Hospital Health Cover and Plastic Surgery – Policy Discussion and Terminology
Health Insurance Terminology including Hospital Coverage, Fully Coverage and Exemptions for Plastic Surgery are confusing concepts for most patients. This blog relates to Health Insurance Policy Terminology and the common misunderstanding of the term “fully covered”. It is published as part of a series of blogs about Medicare and Plastic Surgery vs Cosmetic operations. First published in Feb 2018.
Tiered Health Insurance Policies came into effect in 2019; Hospital health cover and Plastic Surgery policy exclusions from Private Health Funds
First of all, an overview of why private health insurance terminology and policy information is challenging to patients.
- Health Fund coverage has a tendency to change rapidly and without notification to its members.
- Coverage changes or sudden exclusions can also result from Medicare Rebate criteria updates. Which can occur once or twice a year (or more).
- When extensive changes to Medicare, health fund policy coverage and exclusion criteria occur:
- it can not only affect your overall out of pocket surgery costs for plastic surgery, but it can also impact your ability to APPLY for early release of Super for surgery procedures, based on compassionate grounds.
About to have Plastic Surgery? Soon to phone your Private Health Fund? What to expect.
“I thought ‘fully covered’ meant no out of pocket expenses for my surgery.” Why plastic surgery patients find insurance coverage so confusing.
Health Insurance Policies in Australia: What “fully covered” hospitalisation really means.
- Firstly, most cosmetic surgery falls under exclusion categories for not only private health funds but Medicare too.
- Secondly, some corrective or reconstructive Plastic Surgeries that are medically indicated may have some coverage or rebate eligibility.
- Furthermore, read the helpful resources for Plastic Surgery patients seeking health fund insurance coverage. or, rebates for their medically indicated procedures.
- Finally, you can phone us on 1300 264 811 if you have any questions
- Or, send in an enquiry form.
What the terminology “fully covered” really means in terms of Private Health Insurance Coverage
Will I have any out of pocket costs for surgery if I have “full coverage”?
- Health Funds are very strict about what they cover.
- If your surgery and condition does not meet strict Medicare criteria for an MBS Item Number for Plastic Surgery, you will usually NOT be eligible for any Private Health rebate either.
- If you are covered by your policy, note that:
- Waiting times, certain criteria and exclusions in cover can take up multiple pages in a Health Insurance Policy and/or paperwork.
- Consumer groups are pushing for greater transparency and plain language for easier understanding.
- In 2019, Private Health Insurance policies were adjusted to a tiered system to make it easier to understand.
- This may have affected your coverage and policy. It’s important to be aware of changes and phone your insurer directly for information.
- Multiple calls are best to validate and confirm whatever information you receive.
When your Private Health Insurance says you have “Full coverage” – you will often STILL have some out of pocket costs for plastic surgery.
Your fees include a lot more than just the cost of your Surgeon. These additional surgery expenses can include, but are not limited to fees for;
- the anaesthetist
- surgery assistant
- hospital theatre
- overnight stay (bed fee)
- And, imaging services.
Top Complaints about Health Fund Insurance Companies and Policies – Why so many patients are frustrated and disappointed with their Private Health Fund companies?
- Read the list of top complaints about health fund and private health insurance policies.
- There are typically incidental expenses involved with having surgery.
- These may include post-surgery garments, antibiotics and other medicines.
- “Fully Covered” means that Medicare and the Health Fund will cover you to the recommended Government Fee on a particular surgery.
- Unfortunately, this fee often falls far short of what Private Practices charge.
For example: On a $10,000 surgery, you may be rebated $2,000. Therefore, leaving $8,000 out of pocket (for you to pay yourself).
It is not possible for fully qualified, experienced Private Practice Surgeons, with years of training, that uses best-practice care and operating safety standards, to provide services for the very small Medicare or Private Health Insurance Rebate.
Moreover, some rebates from health funds are as low as $300. And, whilst the Public System will do a lot of surgery, across many fields for these rebate amounts, the waiting time for some procedures can be as long as 5-10 years. Additionally, the surgeons performing surgeries in the public system can often be either trainees or general surgeons, not Specialist Plastic Surgeons.
If you want a quality surgeon with extensive experience and qualifications, expect to have out of pocket costs for Plastic Surgery or Cosmetic Surgery.
Public vs Private Health Funds: Impact to Policyholders
No PHI Rebate? Is your Private Health Funds Publicly Traded or Private?
Shareholder focus of stock-exchange listed Health Insurance Providers
When we looked into which Australia Health Funds people COMPLAIN about most in online forums, the KEY COMPLAINT ITEM about PHI policies seemed to be linked to whether the health fund was a client-focused health fund or a shareholder focused health fund with a Bonus-driven CEO and management team. Furthermore, many Australian Private Health Funds appear to focus more on returning shareholder profits than on servicing the clients they charge so much to insure. Unfortunately, many PHI refund very little, if anything at all on cosmetic/ plastic surgery including the hospital stay and surgery care.
BUPA, Medibank, NIB and AHM – hospitalisation coverage – 2019 Policy Changes
What do private health insurance funds (BUPA, Medibank, NIB and AHM, for example) actually cover for hospitalisation?
*This is simply an overview and information may be superseded. Policies are subject to restructure due to government incentives and reviews.*
It’s best to contact your private health insurer directly to find out specifics.
