Hospital Health Cover and Plastic Surgery


Hospital Health Cover and Plastic Surgery – Policy Discussion and Terminology

Health Insurance Terminology including Hospital Coverage, Fully Covered and Exemptions for Plastic Surgery are confusing concepts for most patients. This blog relates to Health Insurance Policy Terminology about the misunderstood 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, last updated 20 November 2018.

Tiered Health Insurance Policies are coming into effect in 2019; hospital health cover and Plastic Surgery policy exclusions from Private Health Funds

First, an overview of why private health insurance terminology and policy information is challenging to patients.

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 private health funds and also Medicare.
  • Some corrective or reconstructive Plastic Surgery that is medically indicated may have some coverage or rebate eligibility.
  • Read the helpful resources for Plastic Surgery patients seeking health fund insurance coverage or rebates for their medically indicated procedures.
  • Phone us on 1300 264 811 if you have any questions or send in an enquiry form.

Private Health Fund Terminology: What Fully Covered Means”

What does the terminology “fully covered” really means in terms of Private Health Insurance? Terminology

Will I have any out of pocket costs for surgery if I am “fully covered”?

  • Health Funds are very strict about what they cover.
  • If your surgery and condition do not meet strict Medicare criteria for an MBS Item Number for Plastic Surgery, you will usually NOT have 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 need to be adjusted to a tiered system that is easier to understand.
    • This could technically change your current coverage and policy – stay abreast of changes and phone your insurer directly for information.
    • Multiple calls are best to validate whatever information you receive.

When your Private Health Insurance says you are“Fully covered” –  you will often STILL have some out of pocket costs for plastic surgery.

There are fees for more than just the Surgeon.

These additional surgery expenses may include (but are not limited to): fees for the anaesthetist, surgery assistant, hospital theatre, overnight stay (bed fee), medications and pathology and imaging services.

Top Complaints about Health Fund Insurance Companies and Policies

Why are so many patients frustrated and disappointed with their Private Health Fund companies?

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, who have spent years training and who use best practice care and operating safety standards, to provide services for the very small Medicare rebate or Private Health Insurance Rebate.

  • Some rebates from health funds are as low as $300.
  • The Public System will do a lot of surgery across many fields for these rebate amounts, but the waiting time for some procedures is 5-10 years.
  • The surgeons performing it can be a trainee surgeon or general surgeons, not Specialists.
  • 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 Privately Health 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

Considering which Australia Health Funds people COMPLAIN about most in online forums, the KEY COMPLAINT ITEM about PHI policies seems linked to whether the health fund is:

  • client-focused health fund
  • shareholder focused health fund and Bonus-driven CEO and management

Sadly, many Australian Private Health Funds appear focused more on returning shareholder profits than on servicing clients they charge so much to insure.

  • They refund very little, if anything at all, for many hospital stays 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, but policies are being restructured due to a government incentive and review. This begins in 2018.

It’s best to contact your private health insurer directly to find out specifics.

  • All Australian PHI (private health insurance) policies are changing in 2019.
  • The new system is a tiered coverage system, gold, bronze, silver and basic – and could impact your future 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).

Health Insurance Hospital Coverage: what fully covered means (resource links)

What may not be covered by your Private Health Insurance Company (your Private Health Fund), 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

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 – specific services that are not covered at all.
  • Restrictions – services that are covered to a limited extent, which means you will have greater out-of-pocket expense. Restricted benefits are not sufficient to cover the full hospital cost of private hospital admission and you will need to pay for the difference in cost.  Sometimes this is called 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 admitted to 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

Understanding BUPA’s policies (corporate site)

Medibank Health Insurance – Hospitals Extras Explained

Health Insurance Companies

Medicare and Health Insurance Codes – added terminology your health fund may use in discussions.

Private Health Insurance – Glossary of Commonly Used Terms (from

  • Community Rating – click here for information on HOW HEALTH FUNDS WORK (Australian Government) – last accessed online 20 Nov 2018
  • 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 (MBS) – Medicare Item Codes and rebate criteria for Plastic Surgery
  • Pre-existing Ailment – 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 be insured BEFORE any cover kicks in

Resources, References and further reading

Health Insurance Consumer Hotlines and Helpful Links

Private Health Insurance Ombudsman


Last updated: 07/08/2020
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Michelle Staughton
Michelle Staughton is a Patient Education Interviewer and Patient Care Coordinator for several top Plastic Surgeons in Melbourne, Victoria, Australia. With over 4 years’ experience helping plastic surgery patients at Coco Ruby Plastic Surgery, after having been a patient herself, Michelle offers a wealth of knowledge to help surgical patients with cosmetic and plastic surgery planning and recovery tips.