I haven’t had a new Breast Prosthesis in years. How do I know if I’m eligible to get a new one?
Call us to check your benefits. We can probably tell you over the phone when you call how often you are eligible for new prostheses and bras. Medicare has a set amount as do other insurances. For Medicare, if you don’t remember when you last received these, we can call and find out for you.
Are Breast Prostheses and Bras Covered under Insurance?
In the State of Maryland it is required for insurance companies to cover Mastectomy related items. But you need to know if you have a Self Funded Plan that is governed by Federal Laws. If this is the case, your items may not be covered. Most insurances do cover Surgical Camisoles, Prostheses and Bras. Some cover Wigs and Lymphedema Sleeves and Gloves. We can check your benefits and let you know what is covered. We can also steer you to some of the State Funds that are available to women who have undergone Breast Cancer Surgery and Treatments.
I have opted to go through Breast Reconstruction. Are Bras and Forms covered?
You will need to provide us with some detail on where you are in this process. We can review your prescription and contact your insurance company to gain information on all benefits you have under your plan.
I have Maryland Medical Assistance. Can I get a Prosthesis and Bra?
Yes, your doctor should give you a prescription that you can bring in to us. We can measure and fit you in a form and bra. These are covered items under Medicaid and Medical Assistance.
Are Lymphedema Garments covered by Medicare?
Lymphedema Treatment Act Final Rule Coverage Summary
What will be covered:
- Custom and standard fit daytime and nighttime garments.
- Custom and standard fit gradient compression wraps with
adjustable straps. - Bandaging supplies for any phase of treatment.
- Accessories including but not limited to donning and doffing
aids, padding, fillers, linings, and zippers.
Frequency allowances:
- Daytime garments – 3 sets (one garment for each affected body
part) every six months, standard or custom fit, or a combination
of both - Nighttime garments – 2 sets (one garment for each affected
body part) every two years, standard or custom fit, or a
combination of both - Bandaging supplies – no set limit in the rule.
- Accessories – no set limit, will be determined on a case-by-
case basis depending on the needs of the patient.
Coverage requirements:
- To be eligible for the above coverage a patient must have been
diagnosed with lymphedema and have a prescription for the
compression supplies. - The coverage will begin January 1, 2024. There will be no
retroactive coverage, meaning, you cannot submit claims for
any garments or supplies purchased or ordered before
1/1/2024.
Codes and reimbursement rates:
- 57 codes specifically for lymphedema compression supplies
will be created, and the rule also outlines the process for the
creation of additional codes in the future if needed. - This list of codes and their corresponding reimbursement rates
will be released soon, and are not included in the final rule.
Deductibles and copay:
- For traditional Medicare – these supplies will be covered under
Part B, so the annual Part B deductible and 20% coinsurance
apply to all compression supplies. - For Medicare Advantage and all other types of insurance – out-
of-pocket costs will vary depending on the specific terms of
your plan. It is likely that your compression supplies will be
subject to the same copay and deductibles as supplies covered
under the DMEPOS (Durable Medical Equipment, Prosthetic
and Orthotic Supplies) section of your policy.
Please call us and we can provide information to you on your specific situation.
Are my compression stockings covered by Medicare?
Medicare will only cover compression stockings that are a high compression (30-40mmHg) IF you have an open ulcer. If this criteria is met your Medicare Part B will pay 80% of the cost. If you have an open ulcer, but your doctor prescribes a lower compression (20-30 mmHg) Medicare will not cover. If you do not have an open ulcer, Medicare will not cover. Please call us with your specific diagnosis and we can review your Medicare or other carrier benefits with you.
Is there a charge for Checking My Insurance Benefits?
No, part of our service to you the Patient is that we will call your insurance company and check your benefits for you. We will need to have information and copies of your insurance and ID cards (or have them read to us if calling on the phone) in order to check your benefits and we’ll need to know what you are being prescribed and what your doctor has as your diagnosis. This combination will allow your insurance company to provide us with exactly what benefits you have for item you are prescribed.
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