Medicare Codes – Plastic Surgery Definitions, Criteria and Rebates.
- The Australian Government announced significant pending changes to the Medicare Benefits Schedule (MBS) for Plastic Surgery code items.
- This MBS changes will be finalised and go into effect immediately on 1 November 2018.
- Changes to surgery criteria and operation coverage could impact ANY Plastic Surgery patient currently scheduled for an operation ON or AFTER 1 November 2018; IF their plastic surgery procedure WAS eligible for a Medicare code/Medicare rebate and/or Health Fund coverage.
- These November 2018 MBS changes do NOT impact purely cosmetic surgery procedures because COSMETIC surgery is NEVER covered or eligible for a rebate from Medicare.
Will you still covered after MBS Changes to Plastic Surgery procedures?
Brief Synopsis of early Media Releases about MBS Changes (Medicare Criteria Changes coming into effect on 1 November 2018)
Originally posted 18 Sept 2018 and updated on 4 November 2018.
MBS changes do NOT impact purely cosmetic surgery procedures.
These upcoming changes to the Medicare Rebate Schedule (MBS) DO IMPACT operations that are corrective, restorative, reconstructive and/or otherwise medically necessary versus cosmetic in nature.
- The Medicare CLAIMS REVIEW Team is being dissolved.
- Instead, the Medical Benefits Schedule Review Task Force is aiming to significantly change the MBS to increase medical treatment coverage CLARITY such as changing criteria and condition definitions.
- Plastic Surgery items are NOT the only MBS code items being clarified or changed. Several other areas of medicine are also being impacted by MBS review changes.
- Many cosmetic patients are self-funded; and these operations have no MBS rebate eligibility.
- However, some patients are having medically warranted procedures.
- These surgeries will correct a deformity or reduce a painful or problematic medical condition that reconstructive Plastic Surgery operations can help improve.
MBS changes mean that IF you WERE covered when you scheduled your operation OR last had a consultation, you may NO LONGER be eligible after 1 November 2018.
If your CURRENT condition and scheduled Plastic Surgery procedure does NOT warrant a Medicare code AFTER the 1st November 2018 changes to the Australian Government’s MBS, it ALSO means your Private Health Fund / Health Insurance company, like BUPA, is NOT going to cover any of your hospital stay, Surgeon’s fees, Anaesthetist and/or other surgery costs.
Bottom line of November 2018 Medicare Changes to Plastic Surgery – likely outcome in terms of costs or prices and Quotes:
- you may no longer meet criteria if eligibility definitions CHANGE or if your procedure code is REMOVED from the Medicare Rebate Schedule
- you’ll likely have to see more Doctors and/or Specialists BEFORE having Plastic Surgery for any items still covered by Medicare after 1 November 2018
- you’ll have even MORE paperwork and reports needing to be completed and submitted to Medicare and/or your Private Health Insurance Fund
- you’ll likely incur greater out-of-pocket expenses prior to your Surgery or your overall surgery costs may increase
- you may need to have separate operations versus two procedures at one time in order to have a rebate
Anticipated/Estimated Surgery Patient Impact:
For patients scheduled for reconstructive, restorative or corrective Plastic Surgery AFTER these MBS changes go into effect on 1 November 2018:
- higher surgery costs (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.
Higher Surgery Costs and No Eligibility from Medicare or Your Health Fund such as BUPA, AHM, Australia Unity Health and other Private Health Funds
- you may no longer be eligible for any rebate coverage from either Medicare or your Private Health Insurance Fund depending on your procedure and how these changes impact your eligibility.
- that’s because to have private Health Insurance Fund coverage/rebates on any medical procedure, it must also first meet Medicare eligibility criteria.
- even condition that meet criteria for MBS rebates sometimes are rejected by Private Health Insurance Funds who have extensive and complicated exclusion clauses
Potential CODES targeted by changes to MBS criteria for medically-indicated (functional) vs cosmetic Plastic Surgery:
- corrective, restorative or reconstructive Plastic Surgery procedures including:
- corrective eyelid surgery (Blepharoplasty) when vision is impeded
- reconstructive breast lift surgery or Reduction Mammoplasty for breast ptosis and/or breast-size related back pain
- other procedures for skin reduction, diastasis recti and hernia repair after significant weight loss (Belt Lipectomy/Circumferential Abdominoplasty, for example, after Bariatric Surgery)
- This information is only general in nature and only an estimate of the impacts based on reports and media releases in relation to the changes to Medicare codes for Plastic Surgery, effective 1 November 2018.
