Insurance Coverage
Health insurance may cover the cost of prescribed medical supplies, such as wigs and compression garments.
The world of health insurance is complicated, and changes every year. A Special Place is happy to help you understand your coverage and file a claim for benefits. Please keep in mind, coverage can vary greatly based on the terms of your policy. Here’s what you need to know:
Insurance Coverage For Wigs
If you are experiencing hair loss due to a medical condition such as alopecia or cancer treatment, you may wonder if insurance will cover your wig.
Insurance coverage can be complicated, and unfortunately, there is a lot of misinformation online. With over 20 years experience in insurance billing, the experts at A Special Place can help you determine what benefits you might be entitled to.
Coverage for wigs varies depending on the specific terms of your health insurance policy. Some insurance plans do provide coverage for wigs, while others may exclude them entirely. It’s important to review your policy details or contact your insurance provider directly to understand your coverage.
Factors that may influence coverage include:
1. The reason for needing a wig (e.g., medical conditions like alopecia or cancer treatment)
2. Whether wigs are included, excluded or not specified on your policy.
3. Any coverage limits or requirements for pre-authorization.
4. Deductible and co-insurance accumulation.
To determine if your insurance covers wigs, check your policy documents or speak with a representative from your insurance company.
No, Original Medicare (Part A and Part B) does not cover wigs. Wigs are not included in Medicare’s list of covered durable medical equipment or prosthetic devices.
Most Medicare replacement plans (Medicare Advantage) and Medicare supplement plans (Medigap) follow Medicare guidelines and therefore typically do not cover wigs either. However, there are a few exceptions:
1. Some Medicare Advantage plans may offer additional benefits beyond Original Medicare, which could potentially include coverage for wigs. These plans vary by provider and location.
2. A small number of Medicare supplement plans might offer limited coverage for wigs, but this is not common.
If you have a Medicare Advantage or supplement plan, it’s advisable to check your specific policy details or contact your plan provider directly to confirm whether they offer any coverage for wigs.
Payment will depend on the terms of your plan. Most insurance companies have a stated limit on how much they will pay.
If they do not have a stated limit or “allowed amount”, they will still only pay what they deem to be “reasonable and customary.”
The quantity you may be entitled to can be different as well. Some plans will pay for 1 wig every 1-3 years. Some pay for 3 wigs per year, and others only 1 per lifetime. And as stated before, some insurance companies will not pay for wigs at all.
Ask your physician to include the following information on your prescription:
His/Her Name (Printed) and NPI number
Your Name and Date of Birth
A statement such as:
Please supply a cranial prosthesis for hair loss due to (your diagnosis)
Please ask your physican to include the diagnosis code.
Prescription should be signed and dated.
Your physcian can give you a written prescription or fax it to us at 336-271-4828.
Before calling your insurance company, get a notepad to write down the information. Make sure you have the following information handy:
- Your policy number
- Your diagnosis code (obtain from your doctor)
- The provider information (that’s us!): A Special Place Wigs, LLC
Call the customer service number on your card and tell them you would like to get specific benefit information. They should transfer you to the correct department. Tell them:
“I am calling to determine if my policy will cover a cranial prosthesis due to (your diagnosis, example hair loss form chemotherapy for breast cancer). I can give you the procedure code and the diagnosis code.”
The representative will probably ask for some additional information.
For the diagnosis code, provide the code your doctor provider. For the procedure code, use A9282.
You will probably be placed on hold while the representative looks up the information.
If they tell you that you do have coverage for a cranial prosthesis, ask:
-Is there is a stated limit on coverage (quantity or dollar amount)?
-Do I have in and out-of network-benefits?
-Do I have a deductible or co-insurance amount left to meet?
-Do I need pre-authorization?
-Are there any other limits or exclusions I should be aware of?
-Write down everything they tell you, get the representative’s name and a reference number for the call.
Sadly, no. There is no federal law requiring that insurance companies pay for wigs. Many insurance companies have deemed that wigs are cosmetic, even when prescribed for a medical reason, and will not pay for them.
While we at A Special Place believe that insurance companies SHOULD cover wigs for medical reasons and WISH that they did, it is not in our control. We understand that it is disappointing when insurance does not cover wigs, but feel that it is important to provide accurate coverage information to you so you can make an informed financial decision.
If you do not have insurance for wigs and need help covering the cost, there are several options.
