Using Private Health Insurance for Plastic Surgery

By May 3, 2022News

Plastic surgery includes a wide range of procedures, many of which are cosmetic. Medicare and private health insurers do not cover any of the costs associated with cosmetic surgery. Cosmetic surgery is surgery that is done to improve your appearance and has no specific health benefit eg breast augmentation to improve breast size. There are a large number of plastic surgery procedures which improve your appearance and also improve your health eg flap repair of a skin cancer defect. These procedures are often called “reconstructive surgery”.

If a procedure is covered by Medicare, it will also be covered by your health insurer, so long as reconstructive surgery is included in the policy. The issue many patients face is that the Medicare item numbers for body contouring surgery are not classified under the plastic surgery section of the Medicare benefits schedule. Many private health insurers will require their customers to take-out top-level cover if they are looking to have body contouring surgery after massive weight loss, such as plastic surgery for loose skin.

In Australia we have a private and public healthcare system. In the private health system, you will receive a Medicare rebate if your surgeon allocates a Medicare number to your procedure. Your surgeon can only allocate this Medicare number if your medical history and examination correlate with the Medicare description for that procedure. If you have Private health insurance, procedures covered by a Medicare number allow the insurer to also cover the cost of your theatre and accommodation at the hospital. Self-funded patients (people who do not have private health insurance) will still need to pay for their hospital stay.

If your procedure is “cosmetic” then it does not have a Medicare item number, for example face lift surgery. Health insurance does not cover the cost of cosmetic surgery, nor does it cover the cost of management of complications of cosmetic surgery.

Examples of Reconstructive/Cosmetic surgery include:

  • Surgery that repairs congenital abnormalities such as nasal deformities and cleft lips.
  • Surgery thar reverses the damage of traumatic injuries
  • Skin grafting for burn victims
  • Scar repair
  • Reconstruction that follows the removal of tumours like skin flap and breast reconstruction.

All these procedures have an item number in the Medicare Benefits Schedule, meaning Medicare and private health funds are likely to cover them. Although, some may require you to meet a specific criterion to receive plastic surgery. If a plastic surgery procedure doesn’t have a Medicare Benefits Schedule umber, it likely will not be covered by a health fund.

Exclusions and Restrictions

Although you may have coverage for some reconstructive surgeries, there are probably some hidden exclusions or restrictions you should know. Exclusions mean that your health fund won’t cover particular procedures, and restrictions mean that they will cover a portion of the cost, but the rest is up to you. It is important to be aware of these things, so you aren’t surprised with a high bill you didn’t expect.

The best way to check if you qualify for rebate from your surgery from Medicare or your health insurer is to have a consultation with us at Southern Aesthetic, so we can provide you with advice regarding which Medicare item numbers you can use.

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