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Insurance & Financing

Insurance Coverage for Breast Reconstruction

One of the most common concerns patients have is: Will my insurance cover breast reconstruction? In the vast majority of cases, the answer is yes.

Thanks to the Women's Health and Cancer Rights Act (WHCRA), all health insurance plans that cover mastectomy are required to also cover breast reconstruction. This includes surgery to restore symmetry to the opposite breast. Reconstruction after a prophylactic mastectomy is also typically covered if you're considered high-risk, such as having a strong family history of breast cancer or testing positive for the BRCA gene.

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We Take Care of the Details—So You Can Focus on Healing

Even knowing your surgery is covered, navigating insurance terms, deductibles, and billing statements can be overwhelming, especially during such a pivotal moment in your health journey.

That's where our expert PRMA Billing Team comes in.

  • We work directly with your insurance company to verify coverage, submit claims, and follow up until they're paid.
  • You'll receive a personalized cost estimate before surgery, so there are no surprises.
  • We've partnered successfully with hundreds of insurance providers over the last 20+ years.
  • We'll keep you informed every step of the way.

Have questions about your benefits or estimate?
Call our Billing Department at 210-447-7829.
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Financial Assistance Resources

If you need financial support beyond insurance coverage, there may be help available:


Travel and lodging assistance is also available through various partners.
Explore Travel & Lodging Assistance

Frequently Asked Insurance Questions

What is a Deductible?
A deductible is the amount you must pay for medical expenses before your insurance begins paying benefits. Most deductibles reset annually based on the calendar year.
What is a Co-Pay?
A co-pay is a set dollar amount you pay each time you're seen for medical services.
What is Co-Insurance?
Co-insurance is the portion of medical expenses you share with your insurance company. For example, in an 80/20 plan, insurance pays 80% of approved costs, and you pay the remaining 20%. (This applies after you meet your deductible.
What is an Out-of-Pocket Maximum? How do I reach it?
This is the maximum dollar amount you pay in a calendar year through co-insurance. Once reached, your plan pays 100% of eligible charges. Note: co-pays don't count toward your out-of-pocket max.
What is an Allowable?
An allowable is the negotiated rate your insurance pays for a specific service. It's the amount your doctor receives from your carrier.
What is Balance Billing?
Some providers charge more than the allowable rate and bill patients for the difference—this is called balance billing. At PRMA, we do not balance bill. We accept only what your insurance allows. There are no hidden costs.
What is a Global Period?
The global period is typically 90 days following surgery, during which your follow-up visits are included in the surgical fee. No additional billing applies during this window. Further procedures, like the next phase of reconstruction, can only occur once the global period ends.
What is an In-Network vs. Out-of-Network Provider?
  • In-network providers have a contract with your insurance and accept pre-negotiated rates.
  • Out-of-network providers do not have such agreements, and you may be responsible for uncovered costs.
All PRMA surgeons are in-network with most major U.S. insurance providers. Please confirm with our staff.
What's Not Covered by My Insurance?
Typically, insurance covers the initial reconstruction and one revision surgery. However, if further revisions are requested purely for cosmetic improvement and not deemed "medically necessary," insurance may not approve them. In such cases, we'll provide clear cosmetic fee estimates.

Insurances We Accept

We are in-network with most major health insurance carriers.

Aetna
  • PPO
  • HMO
  • Whole Health (Tier 3 Only)
  • Aexcel

BCBS
  • HMO ACA/BAV (Marketplace) Levels Bronze-Platinum
  • Blue Choice PPO
  • Essentials
  • Par Plan
  • BCBS Federal

Cigna
  • PPO
  • HMO

Community First
  • State of TX Health Plan
  • Medicaid Star Plan
  • Commercial Health Plan (Exception: CFHP University Family Care Plans)

Medicare
  • Traditional Medicare Part B
  • Champ VA (As a Secondary to Medicare)
  • Tricare (As a Secondary to Medicare)

United Healthcare
  • PPO

Aetna
  • GEHA - Through United Healthcare Shared Svs
  • Molina Medicaid Star +
  • Multiplan/Phcs
  • Superior Medicaid Star +
  • TMHP - Tx Medicaid
  • Wellpoint (Formerly Amerigroup) Medicaid Star +
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