Health Insurance for Weight-loss surgery

Published: September 6, 2019

If your Body Mass Index (BMI) is higher than 35, your doctor might recommend weight-loss surgery, for example, bariatric or gastric sleeve surgery.

Surgery for weight-loss can be costly, and only a small portion of Australians are deemed eligible for a benefit from Medicare.

Several surgical procedures might help obese individuals with their weight-loss. Medicare generally provides 75% of the MBS fee for in-hospital procedures for eligible clients. Private health insurance could help pay for the unexpected out-of-pocket costs while also offering weight management programs. You will most likely need to opt for a Gold level Hospital option combined with Top Extras.

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Does health insurance cover weight-loss surgery?

Generally, Gold hospital policies from private health funds might cover some of the cost of your in-hospital weight-loss surgery. Depending on your insurer and level of cover, private health funds could cover more than 60% of your weight-loss surgery.

Take note: To claim a benefit for weight-loss surgery, you’ll likely need to serve a waiting period of 12 months, because obesity is usually considered a pre-existing condition.

What does health insurance pay for weight-loss surgery?

Depending on your health fund and Hospital policy, your insurer might cover:

  • Hospital accommodation as a private patient in a private or public hospital,
  • Hospital theatre costs
  • Equipment used during surgery; this could include things like the gastric band or other weight-loss devices, such as stapling.
  • Some of the professional fees charged by the team (surgeon, anaesthetist and surgeon assistants.

However, because every surgeon charges their own fees, you might have out of pocket expenses. You must request a complete breakdown of all costs and ask which your insurance will cover, before booking your appointment.

Private hospital insurance for weight loss generally won’t cover:

  • The initial weight loss consultation fee
  • The professional health management fee
  • Follow up visits
  • Dietician’s fees
  • Psychologist’s fees
  • Post-op medication

However, if you have a Top Extras policy, a benefit might be paid to some of the above expenses, like the dietician and psychological services.

Important: Depending on your Hospital policy, you might have to pay an Excess when admitted to hospital.

Request a quote for Hospital and Extras cover

Does Medicare cover weight-loss surgery?

Medicare pays 75% of the Medicare Benefit Schedule (MBS) for weight-loss treatments performed in the hospital. However, the Medicare benefits will usually only be paid if your practitioner approves the weight-loss surgery, and you have diagnosed with clinically severe obesity. Clinically severe obesity is generally defined by a BMI above 40 or above 35 when you have medical conditions, for example, heart disease and diabetes.

If you do qualify for this type of surgery and don't have private health insurance, you can expect a longer waiting time and generally won't have the option to choose your surgeon.

How much does Medicare pay for weight-loss surgery?

Medicare generally applies a set rate to specified weight-loss procedures, of which they typically provide a 75% rebate. This rate is usually lower than actual surgery costs, so you will have to pay out of pocket to cover the gap.

What are the most common types of weight-loss surgeries in Australia?

Bariatric Surgery

Bariatric surgery refers to surgery that directly affects your stomach and how it digests food. The idea is to make your stomach feel smaller so that you feel fuller for longer after small meals. As a result, you might end up eating less food, which means you would absorb fewer calories.

Gastric banding ‘lap banding’

A lap band surgery involves an adjustable ring that is inserted around the top part of the stomach, effectively creating a tiny pouch. This then causes food to stay in the top part of the stomach for longer, creating a sensation of being full.

Gastric sleeve surgery

During a gastric sleeve surgery, a huge part of the stomach is removed, reducing the stomach to a sleeve-like shape. The volume of the stomach is reduced by 80%, and therefore only small amounts of food can be consumed.

Gastric bypass surgery

Gastric bypass surgery is the stapling of the stomach to form a little stomach pouch. A section of the small intestine is then removed, and the bag is then connected directly to the small intestine. Essentially when you eat, the food now bypasses most of the stomach. Consequently, you would now consume fewer calories – which could lead to weight loss.

Gastric balloon

A gastric balloon procedure is non-surgical and temporary. A lightweight, gastric balloon is inserted into the stomach. It then sits in the stomach for six months to help the stomach feel fuller quicker, and in doing so, the patient may eat less.

How much does weight loss surgery cost in Australia?

The average cost of weight-loss surgery in Australia, without the aid of health insurance or Medicare, depends on the state you live in and the type of surgery you’re having. For example, the estimated costs of Bariatric surgery in NSW can range anywhere from $9,000 to $18,000.

Costs to consider for your weight-loss surgery, include:

  • Your initial consultation fee with the surgeon,
  • The type of weight-loss surgery that's recommended,
  • Surgeon's fees,
  • Hospital costs, including accommodation,
  • The anaesthetist’s fees,
  • Medications prescribed after surgery,
  • Follow-up appointments.

How much does weight-loss surgery cost with private health insurance?

With a Gold Hospital policy that includes weight-loss surgery, you could expect to pay anywhere between $2,800 to $7,000. However, it depends on your surgery type, the costs charged by your surgeon and where in Australia you live.

Type of surgery Cost without private insurance Cost with private insurance
Gastric band surgery (Lap band) $10 000 - $15 000* $2 500 - $55 00*
Gastric sleeve surgery $16 000 - $18 000* $4 000 - $6 000*
Gastric bypass surgery $16 000 - $18 000* $4 000 - $6 000*
Gastric balloon cost $5825 Insurance typically will not cover this procedure. They may cover the gastroscopy.
Source: Bariatric Surgery Source (September 2019).

*Medicare rebates not included in the estimate

Examples of private health funds that covers weight-loss surgery, include:

  • AHM Top Hospital Gold
  • Bupa Ultimate Health Cover – Gold
  • CBHS Premium Package (Gold)
  • Peoplecare Gold Hospital & Premium Extras
  • Medibank Gold Ultra Health Cover
  • Nib Top Cover – Gold
  • HCF Hospital Gold

Frequently asked questions and answers

Does health insurance cover weight management programs?

Yes, select insurers do offer weight management programs with their Top Extras policies. These benefits will usually be listed under their 'healthy lifestyle programs’ and might include gym membership discounts and dietary weight loss programs — for example, Weight Watchers, Tony Ferguson and Jenny Craig.

Discounts and programs will vary depending on your provider. Review the health fund’s Private Health Insurance Statement (PHIS) to see which programs are typically included.

Is weight-loss surgery a pre-existing condition?

Generally, obesity is considered a pre-existing medical condition in private health insurance. You'll typically have to wait 12 months before you can claim benefits for weight-loss.

What private insurance covers gastric bypass?

Private health insurers might cover the cost of gastric bypass surgery if it’s a benefit listed on your Hospital policy. Generally, you’ll need a Gold Hospital plan. Check with your fund before making appointments.

What is the average cost of bariatric surgery without insurance?

The average cost of bariatric surgery without insurance ranges from $12 000 to $18 000 after Medicare rebates. The price is mostly dependent on the type of surgery performed and the state you live in.

Request quotes for private health insurance for weight loss surgery

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