Summary: These questions and answers were compiled from some of the top insurance companies across the United States. Remember, you should always check with your own insurance provider for the exact coverage of your plan, as plans vary from person to person. Here you can read questions and answers about the coverage of therapy services, therapeutic devices for both men and women, and what to include with your claim.
These questions and answers were compiled from some of the top insurance companies across the United States. Remember, you should always check with your own insurance provider for the exact coverage of your plan, as plans vary from person to person. This information is for educational and informative purposes only, and in no way solidifies what your insurance company will, or will not, pay for your claims.
Q: “Will my insurance cover my breast prothesis and mastectomy bra?”
A: For exact coverage, contact your insurance company directly. Although, most insurance companies will cover costs for the prothesis and mastectomy bras. Medicare covers this type of prothesis with a prescription from their doctor stating their need and diagnosis.
Q: “Does Medicare cover breast prothesis after cancer surgery?”
A: This information is from the Medicare website. “Medicare Part B (medical insurance) covers some external breast prostheses (including a post-surgical bra) after a mastectomy. Part A covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an inpatient setting. Part B covers the surgery if it takes place in an outpatient setting. You pay 20% of the Medicare-approved amount for the doctor’s services and the external breast protheses. The Part B deductible still applies.” Again, always remember to check in about your specific plan information as many things for breast cancer survivors are covered.
Q: “How will it work with my insurance when I file for my breast forms?”
A: Once you have confirmed with your insurance company how their process works, you can then reach out to those places who sell or make the breast prothesis forms. Some companies will accept Medicare assignment, which means they can help you to file your claim through their system. If they are not a Medicare assigned provider, do not worry.
- If the company is not a Medicare assigned provider, they may not take assignment and request payment from you in full, and then bill your insurance or Medicare on your behalf so that the reimbursement check comes to you.
- If the company is not a Medicare assigned provider, they may not take assignment and request your payment in full, or according to their payment plan. Then, once paid in full, you can file your own claim with your insurance company, with receipt and proper prescription and coding.
- If the company does accept Medicare assignment, they can help you with the entire filing process. This will allow you to take the form without full payment, while the store files for direct reimbursement. In most cases, you will be expected to pay your insurance deductible or coinsurance responsibility.
In most cases, this is typical for insurance companies. You should always verify with your own insurance company and policy to best understand the process to ensure you get reimbursed.
Q: “I am uninsured and do not have the funds to cover the cost for a breast prothesis after my cancer surgery. What can I do?”
A: There are many organizations that can help you and offer financial assistance. Each organization has a different application process and requirements, and all grants are always subject to eligibility verification.
- American Cancer Society / 800-ACS-2345 / http://www.cancer.org/ — Referrals for financial assistance; some local offices provide transportation assistance, temporary housing, wig, prostheses, bras, or prescription assistance.
- CancerCare / 800-813-HOPE / http://www.cancercare.org/ — Financial grants available for transportation, homecare, childcare and pain medications. Linking Arms Program can provide grants for breast cancer patients to help with selected supply costs.
- Patient Advocate Foundation / 866-512-3861 toll-free / — Provides direct co-pay assistance for pharmaceutical products to insured breast cancer patients (including Medicare Part D beneficiaries) who financially and medically qualify.
If you are in medical financial distress, reach out to local organizations as well to find the help you need to get the care and services you deserve.
Q: “Will insurance cover the cost of my penis pump?”
A: While every insurance is different, and you should always check in with your company about your specific plan, most insurance companies do offer coverage for these devices when there is a documented history of cancer related penile dysfunction, cancer and treatment, or other medical issues that interfere with the function of the penis.
To better ensure coverage, many insurance companies state that these things are needed for the claim to be filed:
- Insurance companies do reimburse for the prescription (Rx) vacuum erection devices with a recent prescription from their primary care physician that includes the coding for the therapeutic device.
- In order to be reimbursed, you must have a doctor’s note indicating you have organic erectile dysfunction as a primary diagnosis.
- You must provide proof of payment or receipt of purchase with the insurance code that matches the device prescribed.
Q: “Does Medicare cover erectile dysfunction services, devices or therapies?”
A: Medicare does not offer as much sexual dysfunction coverage for men as they do women. In certain cases, medications, therapeutic devices, and penile implants are covered. This varies on a case by case basis. You should contact your Medicare provider directly to address your plan information to find out if these services are covered for you.
MedicareFaq states, “If you are currently enrolled in only the Original Medicare (Part A and B), erectile dysfunction medications are not covered. Medicare Part B will cover any erectile dysfunction medical equipment, but not the prescription itself. This leaves the patient with a 20% cost to cover, unless enrolled in a Medigap plan covering those costs.
Therefore, you may need to purchase a Part D Prescription Drug Plan to cover any erectile dysfunction medications prescribed. Medicare Part D may cover the cost of the medications, given the private insurers include that. Although, it is common for a Part D plan to not cover Cialis, as it is not considered medically necessary.
If you have a Medicare Advantage plan that includes drug coverage, your medications will likely be covered. Finding a plan that will supply this may be tough. You may end up paying a higher percentage of the cost.”
Q: “Are condoms covered by insurance?”
A: This depends on your insurance company, and if you are purchasing male condoms or female condoms. This is a grey area in many insurance agencies. If the condom use pairs with medical treatment, they can be covered with a prescription. Female condoms are more often covered by insurance than male condoms, further proving the gaps in knowledge and safety with our sexual health, safety and wellness. Thankfully condoms are not the most expensive item you might need, but you should always look out for quality standards and no extra ingredients.
Q: “Is sex therapy or counseling services covered by my insurance?”
A: That depends entirely on your plan and coverage. In most cases, therapy from a licensed and registered psychologist is covered, but they often lack the expertise of a sex therapist or counselor. Medicare does offer therapy services, as do many private insurance companies. If you cannot afford these services, check in with us at Reclaiming Intimacy Through H.O.P.E. to hear about our educational course selections & holistic approaches which can help to get you back on track.
Please remember that it is always best to contact your own insurance company to find out about the specifics of your own plan. You should, however, always have a prescription from your doctor with your diagnosis, proper coding, and your need. This helps to show the necessity and can help you find more coverage.
American Cancer Society
Patient Advocate Foundation