Considering plastic surgery and wondering if Medicare might assist with the costs? Understanding how the Medicare Benefits Schedule (MBS) applies to plastic surgery is essential, but it can often seem complex. Dr Turner and his team are committed to providing clear, honest advice. We help you understand the requirements, the potential for Medicare rebates, and support you in making decisions that align with your health needs and personal goals.
Understanding Medicare Coverage for Plastic Surgery in Australia
The Australian government, through Medicare, offers rebates for many medical services listed on the Medicare Benefits Schedule (MBS). However, for plastic surgery, specific conditions apply.
The Key Principle: Medical Necessity
- What it means: The most crucial factor is medical necessity. Medicare does not cover procedures performed solely to enhance appearance.
- To qualify, surgery must typically:
- Address a significant medical condition.
- Correct functional impairment (e.g., difficulty breathing, obstructed vision).
- Alleviate symptoms like chronic pain or skin infections caused by a physical issue.
- Be reconstructive after trauma, cancer removal, or due to congenital/developmental issues.
The Medicare Benefits Schedule (MBS) & Item Numbers
- What it is: The MBS is the official list of subsidised medical services, each with a unique item number.
- How it works for plastic surgery:
- Your procedure must match a specific MBS item number.
- Your clinical situation must precisely meet the detailed criteria listed for that item number.2
- Strict Criteria: These criteria are often very specific and may include measurable thresholds (e.g., degree of breast droop, extent of muscle separation).3 Interpreting these accurately requires specialist expertise.
The Need for a GP Referral
- Before seeing a specialist like Dr. Turner for a procedure potentially covered by Medicare, you generally need a valid referral from your GP or another specialist.
- This referral is essential for claiming Medicare rebates for both the specialist consultation and the surgery itself, if eligible.
Examples of Procedures Potentially Covered (Subject to Strict Criteria)
Meeting specific MBS criteria for medical necessity is paramount. Some procedures that may be eligible include:
- Breast Reduction (Mammaplasty): For significant neck, back, or shoulder pain due to large breasts (MBS Item 45523).
- Breast Lift (Mastopexy): For severe breast ptosis (drooping) meeting specific measurement criteria (MBS Item 45558).
- Abdominoplasty (Tummy Tuck):
- Post-Pregnancy: For significant rectus diastasis (muscle separation ≥ 3cm) causing pain/functional issues, after failed non-surgical treatment (e.g., MBS Item 30175).
- Post-Weight Loss: For redundant skin causing functional problems (e.g., skin conditions, interference with daily life) after significant, stable weight loss (e.g., MBS Items 30177, 30179).
- Eyelid Surgery (Blepharoplasty): For upper eyelids if drooping skin demonstrably impairs vision (MBS Item 45617).
- Nose Surgery (Rhinoplasty/Septoplasty): To correct documented breathing difficulties caused by nasal obstruction or significant deformity.
- Gynecomastia Surgery (Male Breast Reduction): If deemed medically necessary/reconstructive.
- Skin Cancer Removal & Reconstruction: Standard coverage applies.
The Importance of Documentation
- Objective evidence is usually required to support a Medicare claim. This might include:
- Clinical photographs (often to specific standards).
- Diagnostic imaging reports (e.g., ultrasound).
- Detailed medical records of symptoms and their impact.
- Proof of failed conservative treatments (e.g., physiotherapy notes).
- Dr. Turner’s team will guide you on the necessary documentation.
Understanding the Costs: Medicare, Insurance & The Gap
Even if your procedure qualifies for a Medicare rebate, it won’t cover the full cost. You should expect out-of-pocket expenses.
- Medicare Rebate: Covers a percentage (e.g., 75% for in-hospital procedures) of the MBS Schedule Fee. This Schedule Fee is set by the government, not by the surgeon, and is usually lower than the actual surgical fee.
- Surgeon’s Fee: Reflects the specialist’s expertise, training, and procedure complexity, typically higher than the MBS Schedule Fee.
- Anaesthetist’s Fee: A separate fee, also potentially attracting a partial Medicare rebate.
- Hospital/Facility Fees: Costs for operating theatre, accommodation (if needed) in a private hospital.
- Other Costs: Medications, post-surgery garments, etc.
The “Gap”: The difference between the total fees and the combined Medicare rebate and any private health insurance contribution is your out-of-pocket expense.
The Role of Private Health Insurance (PHI)
If your procedure has an MBS item number (is medically necessary) and you have appropriate hospital cover, your PHI may cover:
- All or part of the hospital/facility fees.
- A portion of the anaesthetist’s fee.
- A portion of the surgeon’s fee.
Crucially: PHI do not cover procedures without a valid MBS item number. Always check directly with your insurer about your specific policy before booking surgery.
Why Choose a Specialist Plastic Surgeon (FRACS)?
In Australia, “Specialist Plastic Surgeon” indicates a surgeon who has completed extensive training accredited by the Royal Australasian College of Surgeons (FRACS). This involves a minimum of 12 years of medical and surgical education, including at least 5 years of dedicated postgraduate training in plastic and reconstructive surgery.
- Expertise: Ensures care from a highly trained expert.
- Medicare Understanding: FRACS surgeons understand the nuances of the Medicare system.4 Medicare rebates generally only apply to procedures performed by FRACS-qualified specialists.
- Safety & Quality: Adherence to the highest standards of practice.
Procedures Offered by Dr. Turner & Potential Medicare Considerations
Dr. Turner specialises in aesthetic surgery of the face, nose, and breast. While many procedures are primarily cosmetic, some may have Medicare eligibility under specific medical circumstances:
- Facial Surgery: (Facelift, Neck Lift, Brow Lift, Eyelid Surgery). Medicare may apply to upper eyelid surgery (MBS 45617) only if excess skin significantly obstructs vision, meeting strict criteria.
- Nose Surgery (Rhinoplasty): Medicare may apply if the primary purpose is correcting documented breathing problems caused by structural issues.
- Breast Surgery: (Augmentation, Lift, Reduction, Asymmetry Correction). Medicare may apply to Breast Reduction (MBS 45523) for severe symptoms or Breast Lift (MBS 45558) for significant ptosis, only if strict MBS criteria are met. Augmentation is rarely covered unless for specific reconstructive reasons.
- Body Surgery: (Abdominoplasty/Tummy Tuck). Medicare may apply post-pregnancy (MBS 30175) or post-massive weight loss (MBS 30177, 30179) only if stringent criteria regarding muscle separation/excess skin and functional issues are met.
