Will Medicare Pay for My Post-Bariatric Surgery?

With the epidemic of obesity in Australia, many people are turning to weight loss surgery when dieting and exercise achieve no results. Weight loss surgery in Australia requires that your BMI needs to be at least 30 and includes 4 specific procedures: gastric sleeve, gastric bypass, lap band, and gastric balloon. These procedures are offered by surgeons in New South Wales, Victoria, Queensland, South Australia and Western Australia.

But does Medicare cover or pay for bariatric surgery?

Qualifying for Bariatric Surgery

If you are looking to undertake lap band, gastric sleeve or gastric bypass surgery, Medicare requires that your BMI (body mass index) be at 30+. Further, for gastric balloon, you need to be at 27+ BMI. If you have a BMI between 30 to 39.9, Medicare requires you to demonstrate other, certain health problems to qualify for coverage. A BMI of 40 or higher however will qualify you for aid with or without other related health issues.

Health Problems at a BMI of 30 or Higher:

  • Poorly controlled type 2 diabetes
  • High risk of cardiovascular disease

Health Problems at a BMI of 35-39.9

Must also have one or more obesity related health problems including:

  • Arthritis
  • Asthma
  • Carpal tunnel
  • Depression
  • Dermatitis
  • Dyslipidaemia Hypercholesterolemia
  • Effectiveness of oral contraception
  • Gall bladder disease
  • GERD
  • Gout
  • Hypertension
  • Infertility
  • Liver disease
  • Migraines
  • Osteoarthritis
  • PCOS
  • Sleep apnea
  • Sleep deprivation
  • Stress Incontinence
  • Cardiovascular disease
  • Death
  • Diabetes
  • Metabolic syndrome
  • Non-alcoholic fatty liver disease
  • Pseudotumor cerebri
  • Venous stasis disease

Health Problems at a BMI of 40 or Higher

  • No health problems required to qualify

However, if your BMI qualifies you for cover, your next step is to decide which procedures are a fit for you. As a result, a specialist bariatric surgeon can help you decide what is best for your body and health.

Patients Who Qualify for Bariatric Surgery Are:

  • At least 36 kg overweight
  • Between 18-75 years old
  • Able to demonstrate a history of failed weight loss attempts
  • Thoroughly understand that weight loss procedures are a tool and that long term success also require significant diet and lifestyle changes
  • At a BMI of 30 or more

4 Most Common Weight Loss Procedures

The four most common types of bariatric surgery in Australia are:

  1. Roux-en-Y or gastric bypass
  2. Gastric sleeve, also called vertical sleeve gastrectomy or sleeve gastrectomy
  3. Lap band or adjustable gastric band
  4. Gastric Balloon

The gastric balloon procedure is also gaining popularity as an “in between” option that is more aggressive than diet and exercise but less aggressive than other bariatric procedures.

Cost of Weight Loss Surgery

The final amount of your procedure will also depend on a number of factors. These include:

  • Initial consultation fees
  • Type of procedure
  • Surgeon fees
  • Surgical assistant fees
  • Hospital fees
  • Anaesthetist fees
  • Medications post-surgery

For a more detailed quote, book an appointment today with a qualified bariatric surgeon. Be sure to always ask if there are any added charges or additional procedures required during or after your surgery.dr richard maxwell plastic surgery melbourne

Medicare for Bariatric Surgery

In Australia, Medicare will provide some reimbursement for weight loss procedures. However, after the November 1, 2018 update, some of the Medicare Benefit Scheme changes may impact your ability to receive a rebate for surgery. Weight loss surgery is also not fully covered under Medicare and will incur some out of pocket expenses. However, most weight loss surgery is performed under Private Health Insurance and is accessible to most Australians.

If your MBS item code is changed due to the November 2018 update, you may get less or no rebate. To find out if you are covered, discuss this with your specialist.

Private Insurance for Bariatric Surgery

Some private insurance services will also provide coverage for bariatric surgery. However, you will still have out of pocket fees over what your insurance company will cover. Further, since obesity is considered a pre-existing condition, you will likely have to wait 12 months between joining a health fund and getting approved for surgery. May surgeons will also not perform any bariatric surgery (other than lap band) if you do not have private insurance.

Consult with a bariatric surgical specialist for further help understanding the total costs and how insurance will apply.

Want further information about Medicare and Bariatric surgery? Contact our team today to book your first consultation!

Last updated: July 19, 2019
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Dr Richard Maxwell
Mr. Richard Maxwell graduated in medicine from Monash University in Melbourne in 1981. He trained in Plastic and Reconstructive Surgery at the Alfred Hospital, the Royal Melbourne Hospital and the Victorian Plastic Surgery Unit in Melbourne. He completed his training in 1989, gaining the Fellowship of the Royal Australasian College of Surgeons in Plastic and Reconstructive Surgery.

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