Breast Implant Problems? Obamacare Can Help!


If you’re having problems with your breast implants, there’s a chance you could benefit from the Affordable Care Act (ACA, or “Obamacare”).

An important change was made when the Affordable Care Act was passed: health insurance companies could no longer refuse to pay for health care arising from a pre-existing condition. Pre-existing conditions are health problems you had before joining an insurance plan. For example, your health insurance company can’t refuse to cover your insulin medication if you were diagnosed with diabetes before buying their plan. This is important because before the Affordable Care Act, insurance companies considered breast implants a pre-existing condition. They refused to cover any breast implant problems and sometimes even problems that occurred in the breast tissue.

Now insurance companies are usually required to pay for “medically necessary” services. Most insurance companies define “medically necessary” as a service that 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 deemed 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, we have found that many companies consider removal of breast implants to be medically necessary for these conditions:

  • Ruptured silicone gel breast implants
  • Severe capsular contracture
  • Infections that don’t go away
  • Chronic breast pain
  • ALCL (a rare cancer of the immune system)

Additionally, insurance companies such as Aetna, UnitedHealthcare, and Cigna tend to have good coverage for medically necessary breast implant removal if you meet their criteria that include the conditions listed above. The language that each policy uses can vary by state and plan type, so be sure to look for the language regarding breast implants in the specific plan you are considering.

There is a window of time called “Open Enrollment” each year when you are able to sign up for a plan through the health insurance marketplace.  Read below to see how to sign up for health insurance through the Affordable Care Act or Medicaid.

How Do I Sign Up During Open Enrollment?

Starting in early November, you likely had the opportunity to choose an affordable health insurance policy through the government’s Health Insurance Marketplace. This Marketplace helps you to shop for insurance plans that everyone can afford. While Open Enrollment for coverage for 2021 had previously ended December 15th, 2020 in most states, the ACA marketplace has reopened and extended enrollment deadline until August 15th, 2021. You will have the opportunity to choose an affordable health insurance policy through the government’s Health Insurance Marketplace. This Marketplace helps you to shop for insurance plans that everyone can afford.  For more information, read here: https://www.healthcare.gov/quick-guide/.

Once open enrollment period for coverage in 2021 through the Health Insurance Marketplace ends for your state,  but you’ve recently lost your health insurance coverage due to recent job loss, including sudden unemployment related to the COVID-19 pandemic, or have had a major life event, like getting married or having a baby,  you may be eligible to sign up for health insurance outside of the Open Enrollment period. If you follow this link: https://www.healthcare.gov/screener/ you can check whether you might be eligible for coverage in 2021 outside of the enrollment period.

This Marketplace allows you to shop for insurance plans and apply savings based on your household income. The lower your income, the less you’ll have to pay. 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 that a doctor determines are 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.

 

All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.