Medicare Codes – Plastic Surgery Definitions, Criteria and Rebates.
Medicare MBS Criteria for Plastic Surgery changed back in November 2018. The Australian Government announced significant changes to the Medicare Benefits Schedule (MBS) for Plastic Surgery code items.
- The changes were to surgery criteria and operation coverage.
- They impacted ANY Plastic Surgery patient scheduled for an operation ON or AFTER 1 November 2018 IF their plastic surgery WAS eligible for a Medicare code/Medicare rebate and/or Health Fund coverage.
- However the November 2018 MBS changes did NOT impact purely cosmetic surgery procedures because COSMETIC surgery is NEVER covered or eligible for a rebate from Medicare.
Do you still have coverage after MBS Changes to Plastic Surgery procedures?
Click here for the LIST of CODES removed from the MBS on 1 November 2018 AND why you need to request a NEW QUOTE if your MBS item code was impacted.
Latest NEWS for MBS update to Medicare MBS criteria for Plastic Surgery rebates and Private Health Fund Cover
The changes to the Medicare Rebate Schedule (MBS) DO IMPACT operations that are corrective, restorative, reconstructive and/or otherwise medically necessary versus cosmetic in nature.
- Rhinoplasty After an injury OR to correct a deviated septum/breathing problem
- Eyelid Lift Surgery/Blepharoplasty when ptosis of the eyelid impedes the field of vision
- Skin reduction after weight loss/Bariatric Surgery
- Breast Surgery after pregnancy
- Other corrective Plastic Surgery procedures
MBSR Task Force Review and criteria changes for Plastic Surgery – Rebate Criteria Changes
- The Medicare CLAIMS REVIEW Team is no longer active.
- Instead, the Medical Benefits Schedule Review Task Force is aiming to significantly change the MBS to increase medical treatment coverage CLARITY such as changing criteria and condition definitions.
- Plastic Surgery items are NOT the only MBS code items being clarified or changed. This has had an impact on several other areas of medicine aswell.
How the 2018 MBS Changes might impact YOU as a patient.
- Many cosmetic patients are self-funded, and these operations have no MBS rebate eligibility.
- However, some patients are having procedures that are medically warranted
- These surgeries are to correct a deformity or reduce a painful or problematic medical condition that reconstructive Plastic Surgery operations can help improve.
What Medicare MBS Criteria for Plastic Surgery means IF you WERE covered OR last had a consultation. You may NO LONGER be eligible after 1 November 2018.
ASAPS media statement about November 2018 changes to the MBS codes for Plastic Surgery
The Australian Society of Plastic Surgeons released a statement about November 2018 Medicare criteria changes for Plastic Surgery procedures.
Likely outcome of MBS item changes in terms of costs or surgery prices and existing quotes:
Likely outcome in terms of costs, prices and quotes:
- You may no longer meet criteria if eligibility definitions CHANGE or if your procedure code has been taken off the Medicare Rebate Schedule
- You will likely need to see more Doctors and/or Specialists BEFORE having Plastic Surgery for any items that still have cover after November 2018.
- Paperwork and reports – you will need complete and submit them directly to Medicare and/or your Private Health Insurance Fund
- High probability that you will incur greater out-of-pocket expenses prior to your Surgery. Furthermore, your overall surgery cost may increase
- You may need to have separate operations versus two procedures at one time in order to still be able to get a rebate
Anticipated/Estimated Surgery Patient Impact:
In summary, for patients scheduled for reconstructive, restorative or corrective Plastic Surgery AFTER these MBS changes go into effect on 1 November 2018:
- Higher surgery costs (estimated)
- More visits and reports to other medical professionals. In other words, more extensive paperwork and image submissions.
- Some conditions may no longer be eligible and NO Medicare code may apply; this means your Private Health Fund will ALSO not cover your operating costs.
Higher Surgery Costs and No Eligibility from Medicare or Your Health Fund such as; BUPA, AHM, Australia Unity Health and other Private Health Funds
- You may no longer be eligible for any rebate coverage from either Medicare or your Private Health Insurance Fund. This depends on your procedure and how these changes impacted your eligibility.
- That’s because to have private Health Insurance Fund coverage/rebates on any medical procedure, it must also first meet Medicare eligibility criteria.
- Even conditions that meet criteria for MBS rebates are sometimes rejected by Private Health Insurance Funds who have extensive and complicated exclusion clauses.
To find out more, contact MBS or your private health fund. Alternatively, you can phone our offices for a Guide to Plastic Surgery procedures on (03) 8849 1444.
September 2018 media releases – other information
- The Australian Society of Plastic Surgery (ASPS) posted a brief news release indicating some Plastic Surgery items will be completely removed from the MBS list (Medicare Rebate Schedule) from November 2018.
- Other surgery procedures will have stricter criteria and more detailed definitions to increase the clarity of what IS – or ISN’T – covered by Medicare; likely meaning fewer patients will be eligible for coverage by either Medicare OR a Private Health Fund, even for corrective post-pregnancy surgeries such as diastasis recti repair or breast lift procedures to treat ptosis after pregnancy.
Find out how MBS reviews and Medicare Rebate Schedule changes occur.
you can also read more here on our updated listing of REMOVED or DELETED MBS Codes from 1 November 2018.
Recommendations for Plastic Surgery Patients in View of Medicare Changes
- Stay informed
- visit MBS for details
- watch for news releases about Medicare Changes in Australia.
- Call our team and ask if your quote could change or, if your insurance coverage is likely to be change.
- You likely need to check with your health fund as well or instead of our team. However, we may be able to provide preliminary information.
This will not impact Cosmetic surgery patients. This is due to the fact that Medicare and Private health funds do not cover cosmetic surgery procedures.
Plastic Surgery that is corrective, reconstructive and/or restorative in nature, such as a corrective Rhinoplasty, a Breast Reduction, post-weight loss skin reduction, arm reduction/bilateral Brachioplasty and Blepharoplasty eyelid surgery when vision is impaired by eyelid skin ptosis (sagging eyelids), may still attract a Medicare rebate. These procedures will, however, likely require additional steps and extensive paperwork and photography to prove eligibility for surgery.
Some patients may have lost eligibility as they may not meet the NEWLY defined condition criteria for specific operations, according to the new 1 November 2018 MBS rebate listing for 2018 and 2019.