Medicare Changes – Abdominoplasty & Skin Reduction Surgery
Posted on: September 28th, 2018
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.
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.
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:
Rhinoplasty after an injury OR to correct a deviated septum/breathing problem
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.
Authors: Taylor, D. Alastair, F.R.A.C.S.(Plast.); Merten, Steven L., F.R.A.C.S.(Plast.); Sandercoe, Gavin D., F.R.A.C.S.(Plast.); Gahankari, Dilip, F.R.C.S.(Ed.), F.R.A.C.S.(Plast.); Ingram, Scott B., F.R.A.C.S.(Plast.); Moncrieff, Nicholas J., F.R.A.C.S.(Plast.); Ho, Kevin, F.R.A.C.S.(Plast.); Sellars, Graham D., F.R.A.C.S.(Plast.); Magnusson, Mark R., F.R.A.C.S.(Plast.)