Common Questions around Private Health Insurance and your Plastic Surgery Procedure

Private Health Insurance

Common Questions around Private Health Insurance and your Plastic Surgery Procedure

Are you considering a plastic or cosmetic surgery procedure?

Here are some questions to consider when thinking about Private Health Insurance.

There are many benefits and risks to weigh up when considering any type of surgical procedure, not the least of them being the possibility of how private health insurance (PHI) will come into play.

Out-of-pocket expenses or ‘gap fees’ for surgical procedures can really hurt, especially when you’re not expecting them. And while talking about money can be uncomfortable, it’s helpful to know there are several ways you can decrease your risk of being hit with a gap-fee unexpectedly after undergoing a medical treatment.

Our team at Valley Plastic Surgery receive an enormous number of questions about PHI and although we’re not able to guide you on specifics relating to individual policies, we have compiled some things to consider, alongside questions you may wish to ask your insurer directly.

Will PHI cover my procedure?

The answer is not quite as simple as “yes” or “no”. Instead, it’s a “sometimes.” Whether or not your PHI will cover you will depend on a couple of factors. As a general rule:

“If the treatment is medically required and has a Medicare Benefit Schedule (MBS) number, your Fund may pay a benefit towards your surgery.”

The key term here is “medically required.” Your private health insurance won’t cover you for elective cosmetic surgery. However, if it’s proven that the procedure is medically necessary and meets the Medicare criteria, then you may be able to claim a portion of the surgical procedure on your private health insurance depending on your level of cover. On your estimate, we will indicate if the procedure is deemed medical and also provide the Medicare item numbers, which will then assist you in discussions with your insurer.

Multiple Procedures:

If you are considering multiple procedures in the same surgery, there may be times whereby some procedures are deemed ‘medically necessary’ and attract Medicare item numbers, whilst others may fall under ‘cosmetic.’ In these instances your surgery is considered a combined cosmetic/medical procedure and this will impact the level of cover you can access through your private health insurance.

An example of this may be when an abdominoplasty, along with breast augmentation, are performed together. If the abdominoplasty component of your procedure is deemed medical by your surgeon (ie it meets the criteria for a Medicare item number) but the breast augmentation is deemed cosmetic, your health insurer will only contribute to the abdominoplasty component and the costs associated. The breast augmentation costs including surgeons fee, hospital and anaesthetist will be out of your own pocket without assistance form your private health insurer and/or Medicare.

Coverage, Tiers and Levels:

Generally, your hospital policy will fall into one of three categories:

  • A comprehensive hospital policy that covers plastic surgery procedures and/or weight loss procedures. (Often referred to as GOLD tier)
  • A mid-tier policy that offers limited or restricted cover for plastic surgery procedures. (Often referred to as SILVER tier)
  • A low-tier policy that excludes cover for reconstructive plastic surgery. (Often referred to as BRONZE tier)

You should weigh up the pros and cons of each level of cover. For example, taking out a comprehensive policy will provide you with cover for more medical procedures but the premiums will be higher.

If you take out a lower level of cover, you will be paying less on your premiums, but will have more exclusions on your policy. Please ensure that your read your policy thoroughly to ensure that you are aware of your specific policy exclusions.

At the end of the day, it’s up to you what level of cover you take out and to be aware that many options for coverage exist.

Waiting Periods:

If you are considering taking out private health insurance, it’s particularly important to note that most health funds have a 12-month waiting period before coverage – for services such as surgery – can be utilised. This may be a major factor when planning the timing of any surgery.

Changing insurers (or even levels within your existing policy) is also something to weigh up carefully as there may be waiting periods to serve before your new tier or policy takes effect.

It’s always best to ask the insurance company directly, so you have up-to-date information about each policy and fully understand waiting periods that may impact how you pay for your treatment(s).


If your private health insurance policy covers you for hospital services, there may still be an excess payable for your stay. Your level of excess is dependent on the type of policy you elect to take out and could range from $250 upwards.

Rebates for Consultations and Out-Patient Services:

Some policies may provide rebates on a range of medical expenses, however fees for consultations with your specialist plastic surgeon are NOT covered or rebatable through private health insurance.

Minor Operations (MOPS) and out-patient services such as procedures under local anaesthetic within the practice are NOT covered.

Generally speaking, there needs to be hospital admission for a health fund to consider policy coverage and a rebate for any surgical procedure.

Informed Financial Consent and How it Assists You:

Informed Financial Consent was developed by the Australian Government and the Australian Medical Association (AMA) to assist patients to understand their health care and its costs. Patients should be informed of all fees associated with their procedure, including their doctor’s fees and the fees of other providers such as anaesthetists, involved in their care before going to hospital as a private patient.

The team at Valley Plastic Surgery will provide patients with an ‘Estimate of Fees,’ which will detail the costs of the procedure you have consulted the surgeon providers and hospital fees. The Estimate of Fees will also list any rebates that may be available and an estimated patient ‘gap.’

Valley Plastic Surgery take Informed Financial Consent very seriously.

Your Informed Financial Consent should include:

  • Information about your procedure, including the item number, and the fee for each item.
  • An estimate of what you’ll pay for things like your in-patient stay in hospital, and use of the operating theatre.
  • What you’ll pay for each medical provider.
  • Contact details for your anaesthetist so as you may obtain a quote directly from their rooms.
  • If applicable, what you’ll pay for any prostheses / implant(s) and support garments.
  • A list of providers – external to VPS – that will be involved in your procedure. (such as pathology or radiology)
  • Your signature, or the signature of your guardian
We urge our patients to READ their paperwork carefully and to consult their private health insurer direct if there are fees or exclusions that you are uncertain about.