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Medicare plastic surgery changes: will they impact you?

Medicare has announced significant changes to plastic surgery item numbers on the Medicare Benefits Schedule (MBS) that will be effective from the 1st of November 2018.
This will impact rebates and health fund coverage for patients with certain item numbered procedures, so if you are having plastic surgery from the 1st of November onwards, it’s important to be aware of these changes and read on.

What does this mean?

Some MBS item numbers are being abolished altogether, while others will have a tighter eligibility criteria. If you have been issued with a quote by your surgeon that lists an item number, this quote is only valid for surgery performed up until the 31st of October 2018. So for surgery that’s planned from the 1st of November onwards, you will need to be provided with an updated quote based on the final version of the new Medicare item numbers.

Which procedures are impacted?

This list covers some popular procedures involved, and is not comprehensive:
• otoplasty: must be performed before the age of 18 or costs will increase
• blepharoplasty: an optometrist or ophthalmologist will need to confirm that your excess eyelid skin obstructs your vision – if you don’t meet the criteria, costs may increase
• breast reductions and lifts (mastopexy): If you don’t satisfy the criteria, costs will increase
• removal and replacement of breast implants: if you don’t satisfy the criteria, costs will increase (depending on your inpatient stay and whether your original implants were covered by a replacement warranty)
• lipectomy procedures (abdominoplasty, thigh reduction, arm reduction etc): even if you meet the criteria for these procedures individually, Medicare and private health funds won’t pay any rebates or cover hospital fees if certain lipectomy procedures are performed together as combined procedures. For example, abdominoplasty and arm lift will be 100% out of pocket, even if you meet the MBS item number criteria if performed together. But if you meet the criteria and have an abdominoplasty and arm lift performed as two separate operations, they will still be eligible for rebates/cover.

I have surgery booked after the 1st of November; what do I need to do?

If you have item numbers listed on your estimate of fees, the item numbers for your procedure may not be one of those impacted at all by these changes and even if they are, you may find that you still meet the updated criteria. If you are having surgery after the 1st of November and you have item numbers on your informed financial consent document that are included in the list of those changed, you should contact your surgeons practice.

I don’t have private health insurance; will this impact me?

If your surgery is currently covered by an item number (eg removal and replacement of breast implants due to complications), at the moment you’d receive a rebate on some of your surgeon’s and anaesthetist’s fees from Medicare. If you no longer meet the new criteria, you won’t be eligible to receive any rebates. If you do meet the new criteria, rebates will still apply for your surgeon’s and anaesthetist’s fees. Private hospital fees are never covered by Medicare, so these remain unaffected for uninsured patients.

I have private health insurance; how will this impact me?

Patients who are privately insured may be significantly impacted by these changes. If your private health insurance policy covers you for an MBS item number – and your surgeon and Medicare deems that you meet that criteria – your fund and Medicare pay a rebate on your surgeon’s and anaesthetist’s fees, and your fund covers your hospital fees (minus any excess or exclusions).
These changes mean that we need to ascertain if you meet the amended MBS criteria for your procedure; if not, your fund and Medicare will not provide any rebates – so you would be out of pocket 100% for your surgeon, anaesthetist and hospital stay. Again, this only applies if the changes impact your specific item numbers.ery before you are ready.

Why are changes occurring – and will there be more?

The government made these changes because they believe some MBS item numbers are being used for procedures that Medicare perceive to be ‘cosmetic’ rather than ‘medical’.
Representatives from the plastic surgery community were involved in the taskforce that contributed to these changes, but not all of their requests and recommendations were implemented or observed in the resulting criteria amendments. Changes to MBS item numbers that impact plastic surgery have been a focus of government cost-cutting in recent years and this may continue. It’s important to remember that when you receive an informed financial consent document, it is based upon the information available to your surgeon, anaesthetist, hospital and health fund at the time. If the government decides to make changes to the item numbers and rebates after your estimate is provided, they are able to do so, and are not required to provide a grace period for people who have already received quotes.

I haven’t booked my surgery yet; is there still time to have surgery before the changes occur?

Out of pocket fees are understandably an important component of your surgical decision making process, however costs alone should not be a reason to rush into elective surgery before you are ready.