Private Health Insurance and Plastic Surgery: New Insurance Changes

New changes to Private Health Insurance Policies – effective next year – could greatly impact what IS or ISN’T covered by your Health Fund for corrective and reconstructive Plastic Surgery procedures.

Read the latest articles on the Gold, Silver and Bronze classification systems being implemented by the Government to help patients and consumers better understand WHAT their health insurance policy actually covers.

Recent Media Releases and stories about pending changes to Health Fund Coverage Classifications

Sydney Morning Herald Article:  New Ranking System to Help Public Compare Health Insurance Coverage – accessed online 17-07-2018

Private Health Insurance Categories and Premium Policies – Coverage – accessed online 17-07-2018 – accessed online 17-07-2018

Ombudsman support for changing your health insurance policy – accessed online 17-07-2018

Quick Tips for the New Changes to Health Fund Policy classifications and your coverage options

  • There are over 70,000 different health fund policies
  • The government is aiming to simplify what COVERAGE means to help consumers better understand what they are – and are not – covered for with their existing policies or new policy purchases.
  • “Junk policies” are being targeted for phasing out (this is a term used to describe a low cost, low coverage policy that appears to be of little value to most consumers)

Great Health Insurance Company transparency and Health Fund policy coverage clarity are the primary aims of these changes to health fund policy classifications and rankings.

  • These changes, to go into effect next year (2019), may impact your Coverage for hospitalisation and surgical fees for Plastic Surgery procedures that involve a Medicare Code and meet strict rebate criteria.
  • If you’re counting on using your Health Fund cover to help pay for your reconstructive or corrective plastic surgery procedure, such as a Breast Reduction or Rhinoplasty, you may want to ask your Insurance company what changes these new ranking systems will have on your existing policy.

Suggestion: Read our other blogs related to surgery and rebates, Medicare and Super Withdrawal: “What does fully covered really mean in terms of private health insurance policies and surgery expenses” and “Super and Plastic Surgery: Changes to the Application Process for Early Withdrawal of Super for Surgery based on compassionate grounds“?

Phone us on (03) 8849 1444 for information on how this might impact your future surgery.

This blog, originally published in early 2018 and updated in July 2018 as Health Fund policies are falling under a new classification and coverage ranking system (Gold, Silver or Bronze) per Health Minister Greg Hunt beginning in 2019, covers how to be prepared for phone discussions with your private health fund about whether or not your plastic surgery procedure is eligible for surgery rebates or hospital cover.

Excerpt from the changes according to Australian Health Minister Greg Hunt’s media release:

For the first time I am proud to mandate vital support for women under the Silver and Bronze categories, which will include gynaecological services, ovarian and breast cancer treatment and breast reconstruction.

This will support thousands of Australian women through cancer diagnosis, treatment and recuperation.

Consumers should expect to see new insurance policies categorised under this new system by early 2019 from insurance companies.

In this blog, we also briefly discuss what you might qualify for in terms of your Cosmetic Plastic Surgery procedure according to Private Health Insurance policies in Australia as well as Medicare rebates.

Updated in July 2018 after media releases and news stories on a changing Health Insurance classification system to Gold, Silver, Bronze and Basic.

We also highlight the importance of your patient status and plastic surgery requirements meeting strict Medicare criteria in order to be eligible for ANY form of Hospital cover or Surgery fee rebate, Medicare or otherwise (e.g., private health fund insurance).

If your surgery procedure does not fall under a current Medicare code and if you do NOT meet the Medicare rebate criteria, your procedure is NOT covered by your Private health fund.

Is Cosmetic Surgery covered by my Private Insurance or by Medicare? 

Helpful information: If your procedure is a cosmetic procedure vs a reconstructive or corrective procedure, it is not covered by insurance or by Medicare.

Why read this blog:

  • Do you have private health insurance?
  • Do you want to understand what’s covered and what’s not in terms of a corrective or reconstructive plastic surgery procedure (versus a cosmetic procedure, which is never covered)?
  • Are you worried about the unexpected changes to your health fund coverage and what will happen in April 2019 when the new, simplified classifications come into effect as per current discussions on pending health insurance policy changes?

If you’re confused, we hope this information helps you to better understand your coverage and how to contact your insurance company to discover what your health insurance policy coverage ACTUALLY means.

