Health insurance & cosmetic surgery: Is it covered?

What is cosmetic surgery?

Cosmetic surgery refers to treatments designed to change the appearance of an otherwise healthy part of a body. As opposed to reconstructive or other medically necessary surgery, the main goal of cosmetic surgery is to improve the way we look, rather than meet medical needs.

Many surgeries can change the way a person looks, but to be officially labelled as ‘cosmetic surgery’, a procedure needs to meet a specific definition. The Medical Board of Australia’s (MBA) official definition of cosmetic surgery covers any medical and surgical procedure performed with the aim to “revise or change the appearance, colour, texture, structure or position of normal body features, with the dominant purpose of achieving what the patient perceives to be a more desirable appearance or boosting the patient’s self-esteem”.

What’s the difference between cosmetic surgery and a cosmetic procedure?

There’s a difference between cosmetic surgery and a cosmetic procedure, too. According to the MBA:

• Cosmetic surgery involves cutting beneath the skin, such as breast augmentation and surgical face lifts.
• “Minor (non-surgical) cosmetic medical procedures”, on the other hand, do not involve cutting beneath the skin, but may involve piercing the skin. Examples include laser skin treatments, mole removal for purposes of appearance, and injections, such as the use of Botox.

What’s the difference between cosmetic surgery and plastic surgery?

The terms cosmetic surgery and plastic surgery apply to different types of medical treatment. While cosmetic surgery is any medical procedure done to improve the physical appearance of a person by making changes to ‘normal body features’, plastic surgery is a more specialised medical field that includes cosmetic procedures as well as reconstructive surgery.  The MBA states that “reconstructive surgery differs from cosmetic surgery as, while it incorporates aesthetic techniques, it restores form and function as well as normality of appearance”.

Why does the definition matter? Certain procedures could attract different levels of Medicare cover and private health cover, while others may not. For example, cosmetic surgery that does not meet the definition of ‘clinically necessary’ or isn’t for a medical reason may not be recognised by Medicare, and may not be covered by private health insurance, depending on a person’s policy. Check with your treating surgeon or other medical professional and your health insurer.

There can be a big difference between plastic surgeons and cosmetic surgeons. As HealthDirect points out, plastic surgeons need to complete at least five extra years of training after becoming a doctor in order to obtain a specialist qualification recognised by the Federal Government. On the other hand, any qualified, registered doctor can call themselves a cosmetic surgeon. It doesn’t call for further training or specialist qualifications.

Who can perform cosmetic surgery in Australia?

According to the Australian Society of Plastic Surgeons, any doctor ‘with a basic medical degree’ can perform cosmetic surgery in Australia. The Australian Health Practitioner Regulation Agency (Ahpra) said while researching practitioners, it could be a wise idea to:

• Check the national online register of practitioners.
• Ask to see any practitioner’s qualifications.  Ahpra states that it could be quite important to choose a surgeon who is “qualified, knowledgeable, skilled and experienced in performing the procedure or surgery” you want.
• Find out if the place the surgery will occur meets the applicable licensing requirements in your state or territory.
• Make sure any medicines or medical devices are approved by the Therapeutic Goods Administration (TGA).
• Practitioners are also required to ask you for ‘informed consent’, which means they have to give you certain information before asking you to sign a consent form, including what the procedure involves, any possible risks, the total cost, and details about their complaints process should you be dissatisfied.
• Ahpra also suggests familiarising yourself with where you could go if you need to make an official complaint.

What are the most common cosmetic surgery procedures?

The International Society of Aesthetic Plastic Surgery (ISAPS) states that a survey of its members found the most frequently performed cosmetic procedures in 2019 (latest available survey) were:

1. breast augmentation
2. liposuction
3. eyelid surgery
4. abdominoplasty (tummy tuck)
5. rhinoplasty (nose job).

ISAPS found that the top five nonsurgical procedures were:

1. botulinum toxin (botox)
2. hyaluronic acid
3. hair removal
4. nonsurgical fat reduction
5. photo rejuvenation.

