Table of ContentsView AllTable of ContentsBreast Cancer CareInsurance CoverageSwitchingWithout InsurancePlanningFrequently Asked Questions
Table of ContentsView All
View All
Table of Contents
Breast Cancer Care
Insurance Coverage
Switching
Without Insurance
Planning
Frequently Asked Questions
Insurance coverage for breast cancer screening, diagnosis, and treatment is critical to getting access to healthcare for this condition. People without insurance or who are denied coverage for certain treatments or procedures need to explore their options.
As many as 313,510 people are expected to be diagnosed withbreast cancerin 2024.Knowing what resources are available is key to getting the best outcome.
This article will outline the treatments you may need for breast cancer, what types of insurance cover them, and what you can do when you do not have insurance.
Mark Kostich / Getty Images
Prevention, Diagnosis, and Treatment of Breast Cancer
Knowing what kind of care you need at each cancer diagnosis level is important.
Free ScreeningThe National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was created in 1990 to increase access to breast cancer screening. The program has provided more than 16.5 million breast and cervical cancer screening examinations.
Free Screening
The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was created in 1990 to increase access to breast cancer screening. The program has provided more than 16.5 million breast and cervical cancer screening examinations.
Diagnosis:A mammogram may raise suspicion of cancer, but abreast biopsy(removing a tissue sample from the breast for analysis in a lab) is necessary to make a formal diagnosis. Information from this biopsy will be key in deciding how to treat you.
Your healthcare provider will also want to ensure the breast cancer has not spread to other parts of the body. This may require additional imaging studies, procedures, office visits, and hospitalizations.
Treatment: Treatments include medication (e.g.,chemotherapy,hormonal therapy,immunotherapy),radiation, surgery (e.g.,mastectomy), or any combination of these.
In 1998, the Women’s Health and Cancer Rights Act required that health plans that cover mastectomy (surgical removal of a breast) also have to offerreconstructive breast surgeryfor people undergoing a mastectomy. This could include breast implants or a prosthesis.
Cosmetic vs. Reconstructive Surgery
Finding Out Breast Cancer Coverage With an Existing Policy
When theAffordable Care Act (ACA)was passed in 2010, it required that insurance plans cover 10 essential health benefits. Those benefits included the services needed to treat serious conditions like cancer.
Screening mammograms were made free, and ambulatory care (care outside of the hospital), hospital care, laboratory tests, prescription drug coverage (such as one drug from every class, including chemotherapy), and rehabilitation services were included in all plans.
Unfortunately, not all health plans have to follow the ACA rules. Individual private plans and small group plans do. However, plans that existed before the ACA (referred to as grandfathered plans) and large-group plans do not. Depending on the type of insurance you have, your cancer coverage may vary.
Marketplace or Private
The ACA created the Health Insurance Marketplace, which many individuals and families turn to for care today. Plans are divided into metal categories (bronze, silver, gold, and platinum). Monthly premiums increase, deductibles decrease and your cost of care gradually decreases as you move from a bronze to a platinum plan.
Premium subsidiesare available to help people keep costs down. Those subsidies originated with the ACA but were expanded with the American Rescue Plan in 2021 so that no one would pay more than 8.5% of their income on healthcare.The Inflation Reduction Act of 2022 has extended these larger subsidies through 2025.
Employer
Depending on the size of your employer, you may be offered group health insurance through your job. The ACA requireslarge employers(defined in most states as those hiring the equivalent of 50 full-time employees) to provide affordable, comprehensive healthcare to employees working more than 30 hours per week.
To be affordable, a plan must not cost you more than a certain percentage of your income (8.39% in 2024 and 9.02% in 2025).To be comprehensive, a plan must giveminimum value, meaning that it covers sufficient hospital and physician services.
Large employers offering insurance canself-insure or fully insuretheir plans. “Self-insured” means the employer puts their health plan together and pays for your care directly. “Fully insured” means the employer purchases care through an insurance company.
