Does insurance pay for MRI for high risk women?

Sahar

Does anybody know if insurace companies cover Breast MRI at 100% as a preventive service for high risk women like me whose mom is BRCA positive? I have a $500 deductible plus 20% co-insurance. If insurance doesn't cover it at 100%, my 20% could be be a lot (depends upon the MRI facility contracted rate with my insurance). My $500 deductible will also be added to it. It is difficult to pay this much money. Does anybody know the average rate of a breast MRI between MRI centers and insurance companies? I understand that it varies but wanted to get a feel. Thank you.

ma111

It depends on ythe insuramce you chose to have. Call the number on the back of your card.

lauri

FYI, my MRI's usually bill out at $5,500 at UCSF but Medicare only authorizes them at $700 and pays 80% with 20% co-insurance. (Just got old enough for Medicare last year.)   Not sure what reduced amount my previous private insurance had contractesd for, but I'm sure it was way less than the billed rate. 

Sherryc

I have to have yearly MRI's as part of my continued screening.  My insurances considers mammo's and US as screening but MRI's a diagnostic.  I have to pay $1500 deductible and then 20% so my MRI's will run me about 2K a year before anyting else.  So I am in the process of having a BMX with reconstruction because I am 49 and just do not see that I can afford 2K before doctors, meds and if anyting else should happen to me or DH. 

Also I have contacted I do believe every cancer organization there is to see if there is any financial help out there.  The answer is no because I have a job and I have insurance.  And this is follow up from cancer not treating the cancer.

peggy_j

I don't think the insurance will pay 100%. My guess is that you'll have to pay the deductible + the co-pay. I believe my B-MRI was about $5000. You can call your place to see what they bill.

My MRI place needed insurance pre-approval even before scheduling, so you'll want to have your doc make the case for it to be covered at all.  (are you seeing an oncologist? that may be the best doc to make the referral vs. a family doc or even a diagnosis radiologist--the mammogram docs). I believe the testing for the BRCA gene is about $3000-$3200 (?). Before paying for B-MRIs on a regular basis, they might want to know you yourself have the BRCA gene. 

Sahar

Thank you ladies for your input.

Peggy_j: if they ask me to do the gene test, do you think they'll pay for the test?

peggy_j

Sahar, I think there's a good chance they'll cover the BRCA test.  The genetic counselor at my breast surgeon's office likes to test every patient who gets Dx'd before menopause. In my case, my insurance would not cover it because I did not meet their criteria for being high risk.   You should call your insurance to find out but as an FYI, I checked ours (Blue Shield) and here's their criteria.

---(start, info from the Blue Shield website)

Certain people have a higher chance of inheriting BRCA1 or BRCA2 gene changes.

• Ashkenazi Jewish women (whose ancestors came from Eastern Europe) are more likely to be BRCA gene carriers. Some experts recommend gene tests for women who are of Ashkenazi Jewish descent if they have one or both of the following:²
  • Any first-degree relative with breast or ovarian cancer. First-degree relatives are parents, sisters and brothers, and children.
  • Two second-degree relatives on the same side of the family with breast or ovarian cancer. Second-degree relatives are aunts and uncles, nieces and nephews, and grandparents.

• If you are not of Ashkenazi Jewish descent, some experts recommend a gene test if you have one or more of the following:²
  • Two first-degree relatives with breast cancer, one of whom was diagnosed before age 50
  • Three or more first- or second-degree relatives with breast cancer, diagnosed at any age
  • Both breast and ovarian cancer in the family
  • A first-degree relative with cancer in both breasts
  • Two or more relatives with ovarian cancer
  • One relative with both breast and ovarian cancer
  • A male relative with breast cancer

-----end

The fact that your mother has the BRCA gene puts you at high risk, a 50/50 chance of having inherited it, right? This is crazy but I know someone who learned she was Jewish when she got her BC Dx. (the family had migrated and converted after the war etc. Her grandfather had male BC).

BTW, I believe your deductible is for the year, so if you've had any doctor's appointments this year you may have paid part (or all) of the deductible already, so you just may need to pay the 20%. (so it's not free but could be worse.) It might also be worth the peace-of-mind to know whether you have the gene or not.  Good luck.  This has to be stressful. My Dx came out of the blue but it seems like worrying about whether you might get it would be hard, esp. if you're still young. take care

Sherryc

I have BCBS and was diag at 48.  No family history of bc that I know of but don't really know much about my dads side of the family health wise.  BCBS paid and never questioned it.  My policy pays all bloodwork at 100% so it did not cost me anything. Maybe because I don't know much about my dads family health history is why they paid it I don't really know.

