Medicare Benefits Schedule (also known as MBS) Item Codes, Definitions and also Criteria for Plastic Surgery changed as of November 2018.
The changes affect your rebate eligibility, for skin reduction surgery (after weight loss) or Bariatric Surgery.
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Brachioplasty, Abdominoplasty or Belt Lipectomy and Revision Rhinoplasty patients may have also been impacted.
The government previously made other changes to the MBS in relation to post-pregnancy Abdominoplasty. This resulted in it Post Pregnancy Abdominoplastys no longer being covered by an MBS item code, however, post-weight loss skin reduction NOT related to pregnancy remained on the MBS. Patients meeting strict criteria about body mass changes and skin reduction needs, also remained on the MBS.
Medically Indicated Plastic Surgery and MBS rebate changes
- These MBS changes will NOT impact Cosmetic surgery patients.
- This is because cosmetic surgery is NOT covered by Medicare.
- Nor is most Cosmetic Plastic Surgery covered by private Health Insurance Companies such as BUPA, AIH, Australian Unity, NIB and other recognised Australian health funds.
- However, some Plastic Surgery procedures are corrective or restorative in nature, such as skin reduction after Bariatric Surgery or lifestyle changes resulting in significant skin folds after weight loss.
- These usually have an MBS item code and also often have some hospital coverage, DEPENDING on your HEALTH INSURANCE PLAN.
Furthermore, surgeries performed by Plastic Surgeons that are medically indicated CORRECTIVE and RECONSTRUCTIVE Plastic Surgery, even though they may have some aesthetic benefits, are performed for reconstructive purposes. For example, surgery to restore natural contours or reduce skin infections, back pain and neck pain caused by excess skin folds or redundant heavy tissue weight.
- Specialist Plastic Surgeons usually perform both COSMETIC and/or CORRECTIVE/RECONSTRUCTIVE Plastic Surgery.
- For example, a purely Cosmetic procedure might be liposuction of the thighs, a facelift or breast augmentation.
- While a Corrective Plastic Surgery procedure might be skin reduction of excess skin folds post-obesity (arms, stomach, thighs), breast reduction to reduce back pain/neck pain and shoulder pain, corrective Rhinoplasty/Septoplasty, Eyelid Surgery for severe ptosis, Breast Lift for ptosis after pregnancy or weight loss, and other similar procedures.
These MBS items may be changing on 1 November 2018. If you were previously covered, you may no longer be eligible.
Note that your Private HEALTH FUND policy such as BUPA, AIH and Australian Unity can change too.
Changes have also occurred to Health Fund Policy Classifications and Private Health Coverage for surgery in terms of redefining classifications. This is so consumers better understand their policies, exclusions and coverage.
The Government is seeking to ensure consumers actually UNDERSTAND what they’re buying. And, that they know what is and isn’t covered. This is due to the fact that current policies are confusing for consumers and exclusion clauses are difficult to understand, leaving many patients unexpectedly NOT covered for medical warranted procedures.
November 2018 MBS Updates to Plastic Surgery criteria.
Moreover, changes to the MBS in the 2018-2019 Budget are NOT limited to Plastic Surgery operations, changes include other areas of medicine, imaging/testing, and various forms of surgery.
For an Australian Government/Department of Human Services News Release regarding 2018-2019 budget MBS Review changes, effective 1 November 2018, click here.
Plastic Surgery and Medicare News and Media (Australia)
Plastic Surgery procedures by genuine Plastic Surgeons are being impacted according to a news release by the Australian Plastic Surgery Association (ASAPS).
The Australian Society of Plastic Surgeons (ASAPS) also released a media statement about November 2018 Medicare criteria changes for Plastic Surgery procedures.
Breast Reduction Surgery Patients, Breast Lift Patients, Removal and Replacement of Breast Implants, and Skin Reduction Lipectomy/Abdominoplasty Patients MAY likely be impacted by changing MBS criteria from the MBS Review team.
How the MBS criteria changes may impact you
- If your MBS item code is removed or changed in any way you may no longer meet criteria, your private health insurance company is also not likely to cover your hospital or surgery costs. This is because health insurance policies usually only cover procedures that are on the MBS list.
- If your MBS Item Code has changed and your condition or surgery no longer meets the criteria, you may become ineligible for a rebate.
- Check the latest MBS publication release and phone your doctor, Surgeon and/or insurance company, if you have any questions.
- Post-weight loss patients meeting strict criteria including weight loss NOT related to pregnancy – may still have some rebate eligibility for skin reduction after bariatric surgery.
- However post-pregnancy conditions typically do not meet criteria.
- In a Budget review of health care expenses, the Medicare Benefits Schedule Taskforce and MBS Review TEAM changed criteria descriptions and Medicate ITEM codes (see the 2018-2019 Budget release).
This resulted in changes to the Medicare Rebate Schedule (MBS). Went into effect on 1 November 2018, this IMPACTED several Plastic Surgery operations even though they are corrective, restorative, reconstructive and/or otherwise medically necessary versus cosmetic in nature.
MBS review and Medicare criteria changes for Plastic Surgery operations can potentially impact:
- Firstly, Rhinoplasty after an injury, or to correct a deviated septum/breathing problem.
- or, Eyelid Lift Surgery/Blepharoplasty, when ptosis of the eyelid impedes the field of vision.
- Skin reduction and also belt lipectomy weight loss/Bariatric Surgery
- It may also impact Breast Lift Surgery after pregnancy or Breast Reduction
- Otoplasty and other corrective Plastic Surgery procedures may also be affected.
Reconstructive Plastic surgery patients have higher out of pocket costs.
Private Health Fund Hospital/Surgery Cover and Medicare Item Codes, how BUPA, AIH and Australian Unity are also impacted by these changes
The potential impact of changes to MBS, for reconstructive, restorative and corrective Plastic Surgery
- Firstly, higher surgery costs to patients / less rebate eligibility (estimated)
- Also, more visits and reports to other medical professionals (more extensive paperwork and image submissions)
- Some conditions may also no longer be eligible and NO Medicare code may apply. This means your Private Health Fund will ALSO not cover your operating costs.
- Lastly, NO coverage for multiple surgeries in one operation session. In other words, surgeries will need to be more sequenced rather than combined
Further research and Media Releases regarding Plastic Surgery, Medicare and Health Insurance;
Source: Plastic and Reconstructive Surgery: March 2018 – Volume 141 – Issue 3 – p 637–645 DOI: 10.1097/PRS.0000000000004100 Cosmetic: Original Articles