How Does Insurance Reimbursement Work?

How Does Insurance Reimbursement Work?

Dana Donofree
4 min read

We often get asked about AnaOno bras and insurance coverage, and while insurance guidelines prohibit us from taking insurance online, you may be able to get reimbursement on your purchases.

We wanted to provide a brief step-by-step guideline that will help you if reimbursement is an option for you. 

Before delving in, we first want to note that all plans and plan benefits are different. Our steps are not a guarantee of payment, nor are they a guarantee of full payment, as you'll see below. We also strongly suggest reaching out to your insurance provider for the full details on what they might need, as this is a basic list of how to proceed.

What is covered?

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:

  • 4-6 Mastectomy bras (bras that have pockets close to the chest) annually, or as many as are medically needed/indicated by your doctor. Additional Bras may be prescribed as a result of surgery and/or loss or gain of weight
  • As many camisoles as are medically necessary, but not more than 3 per month

Again, 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

The only items that are currently eligible on our site for reimbursement are our pocketed bras and tank top camisole. You do not have to use breast forms to be reimbursed, but the garment must have pockets. You can find our pocketed collection here.

    How much is covered?

    This again is dependent not only on who your insurer is, but what 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 $31.39 (minus any coinsurance or deductible) per bra in Colorado, but only $26.68 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 (that is the billing code for mastectomy bra with pockets). 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
    • The fact we are considered an out-of-network company

    How do I get reimbursed?

    Again, we stress the importance of discussing this with your benefits coordinator or health insurance plan in order 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 physician for a mastectomy or pocketed bra or camisole (and how many)
    • A diagnosis code from your physician (this should be on the prescription)
    • Your itemized receipt that you can request from AnaOno after you make a purchase
    • The reimbursement form required by your insurance provider

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

    How does it work?

    After all our your paperwork is in order, you've checked with your insurance provider to make sure you have everything they need, and you've sent everything in, your claim may take anywhere from 30 days to 120 days (another thing to check with your insurance company) to pay. 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 - 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 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.

    Dana Donofree
    Dana Donofree

    Founder and CEO of AnaOno. After a diagnosis of breast cancer in her late 20’s, Dana took her own lived experience and fashion design background and (re)designed intimates for those that have undergone breast surgery. Dana’s story has been published around the world in outlets like New York Times, BBC, Huffington Post, The Today Show, and more.