The key thing to know is that Medicare codes and Health Insurance policies have been subjected to sudden changes with very little warning to the public and health fund consumers.

Understanding Private Health Insurance Hospital Cover and related policy inclusions and exclusions can be very confusing, and the pending changes proposed by the Health Minister, coming into effect in early 2019, could greatly impact what Plastic Surgery procedures are eligible for cover.

You’re not alone if you find understanding Private Health Fund cover frustrating.

Adding to the frustration with Health Fund policy terminology that consumers have complained about for years, are the new changes being implemented in private health fund policy classifications or ratings (rankings), going into effect in 2019 in Australia.

  • These Health Insurance Classification changes AIM to help you more easily understand your cover.
  • They also aim to help consumers to shop around for better private health fund policies that meet your particular needs, budget and lifestyle.

But theoretically, these changes to Health Insurance policy systems – across all Australian private health funds – could feasibly impact your current policy and coverage.

  • New standards and classification rankings are being implemented across ALL Australian health fund companies.
  • These new structures can alter existing policies and impact over 13 million privately insured consumers who hold a Health Insurance policy (as there are over 70,000 of them according to recent news releases).

So your eligibility for hospital operation coverage for corrective and reconstructive Plastic Surgery could be altered by these new changes to Health Fund policy classifications.

The only way to assess your actual coverage is to have a Quote from your Surgeon with details of the surgery procedure code (if applicable), get out your Private Health policy, read and re-read it in detail including reviewing Health Insurance Company terminology, then phoning your Insurance Company, such as BUPA, Medibank, AAMI or Australian Unity, for actual clarification.

** Please note that this information is general in nature, and is a synopsis of selected information available from news outlets and insurance firms. We regularly attempt to update our best ranking Plastic Surgery blogs with updated information.

There is however a chance that in the fast-changing field of health insurance and health cover in Australia, this information may be superseded or likely to change.

If you are aware of a change to this information, please phone us and let us know on (03) 8849 1444.


Early next year, what’s currently covered by your Private Heath Insurance Policy may suddenly change – plus, your policy may not cover what you thought it did.

The good news about these changes is that you’ll benefit from GREATER CLARITY – up front – about your policy coverage and be able to shop around for more suitable insurance policy plans; or at least, that’s the primary aim of these changes over time. The bad news is that what you’re covered for now may change as your policy is adapted to meet the new standard classifications systems proposed by the Australian Government.

Health Fund Hospital Cover and Plastic Surgery (Private Health Fund Rebates can be confusing) – you need to discuss coverage directly with your Insurer to understand what IS or ISN’T covered.

Even today, before these changes take effect, the only way to assess what you’re covered for is to read your policy, shop wisely for health insurance, understand coverage changes rapidly as Medicare codes and criteria also change rapidly (with very little advanced notice to consumers), and to contact your Health Insurance Fund DIRECTLY by phone.

A tip for dealing with your Private Health Fund is to know that you may NEED to phone your Insurer several times to validate the information you receive in a call; as big companies with many employees, and ever-changing policy criteria, doesn’t always lead to the RIGHT information being received when you phone.

What we hear, repeatedly, from patients who complain about their Private Health Funds and misinformation about plastic surgery and hospital coverage:

“How frustrating is it to think you’ve gotten an answer from your Health Fund about your Plastic Surgery coverage for a breast reduction, nose job or abdominoplasty or breast lift after pregnancy, only to discover the next person you speak with says the information you got the first time, was wrong?”

Are you wanting to find out if your Tummy Tuck, Breast Reduction or Eyelid Surgery is covered by your Australian health fund?  Be sure you read part 1 of this 2 part blog (what does “fully covered really mean”) so that you understand the terminology of health insurance coverage documents.

But know that NEW CHANGES to health fund coverage are taking place effective APRIL 2019, and this will likely have unanticipated impacts on what IS and ISN’T covered when it comes to Plastic

Continue reading more about how to discuss coverage with your Health Fund after you preview the latest NEWS STORIES regarding new changes to Private Health Cover mean in relation to Plastic Cosmetic Surgery (Effective April 2019).

New Health Insurance Policy Changes – Government Reforms and Classifications to take effect by April 2019

What do the proposed government-driven changes to Health Insurance Fund coverage classifications MEAN for Plastic Surgery procedures such as Rhinoplasty Surgery, Breast Reduction or Blepharoplasty for eyelid ptosis?

