A Breakdown of Breast Cancer Insurance Coverage

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Insurance coverage for breast cancer screening, diagnosis, and treatment is critical to getting access to healthcare for this condition. People without insurance or who are denied coverage for certain treatments or procedures need to explore their options.

As many as 290,000 people are expected to be diagnosed with invasive breast cancer in any single year.1 Knowing what resources are available is key to getting the best outcome.

This article will outline the treatments you may need for breast cancer, what types of insurance cover them, and what you can do when you do not have insurance.

Prevention, Diagnosis, and Treatment of Breast Cancer

Knowing what kind of care you could need at each level of your cancer diagnosis is important.

Preventive screening: A mammogram is the most effective screening tool for breast cancer.2 Other imaging studies, such as breast ultrasound and breast MRI (magnetic resonance imaging), could also occur if a person has symptoms, has dense breasts, is considered high risk, or has an abnormality that is found by a mammogram.

Free Screening

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was created in 1990 to increase access to breast cancer screening. More than 250,000 people are screened through the program each year.3

Diagnosis:A mammogram may raise suspicion of cancer, but a breast biopsy (removing a tissue sample from the breast for analysis in a lab) is necessary to make a formal diagnosis. Information from this biopsy will be key in deciding how to treat you.

Your healthcare provider will also want to ensure the breast cancer has not spread to other parts of the body. This may require additional imaging studies, procedures, office visits, and hospitalizations.

Treatment: Treatments include medication (e.g., chemotherapy, hormonal therapy, immunotherapy), radiation, surgery (e.g., mastectomy), or any combination of these.

In 1998, the Women’s Health and Cancer Rights Act required that health plans that cover mastectomy (surgical removal of a breast) also have to offer reconstructive breast surgery for people undergoing a mastectomy. This could include breast implants or a prosthesis.4

Cosmetic vs. Reconstructive Surgery

Cosmetic surgery is generally not covered by insurance, but reconstructive surgery may be. Unlike cosmetic surgery, reconstructive breast surgery is performed for medical reasons. It aims to correct a defect caused by a disease or treatment for that disease (in this case, breast cancer).

Finding Out Breast Cancer Coverage With an Existing Policy 

When the Affordable Care Act (ACA) was passed in 2010, it required that insurance plans cover 10 essential health benefits. Those benefits included the services needed to treat serious conditions like cancer.

Screening mammograms were made free, and ambulatory care (care outside of the hospital), hospital care, laboratory tests, prescription drug coverage (such as one drug from every class, including chemotherapy), and rehabilitation services were included in all plans.5

Unfortunately, not all health plans have to follow the ACA rules. Individual private plans and small group plans do. However, plans that existed before the ACA (referred to as grandfathered plans) and large-group plans do not. Depending on the type of insurance you have, your cancer coverage may vary.

Marketplace or Private 

The ACA created the Health Insurance Marketplace, which many individuals and families turn to for care today. Plans are divided into metal categories (bronze, silver, gold, and platinum). Monthly premiums increase, deductibles decrease, and your cost of care gradually decreases as you move from a bronze to a platinum plan.6

‌Premium subsidies are available to help people keep costs down. Those subsidies originated with the ACA but were expanded with the American Rescue Plan in 2021 so that no one would pay more than 8.5% of their income on healthcare.7 The Inflation Reduction Act of 2022 has extended these larger subsidies through 2025.8

Employer

Depending on the size of your employer, you may be offered group health insurance through your job. The ACA requires large employers (defined in most states as those hiring the equivalent of 50 full-time employees) to provide affordable, comprehensive healthcare to any employees working more than 30 hours per week.

To be affordable, a plan must not cost you more than a certain percentage of your income (9.61% in 2022).9 To be comprehensive, a plan must give minimum value, meaning that it covers sufficient hospital and physician services.

Large employers that offer insurance can choose to self-insure or fully insure their plans. “Self-insured” means that the employer puts their own health plan together and pays for your care directly. “Fully insured” means that the employer purchases care through an insurance company.

The difference is important because self-insured plans are not regulated by state law. Having a self-insured plan means you could miss out on certain benefits other people in your state get.

Dense Breasts

Dense breasts are not something you feel; they’re something seen in medical imaging. People who display this radiological finding on a mammogram may be at an increased risk of breast cancer.10

For this reason, several states have enacted laws that require health plans to offer more breast cancer imaging studies like 3D mammograms and breast ultrasounds.11 Keep in mind that these laws do not apply to self-insured plans offered by a large employer.

Medicaid

Medicaid is run on a state level, although it receives funding from both the federal government and the states. It is offered to families with low incomes, pregnant people, children, and those who are medically needy.

States that expanded Medicaid under the Affordable Care Act may also extend eligibility to single people who qualify based on income.12

‌Medicaid, in general, pays toward cancer care. What is covered and what you pay will depend on the state in which you reside.