According to the Cosmetic Physicians College of Australasia, the COVID-19 pandemic has driven a ‘Zoom Boom’ in demand for cosmetic surgery. The theory goes that, with more of us seeing ourselves on Zoom and other online video platforms, we’re casting a critical eye, and forming the view that we could do with a nip, tuck or spot of wrinkle reduction. It’s also been known globally as ‘Lockdown Face’.

The cost of cosmetic surgery in Australia

How much you pay for cosmetic surgery depends on the doctor you use, the procedure you opt for, and if you have private health insurance (as well as whether your policy covers cosmetic procedures). Then you would have to factor in possible expenses for day surgery, anaesthetist’s fees, and costs associated with recovery such as hospital fees. It’s a wise idea to talk to your health professional (and your health insurance provider, if applicable), to find out exactly how much any procedure and recovery may cost. How much a procedure may cost may also depend on where you are having the procedure performed. As there are so many variables involved, it is difficult to provide a full list of potential costs.

Is cosmetic surgery covered by Medicare?

The Commonwealth Ombudsman makes it clear that cosmetic surgery and non-surgical cosmetic procedures are not recognised by Medicare. However, Medicare will cover some or all of the costs of essential reconstructive surgery for procedures listed under the Medicare Benefits Schedule. The other options are paying for cosmetic surgery out of your own pocket or relying on private health cover. However, there are likely to be out-of-pocket costs involved, so it’s best to talk to your medical professional and health insurer in advance of any procedure.

Does health insurance cover cosmetic surgery in Australia?

The cost of cosmetic surgery, that is undertaken purely for the sake of appearances, including hospital costs, is unlikely to be covered by your private health fund, according to the Ombudsman.

However, there may be times when surgery that alters your appearance is also deemed medically necessary. In these cases – and if you aren’t already claiming it on Medicare – the cost of the procedure may be partially covered by your health fund if your policy includes plastic surgery, and if you’ve served out the appropriate wait times. These procedures may include surgeries for burns, the removal of tumours or following traumatic injuries. Bear in mind that you will generally have to pay an excess if you make a claim on the hospital component of your private health insurance policy, so it is likely you will still have some out-of-pocket costs even if your insurer does approve your claim.

As a general guide, Canstar research reviewed the Australian Prudential Regulation Authority’s (APRA) statistics around costs for all plastic and reconstructive surgical operations, which covers cosmetic surgery procedures (where the health insurer has decided to cover them). The research found that the out-of-pocket costs ranged – on average across all surgery types – from about $460 to $2,800, depending on the type of health insurance policy a person having the surgery held, including whether they had a ‘gap agreement’ or a ‘no gap’ agreement in place with their insurer.

If there’s no agreement of either sort, that means the insurer will likely pass on all or most of the out-of-pocket costs, which may include any extra costs a surgeon or other specialist charges above the Medicare Benefits Schedule fee. If there’s a ‘gap agreement’ on a policy, this means the health insurer will cover the out-of-pocket costs of a treatment (the gap payment) up to a certain amount. If there is a ‘no gap’ agreement, this means that the health insurer agrees to cover all out-of-pocket costs (usually with conditions, such as having to have the procedure at one of the health insurer’s nominated facilities and performed by a nominated specialist).

Plastic and reconstructive surgical operations, when covered by health insurance

Subgroup T8.13; items 45000-45797.

Prepared by www.canstar.com.au using APRA Quarterly Private Health Insurance Medical Services Statistics (June, 2021). *For Hospital and General Medical Services. Numbers based on totals for the year ending June 2021.

As the Ombudsman points out, none of us can know what lies around the corner in terms of our medical needs. This could make it worth checking to see if your health insurance covers plastic and reconstructive surgery, as well as any exclusions or restrictions that may apply, especially if you would prefer to be treated in a private hospital.

Bear in mind that Medicare may help cover the cost of some medically necessary surgeries, while purely cosmetic surgeries are unlikely to be covered by either Medicare or private health insurance.

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The table below features a snapshot of hospital & extras policies on Canstar’s database with links to providers’ websites, sorted by Star Rating (lowest-highest) then by provider name (alphabetically). Please note the results are based on a couple aged under 35 in NSW, with no pregnancy cover.

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Main image source: Andrey Popov (Shutterstock.com)

Additional reporting: Nicola Field. Sub edited by Milan Cuk.