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 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:
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.