Will Medicare and my Health Insurance Cover my Breast Reduction Surgery?
You may wonder if your private health insurance cover plus Medicare will cover some or all of your Breast Reduction Surgery costs. Breast Reduction Surgery is one of the very few breast surgery procedures that your private health insurance and Medicare will cover some or all of your hospital costs, and Medicare will make a small contribution to the medical costs (Surgeon, Anaesthetist, Assistant).
Some patients may even use their Superannuation by way of requesting an early release of funds. Why is that the case?
There are often a number of crucial reasons for wanting Breast Reduction Surgery, including:
- relief from chronic skin infections under the breasts (‘intertrigo’)
- relief from back, neck and shoulder pain caused by the heaviness of the breasts
- rectify other breast-weight related health conditions that affect quality of living, for example going to the gym, and jogging
Will Medicare cover my Breast Reduction?
- Having heavy breasts that cause chronic health conditions constitute a medical reason for having breast reduction surgery.
- If the surgery is deemed by your surgeon to be medically necessary and meets strict Medicare criteria, a rebate should be granted.
- You should first attend your GP to request a referral to a Specialist Breast Surgeon such as Mr Maxwell.
The criterion for a Medicare Claim for Breast Lift Surgery is the age of your youngest child:
- Your youngest child must be at least 12 months (1 year) in age but not older than 7 years of age.
- Breast Reduction surgery is life changing. It can prevent or treat recurring problems related to heavy breasts.
- Most breast reduction patients are happy to find they have a new lease on life –ranging from better sleep to being able to participate in new activities e.g. fitness classes which they have been unable to attend in the past.
Further benefits from Breast Reduction surgery include being able to wear fashionable bras, bathers and other items of clothing you formerly felt weren’t suited to your fuller-breasted appearance.
In order to claim your surgery on Medicare, you will need a Medical Referral
To be eligible to Claim a Medicare item number for your breast reduction surgery, as with any other Medicare rebate, visit your GP and ask for a referral to your surgeon or phone Cosmetic Surgery For Women on 1300 264 811 to find out more about Breast Surgery including Reduction Mammoplasty.
You can also register to attend an EVENT night to learn more about your specific surgery options.
Will Medicare cover my Breast Reduction Plastic Surgery?
Reduction Mammoplasty – YES – Medicare Rebates MAY apply – but strict criteria must be met. There is no guarantee, but ask your General Practitioner for information to see if you qualify or speak with a Specialist Plastic Surgeon after getting a referral from your GP.
Why is the Medicare Rebate Question for breast surgery so confusing?
The answer to this question can often be confusing for most patients seeking cosmetic surgery.
- That’s because it will vary depending on the patient and the procedure required.
- Medicare will sometimes offer a minor rebate on some procedures.
- Rebates are generally available only for reconstructive plastic surgery or what is deemed ‘essential’ surgery.
- Not all surgery of the breast falls under this category; but Breast Lift and Breast Reduction MAY fall under this category for many patients.
When it comes to Plastic & Cosmetic Surgery, the Medicare REBATE guidelines are very clear; Medicare will not cover ‘non-therapeutic cosmetic surgery’ NOR ‘non-therapeutic plastic surgery’ procedures. Significant Breast Ptosis after pregnancy and chronic Back Pain or Skin Infections related to large breasts are chronic medical conditions, however, and may lead to eligibility for a minor rebate.
Breast Reduction Surgery and the Medical Benefits Scheme (MBS)
If you meet the current Medicare criteria and required documentation proof for your Breast Reduction Surgery, then yes, you may qualify for a small rebate from Medicare for your procedure. MBS changes at the end of 2018 included additional photographic proof, examination evidence/reporting documentation and stricter patient criteria for Medicare rebates for Breast Reduction Surgery. Similarly, other procedures relating to women’s health were also impacted.