Dense Breasts
Dense breastsare not something you feel; they’re something seen in medical imaging. People who display this radiological finding on a mammogram may be at an increased risk of breast cancer.
Medicaid
Medicaidis run on a state level, although it receives funding from both the federal government and the states. It is offered to families with low incomes, pregnant people, children, and those who aremedically needy.
States thatexpanded Medicaidunder the Affordable Care Act may also extend eligibility to single people who qualify based on income.
Medicaid, in general, pays toward cancer care. What is covered and what you pay will depend on the state in which you reside.
People who do not traditionally qualify for Medicaid may still be able to receive treatment for breast cancer through the program. Specifically, a person of any sex or gender diagnosed with breast cancer through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) qualifies for treatment through Medicaid.
Of note, to qualify for NBCCEDP screening your yearly income must be below 250% of the federal poverty limit.
Medicare
Medicareis a federally funded healthcare program for people 65 and older or those withqualifying disabilities. Care is divided into four parts: Part A (hospital insurance),Part B(medical insurance),Part C(Medicare Advantage), andPart D(prescription drug coverage).
The federal government runs Original Medicare (Part A and B). Private insurance companies run Medicare Advantage (an alternative to Part A and Part B that can offer supplemental benefits) and Part D.
Medicare covers a wide range of cancer care. Mammograms are covered for free if the healthcare provideraccepts assignment. If necessary,breast ultrasoundandbreast MRIare also covered for a fee.
Regarding treatment, Part B covers surgeries, radiation, and a wide range of chemotherapy options. Other medications, including some specialized chemotherapy treatments and immunotherapies, require Part D coverage.
Costs in Original Medicare are relatively standard. There are fixed rates for inpatient hospital care depending on the number of days you are hospitalized.
To help pay down any deductibles, coinsurance, or copays, many beneficiaries on Original Medicare will also enroll in a Medicare Supplement plan, known asMedigap. Costs for Medicare Advantage and Part D plans vary based on the insurer.
Cancer Insurance
Cancer insurance is a kind of supplemental insurance that you can use together with your primary health plan.
Depending on the supplement you enroll in, it will help pay down costs related to your cancer care (deductibles, copays, coinsurance, etc.). It can also help you pay for non-medical expenses such as groceries, mortgage/rent payments, and transportation to and from your appointments.
Unfortunately, these sorts of plans rely onmedical underwriting, meaning they can use preexisting conditions to increase the rates for their plans, decrease the number of benefits offered, or deny you coverage altogether.
Having cancer, unfortunately, is a preexisting condition that will prevent you from taking advantage of one of these plans. The trick is to enroll in one of these plans before you are diagnosed with cancer. Not everyone can afford to do so.
Switching Insurance for Better Breast Cancer Benefits
In a perfect world, your health plan would cover all the facilities, providers, and treatments you want. In reality, not all plans are created equal. Treatments your healthcare provider recommends may or may not be covered.
It may be in your best interest to change to a plan that gives you more treatment options. However, you cannot switch plans whenever you want.
Unless you have a major life event that qualifies you for aspecial enrollment period(e.g., you got married, divorced, lost your job, etc.), you can usually only change your plan once a year. This occurs during a designated period known as the open enrollment period. These are:
Make sure you know when youropen enrollment periodis, so you don’t miss an opportunity to sign up for a plan that best meets your needs.
Talking With an Insurance AgentIf you are uncertain what type of plan will work best for you, reach out to an insurance agent. Ask them about the differences between available plans, about specific coverage options pertaining to your cancer care, and how much you would be expected to pay. It’s important that you make an informed decision.
Talking With an Insurance Agent
If you are uncertain what type of plan will work best for you, reach out to an insurance agent. Ask them about the differences between available plans, about specific coverage options pertaining to your cancer care, and how much you would be expected to pay. It’s important that you make an informed decision.
