Unrestricted and 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 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, or at facilities that have successfully appealed their restriction. These facilities are identified in the list below entitled, "Hospitals & Ambulatory Surgery Centers Where Medicaid Will Pay for Breast Cancer Surgery". Conversely, low-volume facilities, identified in the list below entitled "Hospitals & Ambulatory Surgery Centers Where Medicaid Will Not Pay for Breast Cancer Surgery", will not be reimbursed for breast cancer surgeries provided to Medicaid recipients. Note, that low-volume facilities may still 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 improved five-year survival rates for patients who have their breast cancer surgery at high-volume facilities. The Department will annually re-examine all-payer surgical volumes to revise both lists. 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.
