NYSHIP Empire Plan Breast Reduction Coverage Explained

At Harris Plastic Surgery, we get a lot of inquiries about NYSHIP Empire Plan breast reduction coverage. Every patient is different, and we take a detailed and personalized approach to each person, so there’s no universal answer. However, there are a few commonalities that can help you understand eligibility and your potential out-of-pocket costs.

NYSHIP Empire Plan Breast Reduction Eligibility 

When it comes to coverage under NYSHIP Empire Plan breast reduction provisions, medical necessity is the main criterion. Your plan will only cover it if the breast reduction surgery is likely to permanently resolve the chronic symptoms associated with large breast size. At Harris Plastic Surgery, we ask a few questions to our patients to help determine medical necessity.

Why are you considering breast reduction surgery?

The “why” behind the surgery is incredibly important when it comes to determining medical necessity. There are many different reasons for breast reduction surgery. Some are covered under NYSHIP Empire plan breast reduction eligibility, and some are not. If you’re hoping to resolve a chronic skin condition related to your breasts or issues with neck and back pain, there may be a medical necessity there.  

Are you actively seeking medical treatment for chronic neck or upper back pain?

Medical necessity is often found in cases where the weight of a patient’s breasts are resulting in chronic pain that isn’t resolved through noninvasive methods. The individual may have been undergoing extensive treatment to deal with their neck and back pain like physical therapy, activity modification, medication, and supportive undergarments. When none of those work, breast reduction surgery is often medically indicated.

Are you suffering from any skin irritation or chronic rashes?

Some patients also suffer from frequent skin irritation under their breasts as well as shoulder grooving. Medical necessity might be determined for chronic rashes if they are unlikely to resolve through other means like topical treatments, specialty bras, medication, or other noninvasive treatments.

Breast reduction surgery is considered medically necessary when chronic neck and back pain cannot be resolved with conservative or non-surgical options.

Have you had any previous breast surgeries?

This more often applies to our breast reconstructive surgery patients, as coverage would be provided under state and federal laws in most cases. Breast reduction surgery is also considered medically necessary to correct asymmetry resulting from unilateral (single) mastectomies.

What are your expectations from your surgery?

While many of our patients are primarily focused on how their breasts will appear, those who are approved under the NYSHIP Empire Plan are typically more focused on function. These individuals want to return to their normal activity levels and resolve chronic symptoms . In insurance-covered cases, resolution of the symptoms associated with the large breast size is the primary goal, using surgical techniques that maximize the aesthetic appearance of the breast at the same time.

The answers to these questions will help us determine if you qualify for NYSHIP Empire Plan breast reduction coverage and how much you can anticipate as far as out-of-pocket costs.

Potential Out-of-Pocket Costs

When it comes to potential out-of-pocket costs for NYSHIP Empire plan breast reduction coverage, you’re mainly dealing with three categories:




This is the annual amount you are required to pay before your insurance begins to cover your treatment. The deductible only applies to some categories of treatment—some categories the insurer covers right away.This is the flat dollar amount you pay per visit based on provider type.This is the percentage of costs that you are responsible for based on the amount allowed by the plan.

The amounts you will pay under these three categories will change based on whether you see an in-network or out-of-network provider. While in-network is often assumed to be the least expensive option, that is not always the case, and out-of-network can be particularly useful with breast reduction coverage. It gives you the flexibility to negotiate bills and see the provider that’s best for you.

How Harris Plastic Surgery Guides You From Beginning to End

Dr. Harris is an expert in his field when it comes to breast reduction and breast reconstruction procedures. While this is why many of his patients seek him out, they also benefit greatly from the help of our expert patient coordination team, led by Joanne Parrinello.

Joanne is well-versed in the specific coverage requirements under NYSHIP Empire Plan breast reduction eligibility. She carefully walks patients through all the steps they need to take and procedures they need to follow to minimize their out-of-pocket costs. By working with her, eligible patients can get the care they need while cutting through the bureaucratic red tape.

At Harris Plastic Surgery, we’re focused on the why behind your surgery. NYSHIP Empire Plan breast reduction coverage may be based on medical necessity, but we base our treatment recommendations on something else—how breast reduction surgery will improve your life.

If you’d like to learn more about breast reduction surgery as well as how your NYSHIP Empire plan coverage may help,
contact us to schedule an appointment.