Breast Reconstruction & Medicare

Posted by KK57 @kk57, Apr 19, 2022

I am 64 years old, turning 65 and going on Medicare in November. I am in the midst of reconstruction after a double mastectomy. I’m wondering if anyone else has switched from regular insurance to Medicare in the midst of reconstruction, and if I should try to get everything completed prior to going on Medicare. I have my implants in, but still need some revisions, as well as possible Areola tattoo and nipple. I’ve been taking it slow, but wondering if perhaps I should try to get all completed before the switch to Medicare. Any advice from those of you who have navigated between health insurances.

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I cannot answer your question directly because I did not switch insurance during treatment. I went on Medicare about year after cancer treatment ended, but still have ongoing rechecks.

Have you researched Medicare yet? The answer to your question might depend on type of Medicare plan you sign up for and additional insurance you will have.

Then you need to make sure that your providers accept Medicare, Supplemental or Advantage plan.

Here are basic definitions of types Medicare:
https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare

You might want to talk to an professional about Medicare insurance and options.

I know when I chose my Medicare plan after cancer, I specially asked about amount of maximum out of pocket costs and the options of where I could go for treatment. Knowing what cancer treatment cost, I wanted to make sure that medical cost even with insurance did not bankrupt me. And I wanted to make sure I would not have to change providers.

Laurie

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Look into Medicare Advantage plans. I have a BC/BS PPO so I can use docs in different networks. The ceiling for mine is $3000/year and I pay very little per month. No need for supplementary or drug plan with Advantage plans, also known as Medicare Replacement Plans.

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I would call Medicare. Mine switched to Medicare Advantage after reconstruction was complete. I had an interesting experience with follow ups. Medicare fully covered my Dexa bone scan since it is a preventive screening. Since I can’t have a mammogram, the only preventative screening that is done yearly is an ultrasound. Medicare did not cover the full cost. I called to explain to them that ultrasound is my new normal. The associate was very concerned. She put it on review for their next meeting. She said I would not get the balance refunded that year, but for me to tell the doctor to call so that in the future, they could use a different code. She was very concerned. I have not paid since, but if they hadn’t taken me seriously, I would be paying $40 every year. I can afford that, but many women can’t and that’s why I was advocating. I think Medicare is required to cover reconstruction, but I think there is a level that they have in place, even the types of implants they will accept. Medicare associates were also extremely helpful while I needed extra Dexa scans. They told me that while I was still in osteoporosis phase from the AI, I would be able to have as many Dexa’s as I needed. I don’t know what regular Medicare covers. I suspect that there could be balances just like regular insurance because the year after my surgery Julia Louis Dreyfus modeled a breast cancer tee shirt which I purchased because 100% of the proceeds would go to women who can’t afford reconstruction. Check with your hospital too. The finance department had me fill out forms so that extra expenses would get picked up in the event that I might owe something. The financial office actually called me to make sure all my info was exact. The combination of my Prolia with my anastozole is always listed as chemo because they are combining 2 biologics. The Prolia is given at the cancer center of the hospital because Prolia can also help prevent bone mets, so it is doing double duty for me. Haha, I keep thinking insurance would rather pay $4000 for 2 biologics than what chemo would cost, but their world doesn’t always work that way…
I did not have my reconstruction done in-network due to an accidental second opinion. My provider was out of network, but my original doctors would all have been affiliated with a hospital group. A phone call can go a long way. If you are doing it through a hospital group, I would also call the hospital’s financial office and see what they say. My oncologist is at the hospital, and it has even picked up my copayments because they have a special fund for minor payments. It’s amazing what we don’t know that they can do for us.

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At 79, I was already on Medicare last year when I had my breast reconstruction. Medicare and my supplemental paid 100%. Yours is an interesting situation, and I wish you the very best with your financial quandary.

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