Your eligibility may depend on the following medicare criteria
- (a) at least two-thirds of the breast tissue, including the nipple, lies inferior to the infra-mammary fold where the nipple is located at the most dependent, inferior part of the breast contour; and
- (b) if the patient has been pregnant—the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient; and
- (c) photographic evidence (including anterior, left lateral and right lateral views), with a marker at the level of the inframammary fold, demonstrating the clinical need for this service, is documented in the patient notes
Additionally, you may be eligible for surgery cover from your Private Health Insurance provider. This will, however, only apply if your condition meets the criteria for a Medicare item code/MBS rebate. You will need to check directly with your Health Fund regarding your policy.
It’s important to recognise that Medicare codes and rebate eligibility criteria for Breast Reduction Surgery are subject to change in an instant, with very little notice. Therefore, you should discuss your eligibility with your chosen Specialist Plastic Surgeon as they will have the most up-to-date information on hand.
There are often crucial medical and health reasons that lead women to seek Breast Reduction Surgery, these may include:
- Chronic skin infections.
- Excess perspiration around or under breasts.
- Difficulty purchasing bras and other items of clothing.
- Challenges when exercising caused by large, pendulous breasts.
- Back pain, neck pain or shoulder pain related to breast weight, breast volume or breast ptosis.
- Other breast-weight related health conditions that impact your health and quality of life.
If you are suffering from one or more of the above symptoms due to your breast weight or volume, your Breast Reduction surgery may be eligible for a rebate. However, you will need to meet a strict number of criteria.
Download our Guide to Medicare and Health Insurance for Plastic Surgery
What are the time restrictions for rebate coverage for Breast Reduction Surgery?
As mentioned above, if your youngest child is approaching the age of 7, you may run out of time to claim a Medicare rebate on Breast Reduction Surgery. This is because there are age and timing-related eligibility criteria you will need to meet in order for your procedure to be partially covered by Medicare.
If I am not eligible for a Medicare rebate, will my private health fund cover my breast procedure?
- Private Health Funds only cover a procedure if it has an MBS item number, and the patient meets current Medicare eligibility criteria.
- You will, therefore, need to meet the criteria for a Medicare rebate in order to seek cover from your Health Fund.
- Extensive documentation, examinations, imaging or volumetric testing, and photographs may also be required.
If Medicare or a Health Fund do not cover my breast reduction, how much will my procedure cost?
- The cost of having a Breast Reduction performed by a Plastic Surgeon in Melbourne will vary. This is due to the fact that each procedure is fully customised to meet your specific needs and desired surgical outcome.
- Our team can help you assess your eligibility for coverage by MBS or your health fund. They can also assist you in understanding the cost and risks of surgery.
To access your eligibility to claim a Medicare rebate for your Breast Reduction Surgery, visit your GP or other specialist and ask for a referral to one of our Specialist Plastic Surgeons.
You can also speak to our knowledgable Patient Care Team, who are available to answer your questions. Simply phone us on 1300 264 811.
Can I use my Super Fund for Breast Reduction Surgery?
Some patients may consider requesting an early release of Super funds to help pay for Breast Reduction surgery, however, before doing so, it is important to note that:
- Each application for early Super release is assessed on an individual basis.
- Tax implications apply so seeking professional financial advice is recommended.
- Superfund withdrawal applications can be made through your MYGOV account via the ATO. As of July 2018, the ATO makes decisions about early-super-release applications within about 14 days of your application being received.
Our Breast Reduction Plastic Surgeons in Melbourne include:
- Dr Craig Rubinstein – MBBS, FRACS (Plast) – Specialist Plastic Surgeon,
- Dr Geoff Barnett – MBBS, FRACS (Plast) – Specialist Plastic Surgeon,
- Dr Rebecca Wyten – MBBS, FRACS (Plast) – Specialist Plastic Surgeon,
- Dr Richard Sackelariou – MBBS, FRACS (Plast) – Specialist Plastic Surgeon