It’s difficult to predict, although these classification systems MAY help you better understand what you’re actually buying – and covered for – when you pay for Private Health Coverage from BUPA, Australian Unity and Medibank and other insurers.

Did you know there’s a new ranking system for policies by Private Health Funds?

  • It’s being implemented in response to what’s called “junk funds” that are low cost but low coverage policies that consumers have found confusing.
  • There will be GOLD, SILVER and BRONZE classifications of policies.

Read more on the upcoming changes at these recent news articles (and continue reading THIS BLOG for tips on dealing with your Health Fund when discussing eligibility and policy coverage for Plastic Surgery procedures).



More on preparing to discuss your SURGERY and HOSPITAL COVER with your Private Health Fund.

This article is the 2nd of 2 parts. Read Part 1 – Private Health Insurance Hospital Coverage and Plastic Surgery.

Private Health Insurance and Plastic Surgery

Understanding your Health Fund Coverage


Dealing with private health funds in Australia can be frustrating for many patients.

Recent news stories about health insurance funds show that health insurance company complaints are up by 30% from last year alone. Articles suggest that some of the largest health insurance firms may have some of the highest complaint rates.

So it really DOES pay to investigate your Private Health Insurance Company’s reputation, and terms, BEFORE you buy. And if you, too, have a complaint about your private health insurance fund, you can contact the Australian Health Insurance Ombudsman’s office for information and assistance.

Excerpted from an SBS article, Record rise in private health complaints (May 2018, accessed online 18 June 2018 at

  • Complaints about private health insurance increased by 30 per cent in the last financial year, the worst rise in a decade.
  • The Private Health Insurance Ombudsman received 5750 complaints in 2016/17, up from 4416 in 2015/16.
  • “This is an increase of over 1300 complaints within one year, which is the largest rise we have experienced over the past 10 years,” the ombudsman’s latest State of the Health Funds report said.

To help our patients better understand common health insurance issues and health fund coverage terminology, we’ve published blogs with handy resources and links, to get you started as you connect with your health insurance company to discuss whether or not you’re eligible for any rebates for your Plastic Surgery procedure.

In today’s blog, we provide Australian Government resource links to help you better understand your private health insurance – including what your policy actually means.

health insurance cover plastic surgery - criteria, waiting periods, exclusions

What you’ll NEED to do BEFORE you can assess whether rebates for your surgery by your Specialist Plastic Surgeon will be applicable:

  • Read Part 1 – what the health fund term “fully covered” or “rebate” really mean in terms of plastic surgery costs to patients and then continue with the one you’re reading now.
  • Read and understand your Health Insurance Policy including exclusions, pre-existing conditions and waiting periods
  • GET your documents in order (your Policy, your notes about the surgery including the Medicare ITEM Number that your Surgeon has told you applies to your condition, your original referral from your GP, any accompanying documentation, scans, or images you have, along with your Surgeon’s notes and Estimates/Quote). Other paperwork may also be required so be patient, and be prepared.
  • Find a comfortable spot to be on the phone for some time (and allow adequate time – don’t try to squish in a call to your health fund during a 30 minute office break)!
  • Contact your health fund directly, by phone, with all of your documents in order.

Contacting your Health Insurance Company: Tips

  • Grab a coffee or snack and a fully charged phone
  • Allow at least an hour for the conversation (don’t try to squeeze it in on a short break from the office)
  • Put your feet up and plan to spend some time on hold (or maybe get out the nail polish while you wait)
  • Consider the possibility you may be given different or inaccurate information each time you call.
  • Ask for a reference number or name of person you speak to.

Some patients found it helpful to telephone their health insurance company on two separate occasions, to check what they’ve been told is covered, with different representatives, JUST to verify the information they’ve been given was correct.

Health Insurance Terms, Waiting Periods, and Exclusion Criteria – ‘it’s complicated’

Is it possible the coverage and exclusion terms are so complex, not even the health fund employees always fully understand them?  We can’t answer that question, but there is a push by the Government to insist on more plain-language health fund policy materials – especially in view of the increase in Ombudsman level complaints.

What to DO first, and what to HAVE in front of you, before you phone your private health fund to see what coverage you have in relation to your plastic surgery procedure.