People who do not traditionally qualify for Medicaid may still be able to receive treatment for breast cancer through the program. Specifically, a person of any sex or gender diagnosed with breast cancer through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) qualifies for treatment through Medicaid.13

Of note, to qualify for NBCCEDP screening, the federal government set an income limit of 250% of the federal poverty limit and below.14

Medicare

Medicare is a federally funded healthcare program for people 65 and older or those with qualifying disabilities. Care is divided into four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage).

The federal government runs Original Medicare (Part A and B). Private insurance companies run Medicare Advantage (an alternative to Part A and Part B that can offer supplemental benefits) and Part D.

Medicare covers a wide range of cancer care. Mammograms are covered for free if the healthcare provider accepts assignment. If necessary, breast ultrasound and breast MRI are also covered for a fee.

Regarding treatment, Part B covers surgeries, radiation, and a wide range of chemotherapy options. Other medications, including some specialized chemotherapy treatments and immunotherapies, require Part D coverage.

Costs in Original Medicare are relatively standard. There are fixed rates for inpatient hospital care depending on the number of days you are hospitalized. Physician fees in or out of the hospital and other medical services tend to cost no more than 20%.

To help pay down any deductibles, coinsurance, or copays, many beneficiaries on Original Medicare will also enroll in a Medicare Supplement plan, known as Medigap. Costs for Medicare Advantage and Part D plans vary based on the insurer.

Cancer Insurance

Cancer insurance is a kind of supplemental insurance that you can use together with your primary health plan.

Depending on the supplement you enroll in, it will help pay down costs related to your cancer care (deductibles, copays, coinsurance, etc.). It can also help you pay for non-medical expenses such as groceries, mortgage/rent payments, and transportation to and from your appointments.

Unfortunately, these sorts of plans rely on medical underwriting, meaning they can use preexisting conditions to increase the rates for their plans, decrease the number of benefits offered, or deny you coverage altogether.

Having cancer, unfortunately, is a preexisting condition that will prevent you from taking advantage of one of these plans. The trick is to enroll in one of these plans before you are actually diagnosed with cancer. Not everyone can afford to do so.

Switching Insurance for Better Breast Cancer Benefits 

In a perfect world, your health plan would cover all the facilities, providers, and treatments you want. In reality, not all plans are created equal. Treatments your healthcare provider recommends may or may not be covered.

It may be in your best interest to change to a plan that gives you more treatment options. However, you cannot switch plans whenever you want.

Unless you have a major life event that qualifies you for a special enrollment period (e.g., you got married, divorced, lost your job, etc.), you can usually only change your plan once a year. This occurs during a designated period known as the open enrollment period. These are:

  • Marketplace plans: Open Enrollment is November 1 to January 15.
  • Employer plans: Enrollment period varies by employer.
  • Medicaid: Year-round enrollment is based on eligibility.
  • Medicare: Open Enrollment is October 15 to December 7.

Make sure you know when your open enrollment period is, so you don’t miss an opportunity to sign up for a plan that best meets your needs.

Talking With an Insurance Agent

If you are uncertain what type of plan will work best for you, reach out to an insurance agent. Ask them about the differences between available plans, about specific coverage options pertaining to your cancer care, and how much you would be expected to pay. It’s important that you make an informed decision.

Resources for Patients Without Insurance 

No one should be denied cancer treatment because they can’t afford it. If you do not have insurance, and even if you do, there are a number of charitable organizations you can turn to as a way to decrease the financial burden, including:

These are not the only organizations willing to help. Be proactive and reach out for help.

Financial Planning for Out-of-Pocket Costs 

Cancer can take a toll, physically and emotionally, but it can also lead to financial toxicity, which is a term for how the cost of cancer care can affect your quality of life.

Due to high medical costs, especially for those without insurance, many people do not take their medications as prescribed, and some do not even complete their treatment course. Others cut back significantly on expenses such as food, clothing, or utilities.

Many people go into debt by taking out extra credit cards, refinancing a home, or exhausting their savings. The bankruptcy rate is 2.5 higher for cancer survivors than for people with no history of cancer.15

Know that there are resources to help you through these difficult times. The following organizations have financial planning programs available that may help you manage your expenses and decrease the burden you face:

Summary

Breast cancer treatment can get expensive, making it so important to get insurance if you can. Thanks to the Affordable Care Act, cancer care is offered through most plans.

Whether you’re on a Marketplace plan, an employer plan, Medicaid, or Medicare, make sure you understand what is covered and how much you can expect to pay. Also, be sure to talk to your healthcare providers so you can decide on the most affordable treatment plan.

Beyond insurance, there are charitable organizations and financial planning services that can help you manage costs. Do not let cancer get the upper hand.

A Word From Verywell 

The costs of cancer care add to the burden of the condition. Know that you are not alone. There are a number of resources available, from health insurance to charitable programs. Do not hesitate to ask for help.

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