Resources for Patients Without Insurance
No one should be denied cancer treatment because they can’t afford it. If you do not have insurance, and even if you do, there are a number of charitable organizations you can turn to as a way to decrease the financial burden, including:
These are not the only organizations willing to help. Be proactive and reach out for help.
Financial Planning for Out-of-Pocket Costs
Cancer can take a toll, physically and emotionally, but it can also lead to financial toxicity, which is a term for how the cost of cancer care can affect your quality of life.
Due to high medical costs, especially for those without insurance, many people do not take their medications as prescribed, and some do not even complete their treatment course. Others cut back significantly on expenses such as food, clothing, or utilities.
Know that there are resources to help you through these difficult times. The following organizations have financial planning programs available that may help you manage your expenses and decrease the burden you face:
Summary
Breast cancer treatment can get expensive, making it so important to get insurance if you can. Thanks to the Affordable Care Act, cancer care is offered through most plans.
Whether you’re on a Marketplace plan, an employer plan, Medicaid, or Medicare, make sure you understand what is covered and how much you can expect to pay. Also, be sure to talk to your healthcare providers so you can decide on the most affordable treatment plan.
Beyond insurance, there are charitable organizations and financial planning services that can help you manage costs. Do not let cancer get the upper hand.
A Word From Verywell
The costs of cancer care add to the burden of the condition. Know that you are not alone. There are a number of resources available, from health insurance to charitable programs. Do not hesitate to ask for help.
Frequently Asked QuestionsAll plans are required to cover screening mammograms, but beyond that, coverage will vary from plan to plan. Before you enroll in a plan, it is important that you look into what kinds of treatments it covers and how much you can expect to pay.Learn MoreBreast Cancer Screening GuidelinesCancer insurance is not meant to be used on its own. It is a supplemental policy you can use with your health plan to help to pay for any cancer-related care. These plans can be difficult to get after you’ve been diagnosed with cancer. You often need to enroll in these plans when you are healthy.Learn MoreBreast Cancer Risk FactorsBreast cancer treatments will vary based on thespecific type of canceryou have and whether it has spread to other parts of the body. Chemotherapy costs, in particular, can range from $10,000–$100,000 without insurance. With insurance, you could expect to pay only a percentage of these costs.Learn MoreWhat Happens During Chemotherapy?
All plans are required to cover screening mammograms, but beyond that, coverage will vary from plan to plan. Before you enroll in a plan, it is important that you look into what kinds of treatments it covers and how much you can expect to pay.Learn MoreBreast Cancer Screening Guidelines
All plans are required to cover screening mammograms, but beyond that, coverage will vary from plan to plan. Before you enroll in a plan, it is important that you look into what kinds of treatments it covers and how much you can expect to pay.
Learn MoreBreast Cancer Screening Guidelines
Cancer insurance is not meant to be used on its own. It is a supplemental policy you can use with your health plan to help to pay for any cancer-related care. These plans can be difficult to get after you’ve been diagnosed with cancer. You often need to enroll in these plans when you are healthy.Learn MoreBreast Cancer Risk Factors
Cancer insurance is not meant to be used on its own. It is a supplemental policy you can use with your health plan to help to pay for any cancer-related care. These plans can be difficult to get after you’ve been diagnosed with cancer. You often need to enroll in these plans when you are healthy.
Learn MoreBreast Cancer Risk Factors
Breast cancer treatments will vary based on thespecific type of canceryou have and whether it has spread to other parts of the body. Chemotherapy costs, in particular, can range from $10,000–$100,000 without insurance. With insurance, you could expect to pay only a percentage of these costs.Learn MoreWhat Happens During Chemotherapy?
Breast cancer treatments will vary based on thespecific type of canceryou have and whether it has spread to other parts of the body. Chemotherapy costs, in particular, can range from $10,000–$100,000 without insurance. With insurance, you could expect to pay only a percentage of these costs.
Learn MoreWhat Happens During Chemotherapy?
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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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