Farzana Akkas and Lauren Goldbeck, National Center for Health Research
If you’re having problems with your breast implants, there’s a chance you could benefit from the Affordable Care Act (ACA, or “Obamacare”). You should take advantage of the law while it’s still in place, because good quality health insurance may be less available a year from now.
Under this law, health insurance companies can’t refuse to pay for health care arising from a pre-existing condition. Those are health conditions you had before joining an insurance plan. For example, insurance companies can’t refuse to cover your medication if you were diagnosed with diabetes before buying their plan. Before the Affordable Care Act, insurance companies considered breast implants a pre-existing condition. They often refused to cover any breast implant problems or even other problems in the breast.
Now insurance companies are usually required to pay for “medically necessary” services. Medically necessary means that a service is required to improve your health or keep you healthy. Although some insurance companies say they do not cover services related to cosmetic surgery, many have exceptions when those services are medically necessary. It is important that you read the policies carefully before you choose!
Based on our experiences working with women having problems with their breast implants, here are some tips that might help you make a decision:
- Many companies consider removal of breast implants medically necessary for these conditions:
- Ruptured silicone gel breast implants
- Severe capsular contracture
- Infections that don’t go away
- Chronic pain
- ALCL (a rare cancer of the immune system)
- Aetna, UnitedHealthcare, and Cigna plans tend to have good coverage for medically necessary breast implant removal if you meet their criteria that include the conditions listed above.
What Should I Know Before Signing Up?
Go to www.healthcare.gov to look at the plans offered through your state. You can find pricing information for 2018 plans on the website. The lower your income, the less you’ll have to pay.
If you’ve recently lost your health insurance coverage, you can sign up through the online exchange now. You might also be able to sign up now if you’ve had a major life event, like getting married or having a baby.
Otherwise, you can sign up for health insurance between November 1 and December 15. Coverage would start January 1, 2018. If you live in California, Colorado, Minnesota, Washington, Massachusetts, or the District of Columbia, you have a few more days or weeks to sign up depending on your state [1,2,3,4,5,6]. If you live in these states or DC, you should check their deadlines and when your coverage would start.
If you get health insurance through your job or your spouse’s job, your enrollment dates might be different. You should check with your employer.
Before you buy a health insurance policy, you should ask to make sure it includes coverage for breast implant-related health problems that would qualify you for medically necessary removal. If they can’t answer your question or tell you it won’t be covered, reach out to us at email@example.com. We’ll do our best to help you find a better policy.
Want to know how much your health insurance plan will cost through the Affordable Care Act? Use this calculator to find out.
Is Medicaid an Option?
In many states, Medicaid is available for free to any individual or family under 133% of the poverty line (about $30,000/year for a family of 4). Medicaid provides coverage for surgery or services a doctor considers medically necessary. You can find out if you are eligible for Medicaid at www.healthcare.gov.
Read here for more information on getting Medicaid coverage for your breast implant removal surgery.
Unfortunately, fewer people are eligible for Medicaid in states that did not adopt the Medicaid expansion provided by Obamacare.
Is Medicare an Option?
If you’re over age 65, you are eligible for Medicare. You can also be eligible for Medicare if you’re under age 65 and receive Social Security Disability Insurance (SSDI) or have end-stage renal disease.
Read here for more information on getting Medicare coverage for your breast implant removal surgery.
If you’re on Medicaid or Medicare and have problems getting coverage for your breast implant problems, contact us at firstname.lastname@example.org.
- Covered California and the Department of Health Services. (2017). Open Enrollment Runs Through Jan. 31, 2018. Retrieved from https://www.coveredca.com/apply/. Accessed on November 1, 2017.
- The Colorado Division of Insurance and the Colorado Department of Regulatory Agencies. (2017). Open Enrollment Dates for 2018 Colorado Health Insurance Coverage Set: Nov. 1, 2017 to Jan. 12, 2018. Retrieved from https://www.colorado.gov/pacific/dora/news/open-enrollment-dates-2018-colorado-health-insurance-coverage-set-nov-1-2017-jan-12-2018. Accessed on November 1, 2017.
- (2017). Open Enrollment Period. Retrieved from https://www.mnsure.org/new-customers/enrollment-deadlines/open-enrollment/index.jsp. Accessed on November 1, 2017.
- Washington Health Benefit Exchange. (2017). Washington Health Benefit Exchange. Retrieved from https://www.wahbexchange.org/. Accessed on November 1, 2017.
- Commonwealth of Massachusetts. (2017). Health Insurance Open Enrollment and Waivers. Retrieved from http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commission/patient-protection/health-insurance-open-enrollment-and-waivers.html. Accessed on November 1, 2017.
- DC Health Link. (2017). Open Enrollment & Renewal Deadlines. Retrieved from https://dchealthlink.com/open-enrollment. Accessed on November 1, 2017.