Being a New York plastic surgeon’s office that caters to many public sector employees, we often are asked, “Does NYSHIP cover breast reduction surgery?” Many individuals with large breasts have suffered from neck and back pain for years and are surprised to learn that their insurance policy may offer a way to fix the issue. However, NYSHIP only covers breast reduction surgery in specific situations.
Below, we provide guidance on when this surgery is likely to be approved.
NYSHIP Does Cover Breast Reduction in Certain Scenarios
According to NYSHIP’s policy language, there are situations in which breast reduction surgery is considered medically necessary. Medically necessary is a subjective term mainly used to describe surgeries that are not purely aesthetic and correct functional or structural problems. They’re done because the patient suffers from chronic symptoms that cannot be resolved without surgery. To give you a better example, two scenarios are listed below. One scenario is an example of a surgery that NYSHIP would likely cover. The other is one where coverage probably wouldn’t be extended.
Monica has large breasts that have caused her to slouch most of her life. When she entered her late 30s, she started to develop chronic neck and back pain and has suffered with it for more than a year. She’s under the care of a physician and has tried physical therapy, special support bras, lifestyle changes, medication, and even pain-blocking injections. However, none of these have resolved her chronic pain, and her doctor believes that it is very unlikely it will resolve without surgical intervention. This is a fairly classic scenario in which NYSHIP does cover breast reduction surgery.
Alice is dissatisfied with the appearance of her breasts. She has B- or small C-cup breasts, and she’s noted that the breasts have sagged after breastfeeding her children. She’s not suffering from any chronic pain in her neck and back, nor is she seeking treatment. Her main goal is to lift the breasts and see more fullness in the upper pole of her breasts. Surgically, the breast size needs to be maintained or even enhanced to achieve her goals. While there would be some physical benefit to Alice getting breast lifting surgery, her primary motivation is aesthetic, and as a result, the surgery likely wouldn’t be covered.
These two scenarios highlight classic motivations for breast reduction surgery as well as situations in which insurance considers it medically necessary. When it’s deemed medically necessary, the surgery will likely be covered, but like with most other medical treatments, it won’t be covered in full.
What Am I Responsible For?
If your surgery is approved because it’s considered medically necessary, that doesn’t mean you will escape all out-of-pocket costs. Your copay, coinsurance, and deductible costs will affect how much you pay for this surgery versus how much your insurance covers:
Copays are a fixed dollar amount that you pay based on the type of provider you visit. Typically, specialist visits, like to a plastic surgeon, will have higher copays than generalist visits, like to your primary care provider. However, they are charged per visit, and if you have a lot of visits, these costs can add up.
Coinsurance is expressed as a percentage and is the allowable amount that you are responsible for. If your policy says that you have a 20% coinsurance rate, and your insurance pays an allowed amount of $100, that means you are required to pay $20. Coinsurance is usually charged on top of a copay.
Your deductible is the amount that you have to pay out of pocket before your insurance will begin to cover your costs. If your deductible is $1,250, then you would be required to pay that amount before insurance would take over. The deductible is not applied to all treatments. Preventative care, in-network treatments, and hospital visits may not need to meet that deductible threshold for coverage to kick in.
While NYSHIP does cover breast reduction, it’s difficult to say what your out-of-pocket costs will be until you’ve met with a doctor. There are a lot of different surgical methods, and the type of surgery will change the overall cost. To receive more details about when NYSHIP covers breast reduction, schedule a consultation.
Bringing Patient Advocacy to Breast Reduction and Reconstruction
Harris Plastic Surgery works with NYSHIP and other insurance plans in covering breast reduction surgery for cases in which it’s medically necessary for patients. To find out more, contact us and schedule a consultation.
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.