On 1 November 2018, the Medicare Benefits Schedule (MBS) Item Codes, Definitions and Criteria for Plastic Surgery are changing.
Medicare changes may affect your rebate eligibility for skin reduction surgery after weight loss or Bariatric Surgery: including Brachioplasty, Abdominoplasty or Belt Lipectomy. Revision Rhinoplasty patients may also be impacted.
A few years ago, the government made changes to the MBS in relation to post-pregnancy Abdominoplasty. It was no longer covered by an MBS item code although post-weight loss skin reduction NOT related to pregnancy, and for patients meeting strict criteria about body mass changes and skin reduction needs, remained on the MBS.
Shortly other MBS item codes for plastic surgery after weight loss or pregnancy are changing (it can happen every year due to Government Budget announcements and Task Force Reviews).
If you have plastic surgery planned for AFTER the date of these new changes, and you have previously been eligible for an MBS item number and private health fund coverage for your elective, corrective or reconstructive Plastic Surgery procedure, these NEW DEFINITIONS to the MBS COULD impact your rebate eligibility, your hospital insurance coverage and ultimately – your out of pocket surgery costs.
Medically Indicated Plastic Surgery and MBS rebate changes
- Cosmetic surgery patients will NOT be impacted by these MBS changes.
- That’s because cosmetic surgery is NOT covered by Medicare.
- Nor is most Cosmetic Plastic Surgery covered by private Health Insurance Companies such as BUPA, AIH, Australian Unity, NIB and other recognised Australian health funds.
- However, some Plastic Surgery procedures are corrective or restorative in nature, such as skin reduction after Bariatric Surgery or lifestyle changes resulting in significant skin folds after attaining weight loss.
- These usually have an MBS item code and often have some hospital coverage DEPENDING on your HEALTH INSURANCE PLAN.
Many surgeries performed by Plastic Surgeons are medically indicated CORRECTIVE and RECONSTRUCTIVE Plastic Surgery.
They may have some aesthetic benefits, but they are performed for reconstructive purposes, such as to restore natural contours or reduce skin infections, back pain and neck pain caused by excess skin folds or redundant heavy tissue weight.
- Specialist Plastic Surgeons usually perform both COSMETIC and/or CORRECTIVE/RECONSTRUCTIVE Plastic Surgery.
- A Cosmetic procedure might be liposuction of the thighs, a face lift or a breast augmentation.
- A Corrective Plastic Surgery procedure might be skin reduction of excess skin folds post-obesity (arms, stomach, thighs), breast reduction to reduce back pain/neck pain and shoulder pain, corrective Rhinoplasty/Septoplasty, Eyelid Surgery for severe ptosis, Breast Lift for ptosis after pregnancy or weight loss, and other similar procedures.
These MBS items may be changing on 1 November 2018 – if you were previously covered, you may no longer be eligible.
Note that your Private HEALTH FUND policy such as BUPA, AIH and Australian Unity is also likely to change over the next few months or years.
Changes are also occurring to Health Fund Policy Classifications and Private Health Coverage for surgery in terms of redefining classifications so that consumers better understand their policies, exclusions and coverage. The Government is seeking to ensure consumers actually UNDERSTAND what they’re buying and what is and isn’t covered, as current policies are confusing for consumers and exclusion clauses are difficult to understand, leaving many patients unexpectedly NOT covered for medical warranted procedures.
November 2018 MBS Updates to Plastic Surgery criteria – Media Releases.
Changes to the MBS in the 2018-2019 Budget are NOT limited to Plastic Surgery operations.
These changes include other areas of medicine, imaging/testing, and various forms of surgery.
For an Australian Government/Department of Human Services NEWS RELEASE regarding 2018-2019 budget MBS Review changes, effective 1 November 2018, click here.
Plastic Surgery & Medicare News & Media (Australia)
Plastic Surgery procedures by genuine Plastic Surgeons are being impacted according to a news release by the Australian Plastic Surgery Association (ASAPS).
Breast Reduction Surgery Patients, Breast Lift Patients, Removal & Replacement of Breast Implants, and Skin Reduction Lipectomy/Abdominoplasty Patients MAY likely be impacted by changing MBS criteria from the MBS Review team.
How MBS definition and criteria changes MAY impact you, as a Plastic Surgery patient.
- If your condition diagnosis and treatment MET existing MBS criteria definitions, but your Surgery is scheduled for AFTER 1 November 2018, you MAY find you have higher out-of-pocket costs for your procedure.
- If your MBS item code is removed or changed in a way you no longer meet criteria, then your private health insurance company is also not likely to cover your hospital or surgery costs; as health insurance policies usually cover only procedures that are on the MBS list.
Will my Plastic Surgery for Skin Reduction or Abdominoplasty/Belt Lipectomy after weight loss still be covered after changes to the Medicare Benefits Scheme (MBS) on 1 November 2018?
- If your MBS Item Code is changed and your condition or surgery no longer meets the criteria, you may become ineligible for a rebate.
- Check the latest MBS publication releases occurring in October 2018 and phone your doctor, Surgeon and/or insurance company if any questions.
- Post-weight loss patients meeting strict criteria – including weight loss NOT related to pregnancy – may still have some rebate eligibility for skin reduction after bariatric surgery, for example, but post-pregnancy conditions typically do not meet criteria.
