If you are struggling to lose weight through dieting and exercise alone, you may be looking at interventions like weight loss surgery to help. This can be an effective treatment option but many people may feel held back by the potential costs and out-of-pocket expenses of surgery.
There is good news, however! Medicare and insurance companies will cover bariatric surgery in certain circumstances and as long as you meet certain medical criteria.
Keep on reading to find out more!
What types of weight loss surgery will Medicare cover?
Medicare only covers those procedures that are deemed necessary for medical reasons and have an item number associated with them. These item numbers are what form the Medicare Benefits Scheme (MBS), a large directory of all the procedures Medicare covers.
Here are the current bariatric surgical procedures for weight loss that Medicare covers:
- Laparoscopic gastric bypass surgery
- Laparoscopic gastric banding
- Gastric sleeve surgery (also known as sleeve gastrectomy)
How much is the Medicare rebate on these procedures?
The Medicare rebate for weight loss surgery is up to 75% of the scheduled fee. This means that you will need to pay the remaining 25% plus any gap fees.
For example, the fee for gastric bypass surgery is $1,105.20 according to the latest MBS data.
Medicare pays 75% benefit = $828.90
You pay the remaining 25% gap = $276.30
This is the fee for the surgery and doesn’t include the cost of:
- Consultation fees
- The anaesthetist
- Bed/hospital fees
- Any equipment or devices.
- Prescribed medications
These extras and the 25% gap fee can be covered by private health funds. You can read more about PHI and surgery for weight loss below.
The criteria for Medicare to cover weight loss surgery.
In order to be eligible for Medicare coverage of bariatric surgery, it must be classed as a “medical” procedure, not cosmetic. In order for Medicare to regard weight loss surgery as necessary you must meet the following criteria:
- A BMI (body mass index) of 35 or more.
- A co-morbidity and major health risks directly related to obesity
- Sleep apnea
- High blood pressure
- Heart disease
- Documentation that you have been severely overweight/obese for 5 years or longer.
- Evidence that you have tried other weight loss methods and programs, under the supervision of a medical professional, and have been unsuccessful.
- There is no other cause for your obesity such as adrenal, thyroid or pituitary issues.
- You must be assessed by a team of healthcare professionals, including a surgeon before surgery is approved.
What Criteria do you need to qualify to get a refund?
In order to qualify for a Medicare rebate, you will need to meet the following criteria:
- You must have a valid Medicare card.
- You must have had your surgery performed by a surgeon who is registered with Medicare.
- You must have had your surgery performed in an accredited hospital.
You can learn more about Medicare rebates and how to get a Medicare card here.
How to get weight loss surgery covered by insurance?
If you have private health insurance, you may be able to get coverage for your weight loss surgery, as long as it has an item number associated with it (like the surgeries we listed above on the MBS).
Private health funds also reimburse the cost of hospital stays and other associated fees, however, the amount they pay will depend on the level of cover you have. If you are unsure about whether or not your private insurance supplier covers weight loss surgery, you should contact them and find out. It is also important to take note of any waiting periods if you have recently invested or upgraded your private health insurance.
Can I get weight loss surgery for free in Australia?
No, you cannot get weight loss surgery for free in Australia. However, Medicare and private health funds will cover a portion of the cost of the surgery and other associated hospital fees if you meet the criteria.
How much would a private health insurance policy cost?
The cost of a private health insurance policy depends on a number of factors, such as your age and the level of coverage you need. You can get a quote from a private health insurer to find out how much a policy would cost.
Can you use your Super to pay for weight loss surgery?
Yes, you can use your Super to pay for bariatric surgery. You will need to provide documentation to the ATO from your medical doctor and bariatric specialist that this procedure is necessary. The ATO require this letter as well as a form to be filled in. Approval can take 2-4 weeks, and then a further 4-6 weeks for your super fund to release the money into your personal bank account.
Does insurance help with weight loss?
Yes, insurance can help with covering the cost of surgery for weight loss and other fees such as anaesthetist, surgical consultation, surgeon, hospital stay and equipment. You will need to check with your insurance about the level of private health coverage and if there are any waiting periods.