Tips for Dealing with Medicare for Plastic Surgery
- Understand the difference between Medicare and Health Funds
- Understand the differences between Plastic Surgery (with medical benefits) versus Cosmetic Surgery
- Sometimes Plastic Surgery is called Cosmetic Plastic Surgery – read more about these terms, below
- Know that even if you are eligible for a Medicare rebate or health fund coverage, you will still have surgery expenses as rebates rarely match actual surgery costs
Will Medicare cover a Cosmetic Plastic Surgery procedure such as Breast Augmentation or Rhinoplasty?
- Medicare does NOT cover cosmetic procedures.
- Medicare typically only covers plastic surgery procedures relating to function or reconstruction.
If Medicare doesn’t cover a procedure – You lose any potential health fund rebates as well.
- Health Funds will only provide coverage if there’s a Medicare Number involved with your procedure.
- Find Your ITEM NUMBERS or Updated Item Numbers on MBS Online
- Visit the MBS Website for Code descriptions
- If your procedure has an MBS code, check any health conditions or other requirements for eligibility
- Find out what “medically indicated” means and what “Statement of benefit” means
- Keep your language accurate when dealing with Medicare
- Expect this process to take a lot of your time and energy as well – and expect rebates to be subjected to rapid changes
Why do health funds charge so much and pay so little on the surgery you need to have, after having a baby, for example, to repair the damage to your abdominal area or reduce breast ptosis?
- Remember, most large insurance companies prioritise stockholder returns, well above their care coverage for patients
- They are often profit-driven and may try to exclude any medical procedure they can potentially argue as being unnecessary, even if plastic surgery research clearly indicates the health benefits of a certain procedure, such as Abdominoplasty after pregnancy
- Be a wise and informed consumer about different health funds and their reputations and their rules
- Choose your health fund wisely
It’s also a good idea to read this article on the best and worst Australia health funds according to an Australian Medical Association review
Is your breast surgery covered by Medicare or your Health Fund?
People often ask us if their breast augmentation procedure or breast implants are covered by their Health Fund or by Medicare.
- Sometimes, breast reconstruction after pregnancy OR after cancer treatments required the removal of your original breasts, are eligible for cover.
- But purely cosmetic breast augmentation and other purely cosmetic procedures are NOT covered by Medicare.
So it’s unlikely your cosmetic plastic surgery will be covered, but sometimes – some plastic reconstructive procedures – might result in a rebate from Medicare and/or your Health fund.
Phone us today on 1300 264 811 and ask for the GUIDE to Medicare or Surgery Funding and to meet with a genuine Plastic Surgeon for information on what surgery can accomplish for you after pregnancy or other lifestyle events.
Read the blog about using Super for Surgery as well.
- Certain breast surgery options, such as a breast reduction, may be eligible for rebates for medical reasons (neck pain, back pain, skin infections, chaffing)
- Other breast surgery such as a breast lift after pregnancy, have sometimes been eligible for rebates due to breast ptosis and skin problems
- Eyelid surgery may also attract a rebate where the sagging eyelids impact your vision and eyelid health/eyelid functions (Corrective Blepharoplasty)
- Corrective Rhinoplasty for a deviated septum or nose trauma may also attract a rebate code (but cosmetic rhinoplasty is not covered)
- There’s also a strong call to Government to cover post-pregnancy Tummy Tuck surgery, after new research clearly confirmed the health benefits of Abdominoplasty after pregnancy, because diastasis recti and other post-pregnancy problems create back pain, muscle weakness and incontinence. Read our blog about this Medicare issue.
- Ask your Doctor or Surgeon to affirm in writing (a letter) that the procedure relates to medical needs versus cosmetic (it MUST meet the strict requirements of the Medicare rebate code criteria).
- Your medical consultation photos are critical evidence in getting eligible Medicare rebates approved.
HINT – Choose your language carefully and know what different terms actually mean to Medicare and Health Funds.
If it’s a plastic surgery procedure, some people sometimes mistakenly call it cosmetic surgery when dealing with Medicare. Don’t. It’s Plastic Surgery and reconstructive surgery (e.g. Breast Reduction, Breast Lift for ptotic breasts, Tummy Tuck surgery).
- These terms are sometimes interchangeable in common language.
- But when dealing with Medicare, or a health fund, it’s wise not to get your terms confused.
- If it’s reconstructive surgery or has a medical need, it’s usually Plastic Reconstructive Surgery and may be listed with a Medicare code.
TIP: Plastic Surgery procedures that may be eligible for rebates from Medicare or Health Funds often require a genuine Plastic & Reconstructive Surgeon, not simply a Cosmetic Surgeon who operates in a back room.
- Be sure the fact you’re using a genuine Plastic & Reconstructive Surgeon with hospital operating privileges is reflected in your communications.
- For eyelid surgery, an Oculoplastic Surgeon (an eye surgery specialist) is also the type of Surgeon that may be chosen for any medically valid Blepharoplasty procedures that may be eligible for a rebate.
- Know why choosing a Plastic Surgeon is important, and know why genuine Plastic Surgeons are often recommended for post-pregnancy surgery and breast or tummy surgery rather than Cosmetic Surgeons.