GP Referrals for Plastic Surgery – YES, see your GP before you schedule your appointment.

Get a GP Referral for your concerns before you see a Plastic Surgeon (Specialist) BEFORE you attend a consultation for a corrective or reconstructive procedure.

health insurance cover plastic surgery - criteria, waiting periods, exclusions

  1. Before you investigate any health fund coverage or medicare rebate eligibility for a plastic surgery procedure such as post-pregnancy Abdominoplasty and torn abdominal muscles repair, you need to see your GP to get a referral. That’s because you NEED a referral to be eligible for any form of rebate and you’ll ONLY be eligible if your surgery is NON-COSMETIC in nature.
  2. Remember that Cosmetic Surgery is NEVER covered by Health Insurance or Medicare. Some Plastic Surgery procedures, however, may qualify for a Medicare Code (functional, structural or reconstructive, but never cosmetic procedures).
  3. IF you want a combined cosmetic surgery with plastic surgery (e.g., a cosmetic operation combined with a reconstructive or corrective plastic surgery procedure), any coverage eligibility for the plastic surgery part is typically forfeited and/or becomes non-accessible.
  4. Plastic Surgery procedures that may be covered might include surgery for post-pregnancy damage or changes to the breasts or abdomen core muscles (diastasis recti, abdominal tears, hernias), or chronic skin conditions occurring after weight loss (post-obesity plastic surgery), and/or other functional plastic surgery procedures such as eyelid lift surgery for eyelid ptosis – or a breast reduction or breast lift.
  5. These Plastic or Reconstructive Surgery procedures MIGHT currently qualify for a Medicare Code/Medicare rebate but this is subject to strict criteria and rapid changes.
  6. This does NOT, however, mean your operation is FULLY covered, and that your costs will be reimbursed.  In fact, with a private practice Plastic Surgeon, you WILL have out of pocket expenses for your procedure, even after a Medicare or Health Fund rebate, and these could be significant – but when it comes to your body and your health, consider the benefits of a bonafide experienced Plastic Surgeon and know the difference between a cosmetic vs plastic surgeon (e.g., patients of purely Cosmetic Surgeons attract no insurance rebates and no hospital surgery options as opposed to Plastic Surgeons who typically have private hospital operating rights).
  7. If you are seen by a Specialist and your concerns do NOT attract a Medicare Code (e.g, they do not meet the criteria), then you will be ineligible for either a Medicare OR a Health Fund rebate.


Visit our Downloadable Guides pages

For more information about Cosmetic and Plastic Surgery options and research in Australia.

cosmetic surgery for women and men Downloadable guides


Dig up the copy of your Health Fund coverage and read it thoroughly before you call your Health Insurance Company to ask about Plastic Surgery Coverage.

It’s also very important to read the MBS Online Medicare Criteria for rebates for the condition you have.

Read the Health Fund criteria, in detail, re eligibility for plastic surgery (e.g. a Tummy Tuck, Breast Reduction or Eyelid Surgery), including waiting times and other criteria – this can be very detailed reading and quite variable.

If you don’t understand anything in your health insurance policy about your coverage, make a note about it and be sure you have a list of questions you want to ask the Insurance Representative when you phone them.

In summary: if you have a GP referral to a Specialist for evaluation of a problem (such as torn abs, an abdominal hernia and excess skin bulges, heavy breasts causing you neck, back or shoulder pain, or droopy eyelid skin that impedes your vision), then you MAY be eligible for additional hospital cover or a rebate on your procedure This is only if your private health insurance company’s policy and your coverage plan – covers your particular scenario.

But the only way to find that out what you’re covered for, is to directly contact your Health Insurance Company with all your paperwork in order.

Phone us on (03) 8849 1444 if you need a copy of your original quote from your consultation with a Plastic Surgeon, or for our GUIDE on Medicare and Health Insurance and Plastic Surgery (or send an enquiry, below).


Do you know the difference between a Cosmetic Surgeon versus a Specialist Plastic Surgeon? Find out what they are.








This article is the 2nd of 2 parts. Read Part 1 below.

Private Health Insurance Hospital Coverage and Plastic Surgery


Phone (03) 8849 1444 or Email us at: or Book a FREE 15-minute Phone Chat with our Patient Liaison Manager.


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