Does NYSHIP Cover Breast Reduction Surgery in 2024?

Empire plan does cover breast reduction surgery when it's medically necessary due to chronic symptoms or limitations in physical activity or shoulder grooving from bra straps.

Many women come to our office assuming that plastic surgery is never covered by insurance and don’t think to ask, “Does NYSHIP cover breast reduction?”. But in many cases, breast reduction surgery is deemed medically necessary, and the NYSHIP Empire Plan does cover the procedure.

When Does NYSHIP Cover Breast Reduction Surgery?

If you meet certain Schnur Scale requirements, or the procedure is medically necessary, NYSHIP Empire Plan breast reductions are typically covered. 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 NYSHIP Empire Plan covers “reduction mammaplasty,” the medical and insurance term for breast reduction surgery when certain symptoms are noted related to the breast size.

NYSHIP (Empire Plan) Breast Reduction Criteria

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 or 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.

NYSHIP Empire Plan breast reductions that are needed to improve symmetry following a mastectomy related to cancer are also covered. 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 plastic surgery team, that doesn’t have to be a barrier.

How Much Does NYSHIP (Empire Plan) Breast Reduction Surgery Cost?

If your surgery is deemed medically necessary, 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:

Breast Reduction Costs

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, and the insurance allowance for the treatment is $5000, you’d pay the first $1,250, and insurance would cover the remaining $3,750. 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. However, 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 NYSHIP cover breast reduction surgery?” is to schedule a consultation. Meeting with a plastic surgeon will help you determine if a breast reduction could be considered medically necessary, and you’ll have the necessary information to calculate your out-of-pocket costs.

Bringing Patient Advocacy to Breast Reduction and Reconstruction

If you are wondering, “Does NYSHIP cover breast reduction?” the experts at Harris Plastic Surgery are here to help you find that answer. Call or text anytime to schedule your 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.

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