Breast reduction surgery, or reduction mammaplasty, is a type of plastic surgery that involves the removal of excessive amounts of breast tissue, skin, and fat, resulting in the reduction of breast size.

Breast reduction surgery may help relieve some health issues, such as chronic back and neck pain, rashes and skin chafing underneath the breasts.  If the size of an individual’s breasts are keeping someone from performing routine physical activities, it can impact someone’s physical and mental health. Every year in the United States, well over 100,000 breast reduction surgeries are performed. Some women choose to have the surgery for cosmetic reasons, but most women opt for breast reduction to relieve their health issues.

Out-of-pocket costs for breast reduction surgery without insurance coverage average around $6,000.00 in the United States. This amount varies greatly depending on the location, the cost of the facility, surgeon and anesthetist fees, tests required, prescriptions, as well as the length of stay and after-care. If your physician has suggested breast reduction surgery to relieve your related health issues, it is important to have all the details of whether your surgery is covered by Medicare or Medicaid.

Does Medicare Cover Breast Reduction Surgery?
Original Medicare benefits do not usually cover cosmetic or elective surgeries. Eligibility for Medicare coverage of breast reduction surgery requires that you have been experiencing symptoms for at least six months, and you must have previously tried other non-surgical means of medical intervention that have failed for symptom relief. If your physician certifies that the procedure is medically necessary, Medicare may help cover the costs of your surgery in a facility that accepts Medicare assignment.

Original Medicare Part A (Hospital Insurance) may help cover a surgery you have when you are formally admitted into a hospital as an inpatient. Because there are many variables involved with different surgeries and procedures, it is difficult to determine the exact final cost in advance.

Before admission to the hospital as an outpatient, you are responsible for paying the Medicare Part A deductible which, in 2019, is $1,364.00 for each benefit period. A Medicare benefits period begins on the day of your admission to the hospital and ends when you have not received inpatient care for 60 consecutive days.

From the first day of your inpatient care up to day 60, there is $0 coinsurance cost for each benefit period. From day 61-90, the charge in 2019 is $341.00 daily for each benefit period. After day 91, coinsurance is $682.00 for every lifetime reserve day after day 90 per benefit period. If you go beyond your lifetime reserve days, coinsurance is 100 percent of all costs.

People who are dual-eligibles receiving both Medicare and Medicaid services, Medicaid may pay for the deductible and coinsurance costs depending on which level of Medicaid they receive.

Does Medicaid Cover Breast Reduction Surgery?
More than 10 million people living in the United States get Medicare and Medicaid benefits at the same time. This means they are dual-eligibles because they are federally qualified for Medicare and meet their home state’s qualifications for Medicaid.

When beneficiaries have dual eligibility, first Medicare covers all expenses, then Medicaid pays the other costs and services remaining. These costs may include deductibles, copayments, and coinsurance costs. This coverage includes surgeries such as breast reduction.

Based on individual circumstances, qualification for either full dual eligible coverage, or partial dual eligible coverage is determined by the regulations of your home state. If you have full coverage, Medicaid pays for procedures and services that Medicare does not. If you have partial coverage, Medicaid covers the cost of Medicare premiums and other cost sharing expenses.

The majority of states in the United States use the federal Supplemental Security Income (SSI) income and asset guidelines to determine eligibility. To qualify for full dual eligible coverage, your income must be 300 percent of the Supplemental Security Income limit or less. In 2019, the Supplemental Security Income limit is $771.00 per month, 300 percent of that is $2323.00 per month.

States that apply Supplemental Security Income regulations, have a $2000.00 limit on countable assets per person. When both people in a marriage are receiving care, the limit is $3,000.00. These assets do not include the home you own and reside in.

Every state in the country sets regulations for resources and income allowances. You can find your state’s information online or at a local Medicaid services office.

Related articles:

New to Medicare

Medicare Part A