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NIBYou might require plastic surgery, either due to medical or personal reasons. If you’re looking for cosmetic surgery financing opportunities, you might be considering Medicare and/or Private Health Insurance. Use the guide below to discover whether health insurance and Medicare can help you cover the costs.
Private health insurance for medically necessary plastic surgery is generally available from select health funds. However, your choice of Hospital policy and level of coverage will usually determine if you’ll receive a benefit and how much you can expect.
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Does private health cover plastic surgery?
Health insurance will generally pay a benefit for plastic surgery as part of your Hospital plan if the operation is deemed medically necessary. Australian private health funds aren’t required to pay for treatments that Medicare doesn’t pay a benefit for, including cosmetic procedures and the hospital cost they incur. Cosmetic procedures are usually not covered by Medicare or private health funds.
Is cosmetic surgery covered by Medicare?
No, cosmetic surgery is generally not covered by Medicare when it is not deemed medically necessary.
What does plastic surgery for medical reasons mean?
Plastic surgery for medical reasons can be defined as procedures necessary to assist the patient to overcome a medical condition that is detrimental to their health — for example, breast surgery to remove lesions or tumours.
However, Insurers have different views regarding what constitutes reconstructive surgery and what’s defined as cosmetic surgery. You might want to check with your health insurance provider to see what their terms and conditions are, as well as their exclusions and restrictions.
Examples of plastic surgery generally covered by Hospital insurance and Medicare
The following are examples of item numbers on the Medicare Benefits Schedule (MBS) that relate to medically necessary plastic and reconstructive surgery:
- 45497: Breast reconstruction.
- 30176: Abdominoplasty (tummy tuck) for the sake of removing excess skin and fat that might be detrimental to the patient’s health.
- 42860: Corrective surgery for eyelids to correct defects.
- 45019: Full-face chemical peel to treat severely sun-damaged skin.
- 45680: Repair to cleft lip and palate.
- 45578: Muscle transfer for facial nerve paralysis.
- 45584: Liposuction to one limb or trunk for the treatment of abnormalities.
What’s the difference between cosmetic and reconstructive surgery?
Reconstructive surgery is generally described as plastic surgery that is medically necessary to improve a patient’s health, for example, due to disease, trauma, or congenital and developmental defects. Cosmetic surgery in Australia is typically used to enhance a person’s physical appearance and not to improve their health.
| Examples of reconstructive surgery | Examples of cosmetic surgery |
| Facial reconstruction to correct defects or improve breathing | A face-lift, cheek or chin enhancement |
| Breast reconstruction after breast cancer treatments, such as a mastectomy | Breast augmentation or best lift |
| Repair of a cleft lip and palate | Eyelid Surgery to correct droopy eyelids and wrinkles |
| Skin grafting after severe burns | Rhinoplasty to change the appearance of your nose |
| Foot or hand reconstruction, such as surgery for webbed toes | Tummy tuck or liposuction |
Health funds that cover cosmetic surgery (medically necessary)
Most Hospital policies cover plastic surgery and reconstructive surgery provided it is listed in your benefits and deemed medically necessary. Also, the procedure typically has to be on the Medicare Benefits Schedule. The below hospital policies offer coverage for reconstructive surgery:
- AHM Starter Silver: $132.55
- Australian Unity Intermediate Hospital (Silver Plus): $157.75
- Bupa Mid Hospital Silver Plus: $123.35
- GMHBA Silver Core Hospital: $136.47
- HBF Silver Hospital: $156.85
- HCF Hospital Silver: $137.85
- HIF Silver Hospital: $140.05
- Medibank Silver Everyday: $150.70
- myOwn Health Silver Hospital: $142.57
- NIB Silver Hospital: $142.31
- Peoplecare Silver Hospital: $152.50
Source: privatehealth.gov.au
The above information is based on the monthly premium for a single adult living in NSW purchasing a standalone Hospital policy with a $750 Excess. (18 February 2020)
Take note: The waiting period for plastic surgery is generally 2 months. However, 12 months for pre-existing conditions.
Questions to ask your health fund before scheduling reconstructive surgery
- A list of all the medically necessary reconstructive surgeries covered by your policy and if the one you’re needing will be covered.
- Do you need a referral from your GP to see a specialist, and what documentation is required?
- Does your health fund have a specific preferred provider they require you to use?
- The maximum benefit amount you might be able to claim and for which services exactly, for example, surgeon fees, anaesthetist, medications etc.
- Find out if you’ll have to pay a co-payment.
- Review your surgeons cost prediction with the benefit you can expect to determine out-of-pocket costs.
- How long you’ll have to wait after commencing your policy before you can claim for this benefit. Generally, you’ll have to wait 6 months depending on your health fund.
Frequently asked questions
Can I change my health insurance cover to include plastic surgery?
Yes, you can generally upgrade your health insurance plan to include coverage for medically necessary plastic surgery if it’s available from your health fund. However, you’ll usually have to serve the waiting period if this benefit was not previously covered.What does breast reduction surgery cost in Australia?
The costs for breast reduction surgery in Australia, generally depend on several factors, including the state you live in, the hospital, and your surgeon and anaesthetist fees. As of February 2020, the typical costs for the complete procedure ranges between $8,000 to $14,500.What is the average cost of breast reduction with insurance?
The cost for breast reduction surgery when you have private health insurance can vary depending on your choice of hospital and surgeon, as well as the policy you have. As of May 2019, the total cost is between $4,000 to $10,000 depending on your Hospital policy, and whether the procedure is deemed medically necessary.Will Medicare pay for breast reduction surgery?
Provided the procedure is medically necessary, Medicare will generally pay a maximum of $675.35 per breast as of February 2020. However, Medicare does not cover breast implants.How to find a plastic surgeon that accepts Medicare?
The Australian Society of Plastic Surgeons has a list of accredited plastic surgeons, and you can select one that is relevant to your specific procedure. Alternatively, you can consult your GP for a recommendation as they typically know your history and manage your overall health.Will Medicare pay for liposuction?
Medicare generally covers liposuction provided it is medically necessary.How much does a nose job cost in Australia?
The costs for rhinoplasty in Australia, vary depending on your location, unique requirements, as well as the surgeon’s fees. As of February 2020, the prices generally range between $8,000 to $20,000.Can you claim a rebate for tummy-tuck surgery?
You can typically claim a rebate for a tummy tuck when it is not related to pregnancy, and it is deemed medically necessary. An example of a medically essential tummy tuck is after pregnancy to repair a sagging or bulging stomach.
