Private Health & Medicare for Elective Cosmetic Surgery in Australia
Insurance coverage for cosmetic plastic surgery in Australia depends on whether the procedure is classified as purely cosmetic or medically necessary.
If the procedure is deemed purely cosmetic, such as breast augmentation, breast lift, or facelift, private health insurance and Medicare do not offer any coverage.
What Cosmetic Procedures Does Insurance Cover?
Generally, health funds and Medicare offer coverage for procedures that address health concerns, functional impairments, or significant psychological distress. The procedure must be listed under the Medicare Benefits Schedule (MBS) to be eligible. Some common cases where insurance may provide coverage include:
- Breast Reduction – If a patient experiences chronic back, neck, or shoulder pain due to large breasts
- Breast Reconstruction – Patients undergoing reconstruction after a mastectomy for breast cancer
- Abdominoplasty (Tummy Tuck) – In cases where a patient has lost a significant amount of weight and experiences excess skin causing hygiene issues or infections
- Rhinoplasty – If the procedure corrects breathing difficulties or deformities resulting from injury or congenital conditions
- Eyelid Surgery (Blepharoplasty) – If drooping eyelids impair vision
How much will Medicare Cover?
The Medicare Benefits Schedule (MBS) lists procedures eligible under specific conditions and the amount of the coverage. You can determine the potential medicare coverage by searching the MBS item number of your procedure.
For example, under the MBS, a qualifying bilateral breast reduction (item 45523) offers a rebate of $1,154.10 (as at March 2025).
To qualify for coverage, a doctor holding a Medicare provider number must provide documentation demonstrating the medical necessity of the surgery.
If your procedure qualifies for Medicare coverage, you typically need to pay the full price of the procedure before your surgery. After surgery, you can make a claim directly with Medicare using documentation provided by your surgeon.
How much will Private Health Insurance Cover?
Private health insurance (PHI) can help cover hospital, anaesthetist, surgeon and implant costs for eligible procedures. Unfortunately, it’s a complex area and policies vary significantly, so it’s essential to contact your PHI provider and review your policy to get an idea of how much will be covered.
Things to look out for are:
- Hospital Cover – Ensure coverage for inpatient procedures and that cosmetic surgery is not excluded. Insurance companies have varying agreements with hospitals that can impact the amount of cover.
- Waiting Periods – Most insurers enforce a waiting period of 12 months for pre-existing conditions.
Steps to Access Medicare and or Private Health Coverage
- Consult a Specialist Doctor / Surgeon – Not every doctor / surgeon is able to assess whether your procedure qualifies for Medicare or private health coverage.
- Obtain a Referral – Some procedures require a GP or specialist referral to qualify for insurance benefits.
- Check the MBS Item Number – Ensure the surgery aligns with an eligible Medicare item number.
- Confirm with Your Health Fund – Contact your PHI to confirm coverage and out-of-pocket costs. They will need the MBS item number of your procedure and the hospital you are going to.
- Get Pre-Approval – Submit necessary documentation to Medicare and / or your insurer before scheduling surgery.
Out of pocket costs and financing options
Even with insurance coverage, out-of-pocket costs will apply including your excess. These can still be significant, so it’s important to do your research and get multiple quotes before deciding on your surgeon and if surgery is right for you.
For out of pocket costs patients can explore:
- MINKST Payment Options
- Superannuation Access – In severe medical cases, early superannuation withdrawal may be possible under compassionate grounds. You will need to contact your superannuation to find out more.
- Medical Loans – Some financial institutions offer loans for medical expenses.
Final thoughts
While elective cosmetic surgery is often self-funded, patients with genuine medical needs may access insurance benefits through Medicare and private health insurance.
Contact us below to discuss your options.
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