Does Medicare or Medicaid Cover Breast Reduction Surgery?
- Find out whether Medicare or Medicaid covers breast reduction surgery, including information about medical eligibility criteria, Medicaid income thresholds and dual-eligibility.
People with overly large breasts compared to their body frame sometimes experience negative physical and emotional effects, such as back pain or self-consciousness.
Although breasts of all shapes and sizes are normal, breast reduction surgery may be beneficial if having large breasts makes it difficult to perform regular activities or causes significant discomfort. But is breast reduction surgery covered by insurance like Medicare or Medicaid?
What Is Breast Reduction Surgery?
Breast reduction surgery is another name for a procedure called reduction mammoplasty. During the procedure, surgeons remove excess fat and tissue from the breasts to reduce their size and weight. Breast reduction surgery can help relieve back pain, chafing or rash under the breasts and neck strain. It may also alleviate any psychological symptoms associated with having large breasts.
Although many women choose to have breast reduction surgery to relieve troublesome health symptoms, the surgery is sometimes performed for cosmetic purposes.
How Much Does Breast Reduction Surgery Cost Without Insurance?
The cost of breast reduction surgery depends on several factors, including geographical location, who performs the surgery and whether the procedure is performed for cosmetic or health reasons. According to the American Society of Plastic Surgeons, the average cost of a cosmetic breast reduction procedure is $5,913.
However, this figure doesn't include the costs of anesthesia, supplies or use of the hospital's facilities. Therefore, the true cost of breast reduction surgery will most likely be significantly higher.
Does Medicare or Medicaid Cover Breast Reduction Surgery?
Getting a breast reduction covered by insurance like Medicare and Medicaid is unlikely due to aesthetic reasons. However, there are some circumstances in which they may provide coverage.
The eligibility criteria for Medicare and Medicaid breast reduction surgery coverage are complex, and it can be difficult to determine whether individual cases qualify without consulting a surgeon.
Does Medicare Cover Breast Reduction Surgery?
Medicare may cover breast reduction surgery if it's deemed medically necessary. Medicare only considers covering beneficiaries who have experienced symptoms caused by their breast size for at least six months. Beneficiaries must satisfy at least one of the following criteria to meet Medicare's definition of clinical necessity:
- Back or shoulder pain that interferes with normal activities and doesn't improve with conservative treatments, such as weight loss or supportive garments
- Arthritic and progressive spinal conditions that don't resolve with conservative management and cause ongoing symptoms or lifestyle constraints
- Intertrigo, or infection of the areas under the breasts, that doesn't resolve with dermatologic treatment
- Skin irritation or damage caused by wearing garments to support the breasts
If Medicare agrees to cover breast reduction surgery, it's unlikely to cover the removal of more breast tissue than is clinically necessary to provide symptom relief. In other words, it won't cover the removal of extra tissue to achieve a desired cosmetic effect. It is impossible to say exactly how much breast tissue removal Medicare may cover, as this will depend on each person's unique anatomy.
Some women request breast reduction surgery on a healthy breast to achieve symmetry if their other breast was reconstructed during cancer treatment. Medicare does not consider this type of breast reduction cosmetic, so it may provide coverage in this situation.
If you qualify for Medicare coverage for breast reduction surgery, you will have to pay the deductible under Medicare Part A. In 2023, the deductible is $1,600 per benefit period. Each benefit period spans from the day of hospital admission until 60 days after you last received inpatient care.
There are no coinsurance costs for the first 60 days after your initial admission. From days 61-90, you are liable for $389 coinsurance each day, rising to $778 for each lifetime reserve day from day 91 onwards. Beneficiaries are responsible for paying all costs once their lifetime reserve days have been used up. Depending on your coverage level, Medicaid may cover deductibles and coinsurance if you are enrolled in both programs.
Medicare Supplement (Medigap) Plans Can Help Pay for Covered Breast Reduction Surgery
Medicare Supplement plans – also called Medigap plans – are sold by private insurance companies and help pay for certain out-of-pocket Medicare costs such as deductibles, coinsurance and copayments. There are a several different types of Medicare Supplement plans available in most states, so you may be able to find a plan that fits your coverage needs as well as your budget.
If Medicare covers your breast reduction surgery, a Medigap plan could help pay for the Medicare Part A deductible and certain copays or coinsurance, depending on the type of Medigap plan.
Learn more and compare the Medigap plans available where you live.
Does Medicaid Cover Breast Reduction Surgery?
Medicaid covers breast reduction surgery to the unaffected breast if the other breast lacks or has lost tissue due to a genetic condition. Additionally, Medicaid covers breast reduction if the tissue loss was caused by an accident or cancer treatment. Medicaid breast reduction criteria for coverage varies by state.
As of 2022, 12.3 million people were enrolled in both Medicare and Medicaid. This is known as dual-eligibility. If you're eligible for both programs, you may be able to get most of your medical expenses covered if you qualify for breast reduction surgery coverage. In these cases, Medicaid pays for additional expenses once Medicare has covered what it will. These may include deductibles, coinsurance and Medicare Drug Coverage fees.
Most states decide who is eligible for Medicaid coverage based on whether they receive SSI benefits. Thirty-five states enroll beneficiaries for Medicaid coverage automatically when they qualify for SSI benefits. Each state has its own income threshold for Medicaid qualification, measured as a percentage of the Federal Poverty Level. In 2022, the Federal Poverty Level for individual adults was $13,590, rising to $23,030 for a family of three. States using the SSI eligibility model also discount people with countable assets worth more than $2,000 for a single person or $3,000 for a couple.
Find the Medicaid income limit for your state.