- Male Breast Reduction (Gynecomastia) may also be eligible.
- Download and review the Medicare Guides direct from MBS Online.
TIP: Click on the image below to reach the external MBS Online website.
You can also research your procedure further with our FREE PDF Guides to Plastic & Cosmetic Surgery, online.
HINT: When dealing with Medicare, always give the ITEM numbers relating to the ENTIRE surgery.
- You can’t combine separate procedures. This tends to void any rebate eligibility.
- Some MBS rebate codes include a more comprehensive procedure than others.
- Read and understand all of the codes and criteria in the section that relates to your surgery.
- We’re sorry, but our Team can’t assist you with Medicare or Health Fund processing; that’s solely a patient’s responsibility.
However, we can provide our patients with the BEFORE photos and expert Medical opinions on plastic surgery requirements.
TIP: You’ll have to deal directly with Medicare and your Health Fund. This can take a lot of time and involve a lot of extensive paperwork.
- Our team can’t do much to help you as this is patient-focused and individual circumstances vary.
- We focus all of our energies on your surgery experience and outcomes, so there are limits to how we can help with your forms.
- We DO, however, list the Medicare code(s) on your Quote and on your Invoice(s).
- So if there is eligibility for a Medicare rebate code or health fund rebate, this may help you when you submit your paperwork.
- For example, if you have a medical reason for eyelid surgery, that might attract an MBS code and a rebate of some of the expenses.
If you think there should be an MBS code and you don’t see it on your Quote or paperwork, get in touch with us immediately, and ask us why. It is often that the surgery doesn’t attract a Medicare code. You can also lobby the Government to cover procedures such as many Mums are doing in relation to medically beneficial abdominoplasty surgery procedures.
- Your General Practitioner or Surgeon team may have additional information about your eligibility.
- But again, there is very strict criteria you may or may not meet.
For more information on procedures, download one of our GUIDES to Surgery.
HINT: Combining your surgery with other surgeries may alter or completely VOID any eligibility for cover.
TIP: You will need a REFERRAL from your GP or from another Specialist to see a Plastic Surgeon (Specialist).
- You must have a referral from a GP or Specialist stating your medical conditions.
- A GP Referral is valid for 12 months.
- A specialist referral only lasts 3 months.
- HINT – make sure the referral does not lapse before your surgery date.
Tips for dealing with Medicare: What to expect
- You will be on the phone for a long time – get comfortable and allow time
- Get a coffee ready, put your feet up or do your nails while you wait – get a good book and put the phone on headset or speakerphone – and settle in
- Save ALL your questions for ONE main call or visit – not lots of little calls
- Keep Notes of all Medicare Enquiries including the call date, time and who you spoke to
- Write down any information and reference numbers; e.g. always write down the NAME and ID of the person you spoke with at Medicare, and find out their direct phone line & email address if you are able to.
- At the very least, get a call Reference Number.
- Speak to at least 2 different people (make 2 different calls) to make sure the advice you are given is correct.
- Remember, things change rapidly in terms of government decisions about healthcare and eligibility for Medicare rebates.
- We’ve seen very rapid changes that left patients out of pocket when they weren’t expecting that.
- So it’s best to ask for the advice in writing (or by email) and confirm the conversation and data you were given via email
- Have your Medicare codes (item numbers) ready
- Know the name of your particular surgery AND the details of your particular Surgeon (make sure they are a Specialist with hospital operating privileges)
TIP: Always make a copy before you submit your rebate requests or eligibility information
- Copy all your documents before submitting them to Medicare or your health fund, in case any get lost
- HINT – Take all your receipts and take smartphone photos as well as copies of the receipts
- http://www.mbsonline.gov.au – Download the MBS App!
- A few patients have told us they like Latrobe Health Insurance – possibly the Highest Hospital Cover with no extras
- Be consumer smart about who you choose – read the AMA’s “best and worth health funds” article in the news
Phone us today on 1300 264 811 and further your plastic surgery research and surgery journey.
Find out what surgery options may help you with your concerns, and whether your post-pregnancy hernias or abdominal tears (or other condition) meets the requirements for Medicare or Health Fund eligible rebates.
- Meet our team of expert Surgeons for Plastic Surgery of the breast, body, face, nose and eyelids.
- We have several top Plastic Surgeons in Melbourne to choose from.
- Each Surgeon has a dedicated area of expertise such as Breast Surgery (Breast Augmentation, Breast Lift, Breast Reduction), Tummy Tuck Surgery, Eyelid Surgery or Facial Rejuvenation. We also have leading Rhinoplasty Surgeons for nose reshaping.
You can also RSVP for one of our FREE information evening events.
Plastic Surgery In the news: MBS rebates, Cosmetic Surgery and Plastic Surgery and Tummy Tucks after Pregnancy
“Canberra doctor wants the government to cover the costs of tummy tucks” by Daniella White Read Article in Canberra Times
Tummy tuck eases post-birth back pain by SARAH WIEDERSEHN, Australian Associated Press –
Tummy tucks after pregnancy should be subsidised, specialist plastic surgeons say (by Adrienne Francis) – Posted
Visit our Downloadable Guides pages
For more information about Cosmetic and Plastic Surgery options and research in Australia.