Salon

In the U.S., Medicare sets the general guidelines for what is or is not covered and how the benefits apply. Currently, Medicare guidelines only provide partial reimbursement for the following:

• Four to six mastectomy bras (bras that have pockets close to the chest) annually, or as many as are medically needed or indicated by your doctor. Additional bras may be prescribed because of surgery and/or weight changes.
• As many camisoles as are medically necessary, but not more than three per month.

These are Medicare's guidelines, and while these numbers and partial reimbursement apply to Medicare plans only, the rules are generally the same with private insurers. What may change between your private insurer and Medicare is the following:

• The number of pocketed bras or camisoles you are allowed
• The amount of money reimbursed for each product
• Coverage for Cranial Prosthesis (wigs)

This is dependent on your insurer and the type of plan you have with that insurance company. Companies and plans determine what is a reasonable and customary amount (or fee schedule) for each product billed - and that can range dramatically between insurance companies and even between plans under the same insurance carrier. For example, Medicare reimburses $37.62 (minus any coinsurance or deductible) per bra in Colorado, but only $43.98 per bra in Florida. If you would like to know what your reimbursement could potentially be, we encourage you ask your health insurance carrier what the fee schedule or reimbursement is for code L8000 (the billing code for mastectomy bra with pockets), and for code L8030 (the billing code for silicone breast prosthesis).

The full amount you will be reimbursed can depend on the following:

• What the insurance plan deems is a reasonable and customary fee
• What your copayment or coinsurance responsibility may be
• If the product is subject to your deductible
• If your deductible has been met
• Moffitt being an out-of-network supplier for durable medical equipment (DME)

It is important to discuss this with your health insurance provider to make certain you have everything they require and what their reimbursement rates may look like. You will most certainly need to submit to them the following information:

• A prescription from your provider for a Cranial Prosthesis, mastectomy bras, camisoles, post-surgical bras/camisoles and a prosthesis if needed. (including how many)
• A diagnosis code from your provider (this should be on the prescription)
• Your receipt from Magnolias Salon
• The reimbursement form required by your insurance provider

Your provider’s office should be familiar with the reimbursement procedure and should be able to provide you with all the details you need on the required prescription. Some insurance providers also require pre-authorization of products, so it is important to ask if your plan requires it. Pre-authorization may be initiated through your provider’s office. We strongly suggest you discuss this with your insurance provider.

After all your paperwork is in order, you've checked with your insurance provider to make sure you have all the required information, and you've sent everything in, your claim may take anywhere from 30 to 120 days (another thing to check with your insurance company) to payout. Claims are given at least 30 days to process, so if you don't see anything immediately, don't worry. While most companies process claims quickly, some do not. If you have any questions about your claim, contact your insurance company.

After your claim is processed and approved, you will receive a check for the reasonable and customary fee amount (determined by your insurance carrier) minus any copayment or coinsurance responsibility. Congratulations! You were successfully reimbursed. 

Remember, most insurance plans are annual calendar year rather than fiscal year. So, benefits generally renew (with any deductible responsibility) on January 1. Plan benefits for the year generally end on December 31. There are no limitations on the length of time since surgery for one to file a reimbursement claim. 

Your insurance carrier may also impose limitations from purchase to reimbursement filing (often one year), so please check with your carrier with any questions.