Fearless_One

Impossible to answer.   Depends on your insurance plan and company.   However, I think you would pay 20% of the CONTRACTED rate - not the 20% of the actual facility charge for the MRI.   In my case, the HMO allowable rate for an MRI is about 6K, so you could be looking at a pretty hefty co-insurance.   But it tends to be $$ in my city.   It varies from city to city.

QueenOfHope

There's so many different insurance policies out there, that it's kind of mind-boggling.

I've never really had to pay anything out-of-pocket for MRI's.  My insurance company pays 100%, after meeting the annual $2500 deductible, (which is easy after just one chemo infusion!), and then I have a secondary insurer (god bless him, my husband stayed w/the US Army Reserves for 20 years, and retired with full benefits!) , TriCare, which picks-up 80% of that $2500, so I don't have much of anything out-of-pocket.   Yes--- I know.  I think I'm pretty lucky.

Sahar

Thanks ladies for your insight. I am so surprised hearing MRI rate at 6K. I called several facilities and asked how much they charge for bilateral MRI with contrast for somebody WITHOUT insurance. I got prices from a range of $600-$1500. Interestingly enough, the one that charges $600 is really a good facility and is affiliated with a large hospital in Los Angeles. I guess, not using insurance will cost me less than using my insurance. The only good thing about using my insurance is that my expense will go toward my deductible but if I don't use my insurance, I pay the money but nothing will be deducted from my deductible. Any yes the 20% is on the contracted rate not on their charges. but if you don't know their contracted rate how can you decide which facility would cost less for you?

soccermom

I've been wondering about the same question. I had to switch to Kaiser earlier in the year. I have been getting MRI every other year and am due for one this year. I have heard that Kaiser won't cover it for routine follow up, but I haven't verified it.

Actually if it wasn't a cost issue I'd prefer to go to the same provider I've had since DX in '03- because I trust their quality and they have all my records so there is much better consistency.

Also I have a 30. copay and high deductible with Kaiser so  by the time I wend my way through their system to see a specialist it has already cost me at least 30. x 3.visits. Not sure what to do. I guess I could give Kaiser a try and if there is anything wrong pay for a second opinion with the old provider...

Really can't afford thousands of dollars for a MRI right now...

Sahar

soccermom

 I had Kaiser earlier in the year too and it is so difficult to deal with them. They didn't even want to order mammogram for me because I was under 40, they didn't care when I said I had a strong family history of cancer. Instead my PCP at Kaiser wanted to send me to a genetic specialist. I didn't want to go to a genetic specialist because we went through the same process with my mom and i knew what the genetic specialist would say. Why didn't they order my mammogram and wanted to delay it subject to seeing a genetic specialist?? I had been getting mammogram 4 times before with other insurances and nobody even questioned it. Luckily we changed to a new insurance later.

As I mentioned in my previous post, there are some imaging MRI centers that don't charge that much. I know one place in Southern California that charges $600. If you are in this area, PM me and I will give you their name. If you get it done at a hospital, it may cost you thousands of dollars but there are many free standing imaging centers that charge much less.

Tatina123

My insurance approved it but I had a $5,000 deductible so it went toward that cost. It was my MRIs which caught my ADH, and on this round, my DCiS. The mammograms didn't catch it which meant my biopsies were done by MRI, too.

stage1

I will be looking for an imaging center in Northern Ca.  As I have Kaiser.  As I understand it, the American Cancer Society says MRI is recommended each year if you have had a lumpectomy. My 6 mo mamo was dense due to scar tissue. If anyone has any MRI information in my Ca area, please post.  Thanks, Ladies, all your imput on this thread is so helpful.

Lisa75

glad I found this thread...I was wondering why I had to pay more than the usual $35 copay. Last time the paperwork lady was praising my insurance since it covered the biopsy 100%, and for this MRI I had to pay $300 copay/coinsurance right then and there. I didnt have that, so she let my pay 1/2,,,but I barely had that. Sigh, now Im worried about the lumpectomy cost. Seeing some of the number above though.... wow.

margodae

I was age 29 at the time of my diagnosis in 2009.  I have yearly MRI's for preventative screening, because my cancer was not seen on a mammogram.  Myself, along with my surgical oncologist and radiologist, have been battling my insurance year after year to get them to cover my MRI at 100%.  My radiologist even wrote a letter and included research literature stating that MRI's are standard of care for pre-menopausal women whose breast cancer was not detected with a mammogram.  They still refuse to cover?  So, my MRI annually runs about $3,000.  My insurance does cover about half and my out of pocket has been about $1,400.  My insurance deductible is $3,000 with an additional 30% co-insurance of $3,000.  With my MRI and other additional doctor visits I continually meet my deductible...it is so frustrating...I can never get ahead!