Breast reduction surgery, officially known as a reduction mammoplasty, is covered by Medicare in some instances. Here’s what you should know if you’re considering this procedure.
Women often seek breast reduction surgery for several medical reasons, including:
The short answer is “yes” if heavy and large breast size causes chronic health conditions and constitutes a medical reason for having surgery. Strict Medicare criteria applies, and coverage for beneficiaries is not available if you’re seeking reduction surgery for cosmetic reasons.
Medicare specifically states that it will not cover ‘non-therapeutic cosmetic surgery’ or ‘non-therapeutic plastic surgery’ procedures.
You may need to prove that you have been experiencing symptoms for at least six months and that nonsurgical treatments have not been effective.
You’ll also need to discuss Medicare coverage with your primary care provider or a surgeon specialist to confirm what benefits are available to you. In turn, they will have to certify surgery is warranted for a medical condition before you can seek Medicare payment coverage.
If you’re seeking breast reduction as part of a gender-affirming intervention, Medicare’s decision to cover the surgery will be decided by a local Medicare Administrative Contractor (MAC). You’ll need to contact Medicare to determine how your local MAC may cover gender-affirming surgeries.
If you aren’t experiencing medical symptoms, but your self-esteem is seriously affected by the size or shape of your breasts, talking to a licensed therapist might be helpful. Medicare does cover mental health services under Part B.
To receive full benefits, you will need to get your breast reduction performed at a facility that accepts Medicare. Ask your providers if they accept Medicare before your first visit or search for providers using the Medicare website.
In cases where breast reduction surgery is covered, you’ll probably still have some out-of-pocket costs. However, the deductibles, copays, and coinsurances may differ depending on your Medicare coverage.
If approved, a person with Medicare Part A and Part B (Original Medicare) will be covered and may have additional help if they have Part D and Medigap. The alternative to Original Medicare are Advantage Plans (Part C).
Part A covers inpatient surgeries. A person’s share of the costs would include a deductible for each benefit period and $0 coinsurance for the first 60 days of each benefit period.
Some doctors perform outpatient breast reconstruction and reduction surgeries, such as the implantation of a breast prosthesis following the removal of a breast due to cancer.
In these instances, Medicare Part B provides coverage. A person will need to pay a share of the costs, including 20% of the Medicare-approved amounts and the yearly deductible. Part B also covers some external prostheses, such as a postsurgical bra.
DISCLAIMER: Medi-Solutions Insurance Agency, LLC is not affiliated or endorsed with the Social Security Administration or the Federal Medicare Program. Information is for educational purposes only and should not be construed as an offer of insurance, advice, or recommendation. The information provided is not intended as tax, financial, investment, or legal advice. Please consult legal or tax professionals for specific information regarding your situation.
Other articles:
Learning Center.