Does Medicaid Cover Breast Reduction? – Overview
Yes, Medicaid covers breast reduction surgery if it is considered to be medically necessary and not for aesthetic-enhancing purposes. For instance, if the unaffected breast becomes smaller due to loss of tissue, then Medicaid and Medicare will cover the cost of getting breast reduction surgery.
Besides this, Medicaid also covers the cost of undergoing breast reduction surgery if it is recommended to compensate for tissue loss after an injury or cancer treatment.
In essence, Medicaid covers the cost of reduction mammoplasty (breast reduction) when excessively large breasts are the cause of chronic health issues, such as postural changes and back pain. For this, Medicare will cover the main costs, while Medicaid covers the cost of other expenses.
Need for Breast Reduction Surgery
Breast reduction surgery is mostly recommended to remedy health issues arising from excessively large breasts or to match the size of two mismatched breasts. This surgery is usually considered to be cosmetic, but there are instances when it becomes medically necessary.
In the US, more than 100,000 breast reduction surgeries are performed every year. Undergoing breast reduction can help to alleviate several health problems. Studies have shown that excessively large breasts cause skin chafing and rashes, neck pain, and chronic back pain.
Abnormally large breast size can also become an obstacle to performing routine physical tasks. Besides this, the condition often affects the physical and mental health of the person.
Cost of Breast Reduction Surgery
The total cost of undergoing breast reduction surgery in the US is around USD 6,000 per breast. This amount is usually dependent on several different factors. For instance, the total cost of a breast reduction surgery is influenced heavily by the location of the hospital, the charges of hospital facilities, surgeon and anesthesiologist fees, cost of tests, prescription expenses, and the duration of hospital stay after the surgery.
Insurance Cover for Breast Reduction Surgery
Usually, original Medicare will not cover the cost of breast reduction surgery, as it is considered to be an elective or cosmetic procedure. However, if you experience symptoms for at least 6 months and have tried non-surgical treatments, then you can qualify for breast reduction surgery coverage under Medicare and Medicaid.
Over 10 million people in the United States receive Medicare and qualify for Medicaid benefits due to dual eligibility. For such persons, Medicare initially covers the major expenses for undergoing breast reduction surgery, which is considered to be medically necessary.
Medicaid takes over cost coverage for sundry expenses and related costs. Usually, Medicaid will cover the coinsurance, copayments, and deductible costs for breast reduction surgeries.
If you have complete coverage, then Medicaid will cover the cost of procedures not covered under your Medicare plan. If you have partial coverage, then Medicaid will cover the cost of Medicare premiums and other similar expenses.
Most states in the US use federal SSI (Supplemental Security Income) as a guideline to determine eligibility for Medicaid and Medicare benefits. Under this, qualifying candidates have a USD 2,000 limit on countable assets, excluding the home they reside in or own.
Remember, every state has its criteria for dual eligibility and Medicare coverage for breast reduction surgery. Make sure to contact your local Medicaid service office to find out the criteria for your state.
Medicare Coverage for Breast Reduction Surgery
If you qualify for Medicare coverage for breast reduction surgery, the different parts of the plan cover other expenses. Let’s take a quick look at how Medicare parts cover the overall cost of breast reduction surgery:
Medicare Part A
Medicare Part A is hospitalization insurance and covers the cost of inpatient surgeries. In this, the beneficiary must pay USD 1,484 as deductible during a benefit period. They will have zero co-insurance for the first 2 months of every benefit period. A benefit period starts when you enter the hospital and ends the day after you are discharged.
Medicare Part B
Some breast reduction surgeries are performed on an outpatient basis. In such cases, Medicare Part B, which is medical insurance, covers the cost of breast reduction surgery. You will need to copay for the total cost, which includes 20% of Medicare-approved expenses and USD 203 as an annual deductible. Besides this, Medicare Part B also covers the cost of a post-surgical bra.
Medicare Part C
Medicare Part C, or Medicare Advantage), offers the same coverage for breast reduction surgery as Medicare Part A and Part B combined. This includes covering the cost of extra perks and prescription drugs. You can go to in-network providers to lower the overall out-of-pocket even more. Remember to stay within the limit as Medicare Advantage plans have an annual maximum expenses cap.
Medicare Part D
Medicare Part D will cover the cost of prescription medication, which you may need to buy from non-network pharmacies and are not covered under Medicare Part A.
Medicaid covers the cost of breast reduction surgery if the doctor classifies it as medically necessary. Undergoing breast reduction simply to improve the aesthetics will not qualify for Medicare or Medicaid coverage. Contact your local Medicaid office to learn your state’s specific criteria for Medicare and Medicaid benefits.