To find out more, contact MBS or your private health fund or phone our offices for a Guide to Plastic Surgery procedures on 0388491444.
- The Australian Society of Plastic Surgery (ASPS) posted a brief news release indicating some Plastic Surgery items will be completely removed from the MBS list (Medicare Rebate Schedule) starting 1 November 2018.
- Other surgery procedures will have stricter criteria and more detailed definitions to increase clarity of what IS – or ISN’T – covered by Medicare; likely meaning LESS patients will be eligible for coverage by either Medicare OR a Private Health Fund, even for corrective post-pregnancy surgeries such as diastasis recti repair or breast lift procedures to treat ptosis after pregnancy .
Procedures reported to be impacted by the 1 November 2018 definition and criteria changes to the Medicare Rebate Schedule (MBS) items for Plastic Surgery operations include:
Removal and Replacement of Breast Prosthesis (Breast Implants)
Estimated Patient Impact:
- fewer patients who need removal or replacement of breast implants will meet criteria for MBS rebates or private Insurance coverage
- higher out of pocket costs and paying for the full costs of breast revision operations, even when medically necessary, is a potential likelihood for some patients
Eyelid Surgery and Medicare
Blepharoplasty – you will need to have an independent eye specialist verify your sagging eyelids are impacting your vision (e.g. impeding your field of vision).
Estimated Patient Impact:
- attending additional exams by other Doctors/Specialists to assess eligibility
- more paperwork and photographic submissions may be required, including an extra GP Referral to a Specialist PLUS costs of medical visits and paperwork/reports
- higher medical expenses to see the eye/vision specialist separately to your GP and separately to your Plastic Surgeon or Oculoplastic Surgeon
- not being eligible if there is a marginal level of ptosis or marginal impairment to a person’s field of vision due to eyelid ptosis
- Patient may decide to delay eyelid surgery until eyelid ptosis impedes vision, in order to have Medicare coverage of a Blepharoplasty
Eyelids often sag unevenly – what if one eyelid meets MBS criteria but the other eyelid does not meet criteria? This may impact surgery coverage also.
Skin Reduction or Belt Lipectomy after Weight Loss or Bariatric Surgery
- Definitions and rebate criteria for skin reduction surgery after Weight Loss, such as Abdominoplasty/Belt Lipectomy or Circumferential Abdominoplasty as well as Arm Reduction/Brachioplasty procedures, are changing.
- Multiple procedures at one time will NOT be covered.
Estimated Patient Impact:
- Patients with abundance skin (redundant skin folds) are likely to NOT be permitted to combine skin reduction procedures in one operation if they seek Medicare rebates and/or private Health Insurance Fund cover of hospital or surgery costs (partial rebates)
- higher overall out-of-pocket costs to patients for these operations
- requirement of separate operations may delay a patient in restoring natural contours after losing weight when they have many folds of redundant skin and chaffing, flapping and other excess skin fold problems
- Only covered for individuals under the age of 18s
- Lower rebate is likely
Estimated Patient Impact:
- Surgery must be attained BEFORE patient reaches adult consent level (under 18)
- Requiring parental consent
- Costs will likely be higher overall
Other Plastic Surgery procedures impacted by 1 November 2018 changes:
Note this information may change as more NEWS RELEASES arise in relation to the Medicare Schedule changes.
Were you impacted by changes to your Surgery code or condition criteria for a Plastic Surgery operation?
Read more here on our updated listing of REMOVED or DELETED MBS Codes from 1 November 2018.
In summary of these 2018-2019 MBS criteria, definition and code changes mean your surgery costs could change.
+-Recommendations for Plastic Surgery Patients in View of Medicare Changes effective 1 November 2018
- Stay informed – visit MBS for details and watch for news releases about Medicare Changes in Australia.
- 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).
Cosmetic surgery patients will not be impacted as cosmetic surgery is not covered by Medicare or Health Insurance Funds.
Plastic Surgery that is corrective, reconstructive and/or restorative in nature, however, such as a corrective Rhinoplasty, a Breast Reduction, post-weight loss skin reduction, arm reduction/bilateral Brachioplasty and Blepharoplasty eyelid surgery when vision is impaired by eyelid skin ptosis (sagging eyelids), may still attract a Medicare rebate.
These procedures will, however, likely require additional steps and extensive paperwork and photography to prove eligibility for surgery.
Some patients may lose eligibility as they may not meet NEWLY defined condition criteria for specific operations, according to the new 1 November 2018 MBS rebate listing for 2018 and 2019.
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.