As with all queries about what is or is not covered by your health insurance, the answer is never straightforward. We aim to present you with some guidelines that may help inform your choice of health insurance plan.
So, let us begin at the beginning. The ACA recognizes the value of prevention, protective therapy and, early detection of most common conditions including, breast cancer.
If you buy your plan through a health insurance exchange, whether federal, state, or private, your plan will be ACA compliant. You will be eligible for an annual cancer screening test from the age of 40 through 74. For plans, either group or individual, to meet the ACA requirements, they must cover the following screening services free of charge (including co-pays and cost-sharing)
- Screening mammography
Women with average-risk (aged 40-74) Minimum: Once in two years. Maximum: Once in any one year.
Women with above-average risk* Assessment of increased risk (by primary care physician) and genetic counseling.
If indicated after counseling, women at higher risk may receive genetic testing.
- Medication for risk reduction
Women (aged 35) with increased risk for breast cancer
If indicated, women at low risk for adverse reactions to medication may be offered risk-reducing therapy. A woman’s risk for breast cancer is higher if she has a mother, sister, or daughter (first-degree relative) or multiple family members on either her mother’s or father’s side of the family who have had breast or ovarian cancer. Having a first-degree male relative with breast cancer also raises a woman’s risk. (https://www.cdc.gov/cancer/breast/young_women/bringyourbrave/breast_cancer_young_women/risk_factors.htm)
In summary, early detection at any age increases the chances of successful treatment. ACA compliant plans, Medicare, and Medicaid all provide free screening. Where appropriate, they also cover the cost of medications to increase resistance to cancer.
Some cancers are hereditary, i.e., run in the family (about 5%-10%. See footnote). They are caused by gene mutations in earlier generations. We have no control over our genes, but we can influence some factors that increase the likelihood of getting cancer.
Not being physically active, being overweight, and using tobacco products and alcohol affect all genders. For a list of factors specific to women, see the risk factors for breast cancer: https://www.cdc.gov.
Nobody plans to have cancer! But if you or a loved one is diagnosed with breast cancer, you must have a plan!
Early identification and treatment are critical in all cases, so you must take advantage of the free screening and risk reduction services available under your ACA compliant plan, Medicaid or Medicare.
Will my costs be covered?
If you are unlucky enough to be diagnosed with breast cancer, there will almost certainly be a proportion of the costs you will be responsible for. Even the most expensive and comprehensive health insurance policies will involve deductibles, co-pays and, co-insurance. Mainly, these will arise during the first two to three months of your treatment. You may have budgeted, expecting that you could average your out-of-pocket expenses evenly over the whole year. Suddenly you are faced with having to find the entire sum in a much shorter space of time.
Let’s look at a worst-case scenario. Suppose you do not have any insurance. A patient without insurance would typically face a bill of between $15,000 to $50,000 for a mastectomy (breast removal) and $17,000 to $35,000 for a lumpectomy (the removal of a discrete lump, usually followed by radiation treatment to eliminate further spread)
Of course, that is not the end of the story. Post-operative care (average around 18 months) can bring the total cost to $100,000.
90% of US citizens have health insurance, of which most are private ACA compliant plans (either group or individual) Medicaid or Medicare. All these plans provide for free breast cancer screening and the preventative treatment described above.
These plans also include coverage for treatment, but deductibles you will have co-pays and co-insurance to pay up to the limit of your out-of-pocket expense.
According to the CDC (as above), a woman diagnosed with early-stage breast cancer can typically expect to pay $5800 out of pocket.
If your insurance covers mastectomy, it should also cover breast reconstruction if medically indicated. Your insurance may not cover surgery considered ‘cosmetic.’ or cover the total cost if your chosen provider (surgeon) is not in your plan’s network. Check the details on your plan. Talk to your insurer, your plan administrator (employer) or, your broker (individual plans).
If your physician advises that mastectomy is the appropriate treatment for your breast cancer, you will need to consider your approach to breast reconstruction. When making your choices, you will need to consider the extent to which your health insurance will be cover your expenses.
These points are essential because the cost of breast reconstruction ranges from $5,000-$15,000 (per breast) for implants or $25,000-$50,000 (per breast) for grafts using the patient’s own skin. Cost of Breast Cancer Treatment – 2021 Healthcare Costs (costhelper.com).
You must have a plan
If you are reading this article, you are likely concerned either with your own risk of suffering from breast cancer for a loved one diagnosed as ‘at risk.’
Your first step is to seek the advice of your family physician. The sooner you begin treatment, the less the intervention required and the likely costs of treatment.
The treatment plan you agree with your physician will be designed to meet your specific needs. There is no blanket cure nor the cost determined with absolute certainty.
The critical elements in your plan will be based on one or more of these treatments:-
- Surgeries such as lumpectomy, mastectomy and, lymph node removal
- Radiation/chemotherapy designed to kill or artack cancer cells/ shrink tumors
- Hormone therapies specifically designed to stop/limit tumors growth
- Therapies designed to target cancer cells but with have impact on surrounding healthy cells than radiation or chemotherapy
- Immunotherapy to stimulate encourage the body’s immune system to attack cancerous cells
Even after treatment, you may need:
- Breast reconstruction(surgical)
- Visits to an oncologist at prescribed intervals
- Bone density tests if you have been on certain hormone drugs
- Medications to minimize the risk that your cancer will returncome back