, one prosthesis for a life time) you may want to write to your insurance commissioner or even contact your local congressman or senator who may be able to promote legislation requiring certain types of coverage for all women unrelated to the type of insurance they have.