Breast reconstruction and breast implants

Hi, I have tubular breasts. I have found that Medicare and private health both cover breast surgeries to correct this. I can't get my head around how it works. If I am going private but with Medicare cover aswell how much will I be out of pocket. I can't find what Medicare deem as the correct cost and what they exactly cover. I need to know how much out of pocket I'll be or how will I be expected to come up with the money. It's so confusing. For example if surgeon costs are $6500 how much does Medicare and private cover? What other costs are there involved and what would a rough out of pocket figure look like?

Amy.88 August 18th, 2016 NSW

  • Answer
     Gavin Sandercoe

    Gavin Sandercoe

    32 answers

    Plastic Surgeon
    New South Wales, Australia

    Hi Amy
    Yes, the system is confusing. Medicare has an item number (code) for breast augmentation +/- lift for tubular breasts. If you have a high enough level of health insurance, then your health fund also helps cover the costs (but you may have an excess to pay to the insurance company). What that means is that the costs of your implants, operating theatre time, hospital stay should all be covered. Between Medicare and your health fund, they will partially cover the costs of your surgeon, anaesthetist and assistant. There is very likely to be a gap you will need to pay your surgeon & anaesthetist. The amount of the gap will vary between surgeons, and health funds. You are best to call the rooms of a few surgeons to get a feel for costs.
    Good Luck
    Dr Gavin Sandercoe
  • Answer
     Robert Drielsma

    Robert Drielsma

    191 answers

    Plastic Surgeon
    New South Wales, Australia

    Hi Amy.  Thanks for your question.  The system can be very confusing to understand.  Breast surgery to treat tuberous breasts attracts a Medicare rebate which means you are entitled to claim a Medicare rebate after your surgery is complete.  If you are having the procedure performed privately, you will have surgical fees, implants, hospital and anaesthetist fees.  Depending on your level of private health cover, your hospital and implant fees may be covered by your health fund and you will receive a health fund rebate on your surgeons fees and anaesthetist fee. In addition Medicare will also provide a rebate on your surgeons fees.  There are large gaps between the surgeon’s fees and the amount you can receive back as a rebate from Medicare and your health fund. This is because these rebates have continued to lag well behind inflation and do not reflect the true cost of providing health care.  So even with your Medicare and health fund rebates you will still be out of pocket.  The amount you will be out of pocket depends on your surgeon’s fees.  I am a fully qualified specialist plastic surgeon. Fees very widely depending on the skills, experience and qualifications of your surgeon.  Your best step is to arrange a consultation with a fully qualified plastic surgeon to discuss the procedure and detail and to receive a full overview of the fees and your out of pocket expenses.