NYSHIP Empire Plan Breast Reduction Coverage Explained
At Harris Plastic Surgery, we get a lot of inquiries about what the NYSHIP Empire Plan breast reduction coverage includes in 2024-2025. Because every patient is different, and we take a detailed and personalized approach to each person, 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 the 2024-2025 NYSHIP Empire Plan breast reduction guidelines, medical necessity is the main criterion. Your plan will only cover this procedure if the breast reduction surgery is likely to permanently resolve the chronic symptoms associated with large breast size. At Harris Plastic Surgery, we ask our patients a few questions 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 the 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 results 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.
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 also focused on functional improvements. 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, ideally using surgical techniques that maximize the aesthetic appearance of the breast at the same time. That’s why it’s so important to choose an expert plastic surgeon for your breast reduction. Skilled surgeons like Dr. Stephen Harris can give you the best outcomes to relieve your physical pain as well as the best aesthetic results from your surgery.
Potential Out-of-Pocket Costs
Even if the majority of your surgery is covered by insurance, you will still have to pay some 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:
Deductible | Co-Pay | Coinsurance |
|---|---|---|
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. Other out-of-pocket costs can include additional fees like:
Other Possible Out-of-Pocket Expenses for Breast Reduction Surgery | |
|---|---|
Expense | Description |
Surgeon’s Fee | The fee for the plastic surgeon performing the reduction surgery. |
Anesthesia Fees | Cost for the anesthesiologist or anesthesia team during the surgery. |
Hospital/Facility Fees | Charges for the operating room, surgical staff, and equipment used. |
Post-Surgical Garments | Specialized bras or compression garments needed during recovery. |
Medications | Prescription pain medications, antibiotics, or other post-operative drugs. |
Follow-Up Visits | Post-surgery checkups to monitor recovery and address any complications (included in the surgeon’s fee in some cases). |
Pre-Surgery Tests | Medical exams or lab tests are required before surgery, such as blood work or imaging. |
Miscellaneous Expenses | Costs related to travel, accommodations, or extra expenses for recovery support. |
Frequently Asked Questions About NYSHIP Empire Plan Breast Reduction Surgery Coverage
Yes, the NYSHIP Empire Plan may cover breast reduction surgery if it is deemed medically necessary. This usually requires documentation showing that the surgery is required to relieve chronic symptoms, such as back pain, neck pain, shoulder pain, or skin infections caused by overly large breasts.
This is a common question we get asked, and don’t worry, just because an office is out-of-network doesn’t mean you can’t work with the surgeon you want or that you’ll get stuck with exorbitant fees. At Harris Plastic Surgery we are used to working with insurance providers even when we’re not in-network to negotiate the best prices for our clients so they can have the experience they deserve and the results they want.
Yes, the NYSHIP Empire Plan may cover male breast reduction surgery (gynecomastia surgery) if it is considered medically necessary. The coverage depends on meeting certain criteria and providing adequate documentation that the surgery is required to treat health issues caused by excess breast tissue in men, such as physical discomfort, pain, or psychological distress.
NYSHIP typically requires that non-surgical treatments have been attempted and documented without sufficient relief. These treatments may include physical therapy, chiropractic care, weight management, pain management, or posture support devices. Additionally, your plastic surgeon must provide documentation of the medical necessity, including a history of your symptoms and the anticipated reduction in breast tissue.
While specific criteria can vary, many insurance companies, including NYSHIP, require that a minimum amount of breast tissue be removed (often measured in grams according to the Schnur Scale) to classify the procedure as reconstructive rather than cosmetic. Your plastic surgeon will be able to provide this information based on your case.
You will need detailed documentation from your plastic surgeon, including a letter explaining the medical necessity of the surgery, photographs, and a history of your symptoms. You may also need records of conservative treatments attempted and referrals from other healthcare providers such as physical therapists or orthopedists.
Yes, pre-authorization is usually required to confirm that the procedure is medically necessary. This process ensures that the surgery will be covered by the NYSHIP Empire Plan, provided that all criteria are met. At Harris Plastic Surgery, we will assist you in obtaining this pre-authorization.
If NYSHIP approves the procedure, your out-of-pocket costs may include co-pays, deductibles, or coinsurance, depending on your specific plan. You will need to check your policy for details regarding surgical procedures and hospitalization.
If coverage is denied, you have the option to appeal the decision. This will involve providing additional medical documentation and possibly undergoing further evaluations to demonstrate the medical necessity of the procedure. Your plastic surgeon’s office can often assist with the appeal process.
Generally, if NYSHIP covers the initial breast reduction surgery, necessary post-operative care, including follow-up visits, is also covered. However, coverage for revision surgeries depends on the medical necessity of the revision and whether complications arise.
For more specific details about coverage, you should consult your NYSHIP Empire Plan documentation or speak directly with a representative from your plan.
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 breast reduction coverage may help, contact us online or by phone/text. Or schedule your consultation today.
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.
