Your health fund covers the hospital side of body contouring — the bed, the theatre, the time in recovery. It does not cover the surgeon’s fee, the anaesthetist’s fee or the gap on either. Those are Medicare’s territory, and only where an item applies.
That division is the thing to understand before you ring your fund, because it determines what question to ask them.
Who pays what
| Cost | Medicare | Health fund |
|---|---|---|
| Surgeon’s fee | A benefit where an item applies | No |
| Anaesthetist’s fee | A smaller benefit | Sometimes, through a gap scheme |
| Surgical assistant | A benefit where required | Sometimes |
| Hospital, theatre, bed | No | Yes, where you hold the right cover |
| Garments, dressings | No | No |
The three things that decide it
- A Medicare item number must apply. Funds only pay hospital benefits for procedures with an MBS item. If no item applies, the operation is classed as cosmetic and your fund pays nothing towards the hospital — you would be paying the full hospital cost yourself. This is why the Medicare criteria matter twice over.
- Your policy must include the relevant category. Cover is tiered, and plastic and reconstructive surgery sits in higher tiers on many policies. A basic or bronze policy often excludes it.
- Waiting periods must be served. Twelve months is standard for pre-existing conditions. Upgrading a policy does not make the new benefits available immediately.
What to ask your fund
Ring them with the item number in hand and ask, in these terms:
- “Am I covered for MBS item [number] as an inpatient?”
- “Have I served all waiting periods for that category?”
- “What excess applies to an overnight admission?”
- “Is Westmead Private an agreement hospital for my fund?”
- “Do you participate in a gap scheme for the anaesthetist?”
Ask for the answer in writing or note the reference number. Verbal advice from a call centre is worth less than a written confirmation when the account arrives.
The hospital checks too
You are not doing this alone. Once a plan is agreed, the hospital performs its own eligibility check with your fund and issues its quote on that basis. That is why an itemised quote comes after the consultation rather than before it.
If you have no cover
You can still have the surgery privately and pay the hospital yourself — the hospital will quote you as a self-funded patient. It is a substantial figure, because the hospital component is usually the largest single part. The alternatives are the public system, where skin removal is performed for patients meeting criteria through a public outpatient referral with waiting times often measured in years, or taking out cover and serving the waiting period.
Taking out cover specifically to fund planned surgery is a decision with a twelve-month lead time and ongoing premiums. It is worth doing the arithmetic properly rather than assuming it is the cheaper route.
Common questions
Will my fund pay the gap on the surgeon’s fee? No. Funds contribute to hospital costs, not to gaps on medical fees. Some participate in gap schemes that reduce, but rarely remove, the anaesthetist’s gap.
Does a Medicare item guarantee the fund pays? No — it is necessary but not sufficient. Your tier and waiting periods still apply.
Can I upgrade my policy and have surgery next month? Not with the new benefits. Waiting periods apply.
Is the excess per admission? Usually. If procedures are staged across two admissions, expect to pay it twice — one reason combining is often cheaper. What can be combined.
Next step
Bring a GP referral to a consultation and you will leave knowing which item Dr Kumar believes applies, which is the number your fund needs. He consults at Westmead, Penrith and Orange. Call 1300 267 726. More about what the surgery costs and paying for it.
The initial consultation with Dr Kumar is $400, with a Medicare rebate of approximately $88 where you have a GP referral. Surgical fees are quoted individually after your consultation, in a written itemised quote.
All surgery carries risks, and individual results will vary. Read more about the risks of surgery here. A GP referral is required to see Dr Kumar.
Dr Rohit Kumar (MED0001630444) Registered medical practitioner, specialist plastic surgeon (specialist registration in surgery – plastic surgery).
