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Will Medicare and your health fund help with the cost of a breast reduction?

Posted on Monday, 27 July 2020

breast reduction
By Dr Nick Moncrieff

Many women suffering under the weight of heavy, large breasts ask me if they can claim some of the cost from Medicare and their health fund. The answer for the vast majority is yes!

The Medicare rebate for breast reductions

To qualify for a Medicare rebate, you must meet strict conditions set by the government. A ‘reduction mammaplasty (bilateral) with surgical repositioning of the nipple’ is:

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

(b) not with insertion of any prosthesis

This means you must have very large breasts which are causing neck or shoulder pain, but you must not have the reduction in conjunction with the insertion of implants at the same time.

For a link to the Medicare schedule for more information, you can click here.

What does the Medicare rebate give me?

The rebate itself is just over $1000 but its broader value is that you must qualify for it for your private health insurance to help with the costs of the operation, including the hospital fees. It is very important that you check with your fund before booking surgery that your level of cover includes the Medicare Item number of 45523 as many funds only help if you are on top cover.

How much will I save if I have the Medicare rebate and the right private health insurance?

A combination of meeting the criteria for the Medicare rebate and having private health fund coverage can reduce the total costs of your procedure by $5000 or more, so it is important to understand the rules.

Will I need a GP referral?

Yes. It is important to talk to your GP about your symptoms from heavy breasts if you are hoping to claim a rebate from Medicare and your health fund as a referral is needed to a specialist plastic surgeon to be able to claim entitlement. It also helps us understand your overall health and any other medical conditions we need to be aware of before planning surgery. 

Can breast reductions be done in the public system?

This is rare across Australia but does happen in some areas. For New South Wales, check with the NSW Government Surgery Access Line on 1800 053 456 to see if there is a specialist plastic surgeon who offers public breast reductions near you.

What should you ask when you are considering your options?

These are some questions you might like to ask when looking at different options: 

  1. Is this surgeon a genuine qualified Plastic Surgeon? Understanding this question is crucial. This means they have completed at least 14 years of training and examinations, or even more. For instance, I have invested 17 years in my training and fellowship. This contrasts with the term ‘cosmetic surgeon’ which anyone with a basic medical degree can use.
  2. Will you be operated on in a fully accredited hospital? 
  3. Will a Specialist Anaesthetist administer you a full general anaesthetic? 
  4. How many of this type of procedure has the surgeon performed? 
  5. Can you view a lot of Before and After clinical photos? 
  6. How well are the risks and recovery process explained? 

For more information 

Discover more about breast reductions including information on costs, hospital arrangements, recovery and also a 3D animation of the procedure by visiting the Hunter Plastic Surgery website or follow my clinic on social media: @HunterPlasticSurgery.


Dr Nick Moncrieff is a Fellow of the Royal Australasian College of Surgeons (FRACS) and a member of ASAPS, representing the highest standards of cosmetic excellence by registered specialist plastic surgeons. You can view his profile here.  

 

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