While a wig may seem like a big investment, they are often less expensive than regular salon visits. A Special Place offers wigs at a variety of price points so that we can find something in your budget.
- Ask your doctor for a prescription for potential tax savings.
- Check any ancillary plans you may have. Some cancer policies like AFLAC may have a wig benefit
- If you have an FSA or HSA plan, you can use it to cover a prescribed wig.
- Check with your local hospital to see if they offer assistance toward wig expenses.
- Ask about our no-interest payment plans.
Insurance Coverage For Compression Garments
Most private insurance companies cover compression garments for lymphedema. Both NC and Virginia have state mandates requiring that insurance garments be covered. The Women’s Health Act of 1998 is a federal law stating that compression garments must be covered for breast cancer survivors.
Some insurance companies will cover compression garments for other diagnoses, such as vascular disorders. You will need to check with your insurer to see if your policy covers compression for vascular or other conditions.
YES! This is actually a recent development! Medicare began compression cover FOR LYMPHEDEMA ONLY in January of 2024.
Currently, A Special Place is going through the lengthy and costly process of getting accredited to be a Medicare supplier. So, for the time, you will still have to pay up front for garments purchased through A Special Place and submit the claim yourself for possible reimbursement. We plan on being able to accept Medicare next year.
Ask your physician to include the following information on your prescription:
His/Her Name (Printed) and NPI number
Your Name and Date of Birth
A statement such as:
Please supply graduated compression garments for (body part, ie. arm, hand, leg) due to lymphedema.
Quantity (We recommend an initial quantity of 3-4, and a note that refills are allowed.)
Please ask your physican to include any applicable diagnosis codes.
Prescription should be signed and dated.
Yes! You can use your FSA or HSA to pay for prescribed compression garments.
Frequently Asked Questions About Insurance Coverage
A Special Place is currently in network with the following insurers:
- Anthem/Blue Cross Blue Shield of Virginia
- Aetna
We are also a certified Tricare Provider.
This means we take most Anthem, Blue Cross, Aetna and Tricare insurance.
We are in the process of being accredited for Medicare (for compression only).
Please note, there are many new HMO plans that have more limited networks, so we may not be participating with every plan. We are also not in network with Medicare or Medicaid replacement plans.
To find out if we are in-network with your specific plan, please call us with your insurance ID and we can verify our participation with your plan.
Out-of-Network, or Non-Participating, means that A Special Place does not have a negotiated contract with your specific insurance plan.
What this means for you depends on the terms of the policy.
- Some policies may not have any out-of-network coverage. This means they will not pay for your items if purchased out-of-network. You must go to an in-network provider
- Some policies have out-of-network coverage, but you may be subject to a higher deductible /co-insurance, which means you will pay more out of pocket than if you went to an in-network provider.
- Some polices pay the same in or out of network.
When speaking to your insurance company, it is important to find out if A Special Place is in-network and what that will mean for your coverage.
With all out-of-network plans, you will need to pay up front for your items and submit the claim for possible reimbursement.
A deductible is the amount you must pay out of pocket before your insurance company will pay toward your covered medical expenses.
Co-insurance is a percentage of the claim amount that you are responsible for paying. Many plans have an annual out-of-pocket maximum. Once that is met, claims pay at 100%.
A Network Gap Exception (NGE) is a request to your insurance company to pay a claim from an out-of-network provider at the same rate as they would from an in-network provider.
An NGE may result in higher reimbursement on your claim, but it is important to note it is not the same as pre-authorization or a guarantee of payment.
To obtain an NGE, there must be no in-network providers for the specified benefit in your area.
For more information, ask to speak to an insurance specialist at A Special Place.
Some plans require pre-authorization. Speak to an insurance specialist at A Special Place for more information.
A Special Place verifies benefits on in-network insurers (Aetna, Anthem, Blue Cross and Tricare).
With out-of-network providers, we recommend that you call them to check benefits as they often will not give us the information. If you would like our help, you can call while in our office or we can schedule a 3 way call.
For in-network providers, if we have verified your benefits you will only have to pay amounts not covered by your insurer. (Such as deductible, co-insurance, or for uncovered items and non-covered upgrades.). Your insurance company will reimburse us directly for the covered amounts.
If we are unable to verify your coverage, you will need to pay upfront, and if insurance reimburses us, we will refund you the amount reimbursed.
For out-of-network claims, you will be required to pay upfront (even with an NGE). Any reimbursements from your insurer will go directly to you.
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