- All Australian PHI (private health insurance) policies were changed in 2019.
- The new system is a tiered coverage system, gold, bronze, silver and basic – and may have had an impact on your surgery coverage.
- Buyer beware: READ and try to understand your policy materials, inclusions, exclusions and waiting periods BEFORE you choose a private health fund.
- Phone your Insurer directly to discuss these changes.
- Tips: take notes, get the reps name and ask for everything in writing/email;
- Consider asking to make your OWN recording of the call (seek permission first, as the company does to record your own call participation).
- Why is this a good idea? Because patients often report hearing misinformation from various staff at Insurance Fund offices.
- Some PHI policies are so full of jargon and exclusions that their own staff can’t understand them accurately; insurance funds have high employee turnover rates as well.
- Find out which health insurance policies have the highest complaints and what they relate to.
Private Health Insurance Policy Exclusions: Cosmetic Plastic Surgery
Many private health fund companies do not offer hospitalisation or procedure coverage even though they can charge hefty premiums.
In particular, cosmetic surgery and most Plastic Surgery is not covered by general Private Health Funds. Nor is it eligible for medicare rebates (a limited number of surgeries may qualify – click here for MBS criteria).
- Although research clearly shows that certain Plastic Surgery procedures are highly effective for treating urinary incontinence, back pain and neck pain, such as Abdominoplasty Surgery, it seems that if a Private Health Fund company can avoid paying for surgery, they will do their best to NOT reimburse a patient.
- Recent media stories (such as Four Corners), shows Health Funds representatives try to shift their focus to Surgeon’s gap fees or booking fees. Whilst ignoring CEOs bonuses gained by keeping Surgery Rebates LOW to existing policy holders, often through complex exclusions and other loopholes.
- Example: Salaries of CEOs of Private Australia health insurance funds average over $50 million per year (each).
- Read the revealing expose on Health Fund CEO salaries.
Health Insurance Hospital Coverage: what fully covered means (resource links)
What your Private Health Insurance Company covers you for, and what it doesn’t. Even though it says you’re ‘fully covered’ for surgery?
Excerpted from the article source link above (Accessed online on 20 Nov 2018):
Read More about Health Funds, MBS and Plastic Surgery Costs
- Call for Government Funded Tummy Tucks – New Research On Back Pain & Incontinence
- Canberra Doctor Believes Medicare should help cover the cost of a Tummy Tuck (Abdominoplasty) as it can treat back pain and incontinence
- Tummy Tuck Can Ease Back Pain – Incontinence Study (Abdominoplasty)
Health Insurance Policy limitations and hospital coverage
The health insurance policy you buy will have some limitations on hospital treatment. These limitations may impact coverage for corrective plastic surgery procedures.
These insurance policy limitations might include:
- Exclusions. Are specific services that you do not have cover for, at all.
- Restrictions.Services that have some cover for (limited cover). In other words, you will have a greater out-of-pocket expense.
- Restricted benefits are not sufficient to cover the full hospital cost of private hospital admission. You will need to pay the difference.
- Also known as a co-payment.
- Benefit limitation periods – which pay reduced benefits on one or more services for a set period of time after the waiting period, then pay full benefits after this period.
- Surgery or hospital treatment that Medicare does not pay a benefit for – Medicare pays a benefit on all medical services necessary to maintain your health, but does not cover optional treatments such as elective cosmetic surgery.
- Single vs shared rooms – some hospital policies cover the full cost of a shared room, but not a single room. Depending on your policy, this limitation can apply in a private hospital, or a public hospital, or both.
- If you are put in a single room and your policy does not fully cover the cost, the hospital should inform you that you will need to pay the difference between the fund’s benefit and the hospital’s charge.
- Your health fund can also provide more information about your cover.
Helpful Resources for Understanding Private Health Insurance Funds in Australia
Medicare and Health Insurance Codes – added terminology your health fund may use in discussions.
Private Health Insurance – Glossary of Commonly Used Terms
- Co-payment – your part of the cost or fee
- Excess or Front-end deductible – even if covered, this is your out of pocket expense BEFORE coverage kicks in
- Exclusion – reasons they will not cover you
- Gap – another word for your co-payment or out of pocket costs; usually the price difference between a very low rebate or cover and the actual price of quality surgery in Australia
- Medicare Benefits Schedule is also known as MBS – Medicare Item Codes and rebate criteria for Plastic Surgery
- Pre-existing Ailment, in other words, a condition that your insurer MAY exclude coverage for if you change policies or buy a new one
- Public Hospital (or basic default) table – ask your health fund for their policy info
- Restricted Benefits – ask your fund
- Suspension of private health cover – ask your fund
- Waiting Period, ask your private health fund how long you need to have insurance BEFORE any cover kicks in.
Resources, References and further reading
Health Insurance Consumer Hotlines and Helpful Links
- ACCC information about Health Insurance
- Source: https://www.accc.gov.au/consumers/health-home-car/private-health-insurance (accessed online on 20 November 2018)
- Consumer Insurance Information for Private Health Insurance (ACCC)
- Source: https://www.accc.gov.au/consumers/health-home-car/private-health-insurance
Private Health Insurance Ombudsman
- Source: http://www.ombudsman.gov.au/about/private-health-insurance
- First visit: https://www.privatehealth.gov.au/contactus/