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Medicare plastic surgery changes – how will they impact on you?

Medicare have announced some significant changes to plastic surgery item numbers effective from  1 November 2018.   Some item numbers are no longer included in the medicare benefits schedule while other item numbers now have very strict criteria to meet eligibility requirements.

What procedures have been affected by medicare changes?

The following are a list of procedures affected:

Otoplasty Item No. 45659 : Must now be performed before the age of 18 to be eligible for medicare rebates and private health insurance rebates.  After 18 years, medicare deem otoplasty as a cosmetic procedure for adults and therefore medicare and PHI rebates will not apply.

Blepharoplasty / Upper Eyelid Reduction Surgery Item 45617: an optometrist or ophthalmologist will now need to confirm in writing that any excess eyelid skin obstructs your visual field – if you don’t meet this criteria, blepharoplasty or upper eyelid skin reduction surgery will be deemed cosmetic.  Please ask our friendly team if you require a letter requesting this assessment  by your optometrist or ophthalmologist.

Breast lift (mastopexy) Item No. 45558

For correction of Breast ptosis by breast lift or mastopexy the following Medicare criteria now apply :

(a) at least two-thirds of the breast tissue, including the nipple, lies below to the infra-mammary fold.   The nipple should also be located at the most, inferior part of the breast contour; and

(b) if the patient has been pregnant—the correction is performed not less than 1 year, or more than 7 years, after completion of the most recent pregnancy of the patient; and

(c) photographic evidence demonstrating the clinical need for this service, is documented.

Breast Reduction Item No. 45523

Reduction mammaplasty (bilateral) with surgical repositioning of the nipple:

(a) for patients with large breasts and experiencing pain in the neck or shoulder region; and

(b) not with insertion of any prosthesis

Removal and replacement of breast implants Item No 45553 and 45554: Medicare and PHI will no longer provide rebates for removal and replacement of breast implants due to medical complications (for example for rupture of a breast implant, migration of prosthetic material or capsular contracture).  If the original reason for placement of breast implants was for cosmetic reasons then medicare and PHI also deem the treatment of complications as cosmetic and therefore no rebate will apply.

In very particular or extraordinary circumstances a medicare and PHI rebate may apply only if:

(i) it is demonstrated by intra-operative photographs that removal alone would cause unacceptable deformity; or

(ii) the original implant was inserted due to breast cancer or developmental abnormality.

Lipectomy procedures (abdominoplasty 30177, thigh lift 30171 , arm lift 30171 etc):

–  Medicare and private health funds won’t pay any rebates or cover hospital fees if certain procedures are combined. For example, abdominoplasty and arm lift will be 100% out of pocket, even if you meet the MBS item number criteria, if performed together.

– But if you meet medicare criteria and have an abdominoplasty and arm lift performed as two separate operations, they will still be eligible for rebates/cover.

– Refer to our recent blog titled ‘what is an arm lift or brachioplasty’, specifically  can I use my private health insurance?

I have surgery booked after the 1st of November, what do I need to do?

If you no longer meet the new criteria, you won’t be eligible to receive any rebates. If you do meet the new criteria, rebates will still apply for your surgeon’s and anaesthetist’s fees. Private hospital fees are never covered by Medicare, so these remain unaffected for uninsured patients.

I have private health insurance, how will this impact me?

Patients who are privately insured may be significantly impacted by these changes. If your private health insurance policy covers you for an MBS item number – and your surgeon and Medicare deems that you meet that criteria – your fund and Medicare pay a rebate on your surgeon’s and anaesthetist’s fees, and your fund covers your hospital fees (minus any excess or exclusions).

If your procedure is affected and you no longer meet medicare criteria for rebates you will need to discuss alternative arrangements with our team including the following:

-fees for your surgery particularly if the procedure is now considered cosmetic e.g. removal and replacement of breast implants

-changing the location of your surgery e.g. to a day surgery hospital facility with same day discharge

-reducing your proposed hospital inpatient length of stay

-procedures may have to be performed separately if you wish to utilise medicare and PHI

Why are changes occurring – and will there be more?

The government made these changes because they believe some MBS item numbers are being used for procedures that Medicare perceive to be ‘cosmetic’ rather than ‘medical’. Representatives from the plastic surgery community were involved in the taskforce that contributed to these changes, but not all of their requests and recommendations were implemented or observed in the resulting criteria amendments.

Changes to MBS item numbers that impact plastic surgery have been a focus of government cost-cutting in recent years and this may continue. It’s important to remember that when you receive an informed financial consent document, it is based upon the information available to your surgeon, anaesthetist, hospital and health fund at the time. If the government decides to make changes to the item numbers and rebates after your estimate is provided, they are able to do so, and are not required to provide a grace period for people who have already received quotes.

Dr Eddie Cheng is a board certified Specialist Plastic Surgeon in Brisbane, Australia.  Socialise with us @arplasticsurgery to learn more about Dr Eddie Cheng and our Team.

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