- Read the ASAPS Media Statement on MBS Item removal for Abdominoplasty and how it helps women after having children.
CORRECTIVE, RECONSTRUCTIVE or RESTORATIVE Plastic Surgery procedures and Medicare Codes, Criteria and Definitions
As a brief summary of the difference between TYPES of Plastic Surgery procedures ELIGIBLE vs INELIGIBLE for Medicare rebates:
- Cosmetic surgery, such as liposuction or breast augmentation for aesthetic-only purposes, was NEVER covered by Medicare.
- All COSMETIC surgery is paid for directly by patients as an elective procedure.
- CORRECTIVE, RECONSTRUCTIVE or RESTORATIVE Plastic Surgery procedures, however, such as Eyelid Surgery for eye lid ptosis, Septoplasty/Rhinoplasty surgery for breathing problems, Breast Reduction/Breast Lift Surgery and Skin Reduction after weight loss to relieve back pain or skin infections, HAVE BEEN included in the MBS in the past.
- There is always very strict patient and condition criteria.
- In a Budget review of health care expenses, the Medicare Benefits Schedule Taskforce and MBS Review TEAM changed criteria descriptions and Medicate ITEM codes (see the 2018-2019 Budget release).
Changes to the Medicare Rebate Schedule (MBS) – going into effect on 1 November 2018 – WILL likely IMPACT several Plastic Surgery operations even though they are corrective, restorative, reconstructive and/or otherwise medically necessary versus cosmetic in nature.
MBS review and Medicare criteria changes for Plastic Surgery operations may potentially impact:
Summary of Medicare Benefits Schedule (MBS) Changes on 1 November 2018
- Definitions and criteria to meet Plastic Surgery eligibility for MBS rebates are changing for the 2018-2019 Budget and per recommendations from the MBS Taskforce.
- If you have plastic surgery for skin reduction after weight loss, scheduled ON or AFTER 1 November 2018, any earlier eligibility for Medicare rebates or Health Fund hospital/surgery coverage COULD change and you may NOT be eligible.
- These changes could significantly increase your expected out-of-pocket plastic surgery costs.
Additionally, some Plastic Surgery items are being removed entirely from the MBS, meaning patients will lose any eligibility for Medicare funding or Private Health Fund cover for those operations.
Results: Some reconstructive Plastic patients will be left with higher out of pocket surgery costs.
Private Health Fund Hospital/Surgery Cover and Medicare Item Codes – How BUPA, AIH and Australian Unity are also impacted by these changes
Plastic Surgery MBS Codes and your Private Health Funds
- If your CURRENT CONDITION and scheduled Plastic Surgery procedure do NOT warrant a Medicare code AFTER changes going into effect on 1st November 2018
- THEN your Private Health Fund / Health Insurance company, like BUPA, Australian Unity and AIH, is ALSO NOT going to cover ANY of your surgery fees such as your hospital stay, Surgeon’s fees, Anaesthetist and/or other surgery costs.
Read the full article here about health fund changes.
Potential impact of changes to MBS for reconstructive, restorative or corrective Plastic Surgery:
- higher surgery costs to patients / less rebate eligibility (estimated)
- more visits and reports to other medical professionals (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 operation costs.
- NO coverage for multiple surgeries in one operation session – surgeries will need to be more sequenced rather than combined
Note this information may change as more NEWS RELEASES arise in relation to the Medicare Schedule changes.
Check with Medicare or your Health Insurer BUPA, AHM, Australia Unity Health and other Private Health Funds as to how your procedure will be impacted by these changes.
- Note that health insurance policies are also undergoing changes and you’ll see new classifications for simplicity.
- Call your Health Insurer before and after the changes so you know what to expect.
Plan for either increased surgery costs/less MBS or Health Insurance rebate eligibility – OR
Expect to have to do extensive documentation/paperwork, photographic submissions/reporting, and Specialist visits BEFORE your surgery is verified as meeting the new criteria.
Recommendations for Plastic Surgery Patients
- Check the news and keep abreast of news releases and check with your Doctor, Surgeon and Insurers as to how this will impact your surgery if scheduled after 1 November 2018.
- Visit the MBS site and download their guides.
- Call our team and ask if your Quote is going to change or if your insurance coverage is likely to be impacted (you likely need to check with your health fund as well or instead of our team, but we may be able to provide preliminary information based on news releases).
For any Plastic Surgery patients with a corrective or restorative surgery that is currently eligible for a Medicare code/Medicare rebate and/or Health Fund Coverage, that is booked for ON or AFTER 1 November 2018, phone our offices to discuss how this may impact your price quote and out of pocket costs for your surgery procedure.
Further research and Media Releases – Plastic Surgery: Medicare and Health Insurance
Subsidising Tummy Tuck Surgery – Calls for Plastic Surgery Cost Assistance for women after having children
The Australian Society of Plastic Surgeons (ASAPS) also released a statement about November 2018 Medicare criteria changes for Plastic Surgery procedures.
ASAPS Media Release about Abdominoplasty MBS Item Code Removal and Women’s Health Outcomes and Surgery Costs
Source link: https://journals.lww.com/plasreconsurg/Abstract/2018/03000/Abdominoplasty_Improves_Low_Back_Pain_and_Urinary.13.aspx