Does Medicare Cover Breast Reduction Surgery?

Original Medicare (Part A and Part B) may cover breast reduction surgery that is deemed medically necessary by a doctor. The part of Medicare (Part A or Part B) that covers your breast reduction surgery will depend on the type of facility in which you undergo surgery.

Medicare Advantage (Part C) plans may also cover a breast reduction surgery that is deemed medically necessary by your doctor.

Medicare Advantage plans also offer an annual out-of-pocket spending limit, which can potentially save you money in Medicare costs for your surgery.

Original Medicare does not include an out-of-pocket spending limit.

A woman smiles as she speaks with her doctor

When does Medicare pay for breast reduction surgery?

Medicare may help cover breast reduction surgery if your doctor determines it is necessary to help treat or eliminate issues like severe back and neck pain by removing excess breast skin and tissue.

These symptoms can stem from breast hypertrophy (also called macromastia), which is a notable increase in the density and weight of the breasts relative to the rest of your body.

Breast reduction surgery may be considered medically necessary when:

  • The surgery purpose is to reduce symptoms of back pain, neck pain, numbness, or skin issues like dermatitis

  • The surgery is for reconstructive purposes after breast cancer or mastectomy

  • You have tried and failed non-surgical options

  • Breast hypertrophy is the primary cause of the health issues that are being addressed by the surgery

Depending on whether your breast reduction surgery is performed as an inpatient hospital procedure or as outpatient surgery, Medicare Part A or Part B may cover some of your costs:

  • If you receive the surgery as an inpatient, the hospital and inpatient care costs related to the breast reduction surgery are typically covered by Medicare Part A (Hospital Insurance).

  • If you receive the surgery as an outpatient, any doctor’s services related to the breast reduction surgery are typically covered by Medicare Part B (Medical Insurance).

    Even if you receive your surgery as an inpatient, Medicare Part B is responsible for doctor’s visits for pre-op and follow up.

How much does breast reduction surgery cost with Medicare?

While it is possible Medicare may cover some costs related to your breast reduction surgery, you may be required to pay certain out-of-pocket costs, which may include:

  • Inpatient surgery
    • Part A deductible
    • Part A coinsurance
  • Outpatient surgery
    • Part B deductible
    • Part B coinsurance or copayment

Medicare Part A deductible for hospital services

The Medicare Part A deductible is $1,364 per benefit period in 2019.

A Part A benefit period starts when you are admitted for inpatient hospital care and ends when you have stopped receiving inpatient care for 60 consecutive days.

The Part A deductible is not annual, and you could experience more than one benefit period in a given calendar year.

Medicare Part A coinsurance for hospital services

When you meet your Part A deductible in a benefit period, you could face Part A coinsurance costs for inpatient hospital stays that last longer than 60 days (which is not common for breast reduction surgery):

  • Days 1-60 spent in the hospital: $0 coinsurance for each benefit period
  • Days 61-90: $341 coinsurance per day of each benefit period in 2019
  • Days 91 and beyond: $682 coinsurance per each “lifetime reserve day” after day 90 for each benefit period in 2019
  • Beyond lifetime reserve days: you pay all costs

Medicare Part B deductible for outpatient costs and doctor’s services

The Medicare Part B deductible is a total of $185 per year in 2019. You must meet your Part B deductible before your Part B coverage will kick in.

Medicare Part B coinsurance or copayment

After your Part B deductible is met, you typically pay 20 percent of the Medicare-approved amount for most doctor’s services.

There is no annual limit on how much you could pay for the Part B coinsurance in a given year. This means that the costs related to your breast reduction surgery could add up quickly.

Medicare Advantage plans have an out-of-pocket spending limit

Medicare Advantage plans are sold by private insurance companies and must cover everything that Original Medicare covers.

If your breast reduction surgery is covered by Original Medicare, it will also be covered by a Medicare Advantage plan.

Many Medicare Advantage plans may also cover prescription drugs, which Original Medicare does not typically cover. The out-of-pocket spending limit offered by Medicare Advantage plans is also something Original Medicare does not offer.

Some Medicare Advantage plans may also offer additional benefits, such as:

Learn more about Medicare Advantage plans that are available in your area and the benefits they may offer. Call today to speak with a licensed insurance agent who can help you compare plans if you’re eligible to enroll.

 

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