Medicaid sometimes covers plastic surgery even when low-income patients pursue the procedure for cosmetic reasons: to improve appearance or symmetry.
The key to success is proving in advance that the operation is medically necessary or reconstructive: treating an illness, injury, or functional impairment.
Therefore, you may need to find alternative ways to pay for cosmetic surgery, such as financing or combining the procedure with a medically necessary operation.
Finally, finding local plastic surgeons accepting your Medicaid plan requires a specific strategy rather than a Google search.
Does Medicaid Cover Cosmetic Surgery?
Medicaid does not cover cosmetic surgery that exclusively reshapes healthy tissue to improve appearance or symmetry. Therefore, low-income patients should consider alternatives and creative ways around the problem.
Financing Options
Medicaid does not cover cosmetic surgery unless the procedure is medically necessary. Therefore, low-income patients seeking to improve their appearance might need another way to pay for the operation.
No credit check cosmetic surgery financing might help low-income patients unable to get a loan or payment plan through traditional channels. This approach might fit if you fall into one of these categories.
- Your credit report contains adverse payment history (charge-offs, bankruptcy, etc.)
- You have not established a consumer report with six months of payment history.
Diastasis Recti
For example, getting Medicaid to cover Diastasis Recti will be challenging unless you can identify a creative workaround. The closure of separated abdominal muscles after pregnancy typically falls into the cosmetic surgery category because it addresses appearance, not function.
Financial help paying for surgery might come by combining the Diastasis Recti procedure with a medically necessary one, such as an umbilical hernia repair. Medicaid might pay for the anesthesia, nurses, operating room, and other shared expenses while rejecting claims connected exclusively to cosmetic services.
Does Medicaid Cover Plastic Surgery
Medicaid often pays for plastic surgery deemed medically necessary or reconstructive – even when the procedure improves appearance. Of course, you must prove the operation meets precise criteria in these examples and others.
Medically Necessary
Medicaid often covers plastic surgery that reconstructs facial and body defects or treats an illness, injury, or symptoms. These procedures are medically necessary; your surgeon must submit documentation before the operation for pre-certification.
The steps for getting health insurance to pay for plastic surgery are the same for Medicaid. Taxpayer funding of the program does not alter the claims underwriting process.
The requesting physicians should submit documentation to the Managed Care Organization (MCO) or state agency for pre-certification, including photographs, measurements, chart records, and any other evidence supporting the specific diagnosis.
- Address how it treats a disease or illness and why it is consistent with the applicable standard of care.
- Include the appropriate ICD-10 and CPT codes and the prognosis or expected outcome.
Liposuction
For example, Medicaid might cover liposuction if you can establish a medically necessary reason upfront for this plastic surgery to harvest fat from targeted areas of your body.
The steps for getting health insurance to pay for liposuction are the same for Medicaid, as this publically-funded program follows similar claims underwriting rules. At least two medically necessary reasons might qualify.
- Liposuction to treat lipedema (abnormal build-up of fat in your legs and arms, causing pain or limiting movement)
- Liposuction to support breast reconstruction after mastectomy or lumpectomy requiring the harvesting and grafting of autologous fat
Plastic Surgeons That Take Medicaid
Finding local plastic surgeons who accept Medicaid is another front in your battle. Many providers will not treat recipients because the reimbursement rates are stingy, and the government limits their ability to balance bill patients.
Provider Directory
The online provider directory published by your Managed Care Organization (MCO) or state agency is the primary way to find a plastic surgeon who takes Medicaid in your area. An MCO is often a private company hired by states to administer plans.
Open your wallet and retrieve your Medicaid card. You should find the MCO or state agency listed prominently on the card. Go to the website and find the provider directory. Input your zip code, and search for plastic surgeons within a specific radius of your home.
Below are links to the five largest MCOs.
- Anthem
- Centene
- Amerigroup
- United Healthcare
- Wellcare
Primary Provider
Your Primary Care Provider (PCP) is sometimes the only resource for finding a local plastic surgeon who takes your Medicaid plan. Many recipients enroll in Health Maintenance Organizations (HMOs) that require specialist referrals.
For example, many Medi-Cal programs operate under this model.
Therefore, your first step is meeting with your designated PCP, who must diagnose you with an illness, injury, or functional impairment requiring plastic surgery. After the diagnosis, the PCP would refer you to a nearby specialist participating in your plan.
Online Searches
Going online and searching for nearby plastic surgeons who accept Medicaid is a lousy strategy. Google and Bing have no insight into the contractual status of these providers and can merely output a random list on a map.
Nor do they know whether your proposed procedure is medically necessary. Plastic surgeons only take Medicaid when they believe the state insurance plan will pay claims. Scroll back to previous sections for better approaches.
