How Much Money Does Maryland State Medicaid Pay Doctors for a Breast Reduction?

Maryland fee schedule for CPT 19318 (breast reduction) pays 834 for the first breast and 417 for the second.

This includes before and after care for 90 days around the procedure and the procedure itself.  It does not include anesthesia or hospital fees.

Your doctor will most likely need to get the procedure pre-approved.
 

Every insurance plan has their own unique criteria on whether they will cover a breast reduction. More and more, we are seeing plans where a breast reduction is not a covered benefit. If it is a covered benefit, some insurance plans set a minimum required amount of tissue to be remove in order to met their threshold for coverage. Some set the amount in relation to your BMI (height and weight). Others require extensive medical records documenting neck pain, back pain, and history of rashes. The other alternative is to opt for a breast reduction as a self-pay option. Start by visiting with a board certified plastic surgeon to learn more about your options.Best wishes,Dr. BasuHouston, TX

I'm not familiar with Maryland Medicaid but can comment on private insurance.  Breast reduction may be covered by private insurance if you meet certain critera, specified by your insurance coverage.  Often times, insurance company will need documentation of back pain, shoulder pain, photos, your height and weight, size of your breasts and proposed weight of breast tissue that would be removed.  If you do not meet the criteria set by your insurance coverage, you will need to undergo breast reduction by self-pay.  Your self-pay breast reduction cost will differ depending on your surgeon's fee, facility fee, and anesthesia fee.  There is a geographic difference as well.  It will vary from $8000-$10,000.  Please visit with board-certified plastic surgeons to discuss the overall cost as well as potential risks, alternatives, and benefits.  Good luck to you.

Thank you for the question and picture.

Although you may be an excellent candidate for breast reduction surgery I think the biggest challenge  you will have is finding a reputable plastic surgeon who works with Medicaid.

Best wishes.

If it is anything like Texas it would be about $800.00 which is not enough for the Doctor to justify the time to do the procedure. Even regular health insurance pays very little for procedures like this at around $1800.00.  The time it takes to do the reduction and the follow up care is great and this level of compensation is ridiculous for the services provided. 

Hi FOA,

The real question is whether you can find a surgeon you're comfortable with who will accept whatever the payment is as payment in full for a breast reduction.

A breast reduction is a reasonably long and complicated procedure.  While it may not require the most sophisticated techniques (such as microsurgery) it takes many hours to perform, and there is the preoperative assessments and postoperative care to consider - all of which are included in what the payers refer to as a "global" fee.  In other words, the surgical fee includes all (routine) pre and post operative care.

So it may be a good idea to start with a list of providers who accept the insurance you have, or who participate in that insurance plan.  If you're comfortable with one or more of those, it'll make the most sense to go in that direction.  If not, you may have to expand the circle of doctors you're willing to consider.  In that case, though, the financial arrangements may become a little more complicated.

I hope that this helps, and good luck,

Dr. E