Restricted Breast Cancer Surgery Facilities for Medicaid Recipients

It is the policy of the New York State Department of Health that Medicaid recipients receive breast cancer surgery services at high volume facilities - those performing 30 or more all-payer mastectomy and lumpectomy procedures associated with a breast cancer diagnosis on average over a three-year period. Low-volume facilities, identified in the listing below, will not be reimbursed for breast cancer surgeries provided to Medicaid recipients. This policy does not affect a facility´s ability to provide diagnostic or excisional biopsies, and post-surgical care (chemotherapy, radiation, reconstruction, etc.) for Medicaid patients.

This policy is part of an ongoing effort to reform New York State Medicaid and to ensure the purchase of cost-effective, high quality healthcare, and better outcomes for its beneficiaries. Research shows that five-year survival increases for women having their breast cancer surgery performed at high-volume facilities and by high-volume surgeons. The Department will annually re-examine all-payer surgical volumes to revise the list of low-volume hospitals and ambulatory surgery centers. This assessment is performed using the Statewide Planning and Research Cooperative System (SPARCS) database. The annual review will allow restricted providers meeting the three year average minimum all-payer volume threshold to receive payment for breast cancer surgery for Medicaid recipients.

  • Hospitals & Ambulatory Surgery Centers Where Medicaid Will Not Pay for Breast Cancer Surgery - 4.1.21