Many of the patients who visit our office are very happy to learn that their Empire Plan does cover breast reduction surgery. A lot of them come in assuming that plastic surgery is disqualified. After all, that’s what it says in their 100-page policy written in legalese and industry-insider jargon. But that’s misleading because very often, breast reduction surgery is medically necessary. When that’s the case, the answer to “does Empire Plan cover breast reduction surgery” is almost always yes.
When Does Empire Plan Cover Breast Reduction Surgery?
When it’s “medically necessary,” Empire Plan does cover breast reductions. Of course, what’s deemed medically necessary requires documentation based on a detailed history and physical examination. From experience, I can tell you there are quite a few conditions where this surgery is approved and covered by insurance. The Empire Plan covers “reduction mammaplasty,” the medical and insurance term for breast reduction surgery when certain symptoms are noted related to the breast size.
- Chronic neck or back pain: Large breasts put a lot of weight on your neck and shoulders. This can cause cervical (neck) or thoracic (mid-back) injuries that don’t resolve with noninvasive methods like physical therapy, over-the-counter medication, or exercise. The neck or back pain has to be clearly related to the weight of the breasts and treatment has to be documented by a primary care provider or another specialist to qualify.
- Skin conditions: Large breasts can cause “submammary intertrigo” or a chronic skin rash that will not resolve through conventional treatment. Another often-covered chronic skin issue is “shoulder grooving” or the permanent indents caused by bra straps that can result in skin ulcers that won’t heal.
- Nerve damage/impingement: Heavy breasts can pinch the blood vessels and nerves in the chest, resulting in a group of disorders dubbed “thoracic outlet syndrome.” This condition can cause neck and back pain, but it can also result in numbness in your fingers and arms, as well as headaches.
The Empire Plan will also cover breast reductions that are needed to improve symmetry following a mastectomy related to cancer. However, those types of surgeries usually fall under breast reconstruction, which is a different category of coverage.
Of course, just having one of these conditions is not enough to guarantee coverage. You’ll need a documented history of your issue and attempts to resolve it. On top of that, your plastic surgeon will have to submit information to show that the reduction is likely to resolve your symptoms. There’s a lot of bureaucratic red tape to getting your surgery covered, but with the right practice, that doesn’t have to be a barrier.
How Much Will Breast Reduction Surgery Cost With Insurance?
If your surgery is deemed medically necessary by your Empire Plan, it could be covered. But in insurance “covered” rarely means “in full.” You can expect some out-of-pocket costs depending on the doctor you choose, your surgery type, and your policy language. Specific costs you’ll need to consider include:
- Copayments: These are represented by a specific dollar amount and are paid based on the provider’s category. Your Empire policy may say that you must pay $25 for a doctor’s office visit, $40 for labs, $30 for urgent care, and so on. These are usually paid at the time of the visit and are relatively low.
- Deductible: Your deductible is the amount that you must contribute to your medical costs before your insurance begins to cover it. If your deductible is $1,250, and you have $10,000 in medical treatment, you’d pay the first $1,250 and insurance would cover the remaining $8,750. Keep in mind that not all medical costs have to meet that deductible threshold. Preventative care services, treatment at in-network facilities, emergency care, and many others are excluded from the deductible requirement.
- Coinsurance: Coinsurance is the percentage of the provider’s bill you pay compared to the percentage your plan covers. Coinsurance is based on the allowed amount, not necessarily the amount billed. The amount you owe is also based on the allowed amount. So, a hospital bills the insurance company $200, your insurance allows $100. You have a 20% coinsurance responsibility, so you’d pay $20. Coinsurance charges are usually applied on top of any copayments or deductibles.
- Out-of-pocket maximum/limit: Your out-of-pocket limit is the maximum amount that you’re expected to pay during a covered period (usually one year) before insurance will take over 100% of the charges. So if you had an out-of-pocket maximum of $1,875 annually, once you’ve met that amount, insurance would cover 100% of the charges. Keep in mind that many out-of-pocket costs are not calculated into your out-of-pocket limit.
Another big factor in how much you pay comes from in-network versus out-of-network treatment. While out-of-network is often deemed expensive, it may turn out to be a good option.
In-Network vs. Out-of-Network Breast Reduction Coverage
Out-of-network has almost become a dirty word in the medical industry. Everyone has seen horror stories about the surprise million-dollar emergency room bills from patients taken to the dreaded out-of-network hospital. But out-of-network can actually work to your advantage when it comes to elective but medically necessary surgeries like breast reductions.
In-Network Breast Reduction Coverage
“In network” is taken to mean the provider accepts your insurance. What it really means is that the providers, such as the doctors, anesthesiologists, and hospital facility, are contractually bound to an agreement they made with your insurance company. The insurance company pays a specific amount—right down to a granular level, like how much they’ll pay for disposable ice packs used post-op. As part of that agreement, the providers promise not to bill the patient for charges outside that fee schedule. But there are cost sharing provisions, (like those listed in the prior section) that assign a portion of the fee allowable and payable by the insurance company to the patient.
So, getting treatment by an in network doctor doesn’t mean you don’t have any out-of-pocket costs. Deductibles and copays can really add up and it can be a long time before you reach your out-of-pocket limit. In-network can still come with a price tag in the thousands.
Out-of-Network Breast Reduction Coverage
An out-of-network provider isn’t bound to a fee schedule. They have more flexibility in what they charge and the ability to negotiate with the insurance company all those expenses that make up the cost of your surgery.
Out-of-network can be particularly useful in surgeries that are typically considered elective because it immediately expands your options. Many plastic surgeons avoid working with insurance companies because of the challenge of getting procedures covered, even when they’re medically necessary. The list is already short, so cutting it down to only in-network providers really limits your options to a handful of experts—probably with six-month waiting lists.
The best thing you can do to answer the question “Does Empire Plan cover breast reduction surgery” is to schedule a consultation. That will help you determine if a breast reduction could be medically necessary in your case. Then, you’ll have the information you need to calculate your out-of-pocket costs.
Bringing Patient Advocacy to Breast Reduction and Reconstruction
At Harris Plastic Surgery, every consultation includes a thorough evaluation of your Empire Plan coverage for breast reduction surgery. We take a concierge approach to treatment, which includes working to minimize your out-of-pocket costs. Contact us to schedule a consult!
Joanne Parrinello, Practice Manager
Joanne Parrinello is an expert patient care coordinator, with two decades of experience navigating the complex financial side of medically necessary breast reduction and reconstruction surgery. She acts as a guide to patients, helping them understand their options and their expected out-of-pocket expense. The insurance industry can be complex and filled with jargon that makes you feel like you need a translator. At Harris Plastic Surgery, Joanne is that translator.