How Does Medicare & Private Health Insurance Work for Body Contouring Surgery?
Mon 19th Oct 2026
If you’re considering Body Contouring surgery and have, or are thinking of taking out, Private Health Insurance, there are several factors you should understand. Your eligibility for Medicare rebates depends on meeting specific criteria. And although Private Health Insurance can help with some costs, it won’t cover everything. You’ll still have out-of-pocket expenses to pay. This article explains what you need to know.
In Simple Terms (A Summary)
- Medical necessity: Your Body Contouring surgery must meet specific medical criteria to attract an MBS item number. Surgery performed purely for cosmetic reasons is not eligible for a Medicare rebate.
- Medicare: If an applicable MBS item number applies, Medicare may provide a rebate towards eligible medical fees.
- Private Health Insurance: Your health insurance may then contribute towards eligible medical and hospital costs, depending on your policy.
- Your out-of-pocket costs: You will usually still have some costs to pay. This includes any applicable excess, co-payment or gaps between the fees charged and the benefits provided.
- Your policy: An MBS item number does not guarantee your health fund will cover your procedure. Always check your policy and expected costs with your insurer before surgery.
Medicare Comes First
Before we even think about Private Health Insurance, the first step in your surgical journey is to determine whether your Body Contouring procedure qualifies for a Medicare item number.
If your procedure is purely cosmetic, Medicare will not assign you an item number.
To attract an MBS item number, you must meet specific medical criteria.
For example, if you were having a Thigh Lift (Thigh Lipectomy), you would have documentation showing factors such as:
- a documented weight loss of at least 5 BMI units
- a stable weight for 6 + months
- evidence of medical complications causing specific functional problems
- previous nonsurgical treatments, such as barrier creams, supportive breathable garments
- an assessment by a Plastic Surgeon to determine whether your circumstances and documentation meet Medicare’s requirements.
You can read more about Thigh Lift (Lipectomy) surgery and Medicare eligibility here.
If you meet the criteria and an applicable MBS item number is identified, you may be eligible for a Medicare rebate. However, this does not mean Medicare will cover all your expenses.
Let’s look at Medicare’s contribution in more detail.
The Medicare Contribution Explained
Medicare can contribute towards eligible medical fees associated with surgery, including your surgeon’s fee and fees charged by other medical practitioners involved in your care (e.g., your anaesthetist’s fee).
If you are a private patient admitted to hospital, Medicare generally pay 75% of the relevant MBS fee. Your Private Health Insurer may then contribute towards the remaining 25%, provided your policy covers the procedure.
However, keep in mind that the MBS fee is not necessarily the same as the fee your surgeon or your anaesthetist charges. If their fees are higher, you will have an additional out-of-pocket cost.
In summary, Medicare provides a rebate toward eligible medical practitioners’ fees, but it will not cover the full cost.
Medicare will not cover your private hospital costs, such as your accommodation and theatre fees. These may be covered by your Private Health Insurance fund, depending on your policy.
Private Health Insurance
Having an MBS item number doesn’t necessarily mean that you will automatically receive a rebate from your Private health insurance fund.
An MBS item number is generally required for Private Health Insurance benefits to apply, but your particular policy must also cover the relevant treatment.
Once you have determined that an applicable MBS item number has been identified, you can contact your health insurance fund and check whether your particular policy covers a treatment. Private Health Insurance policies can have exclusions, restrictions, waiting periods and excesses.
This can all sound rather complicated. To keep things simple, call your health insurance fund and talk to them. Give them your policy details, along with your MBS item number and ask them to explain what your policy covers.
Your insurer will be able to check all the pertinent details and tell you what you’ll be entitled to. This involves checking the following issues:
- Does your policy cover the relevant MBS item number?
- Is there an exclusion or restriction on your policy?
- Do you have the required level of hospital cover?
- Have you served the applicable waiting period?
- What hospital costs will you be covered for?
- What excess or copayment will apply?
- What benefits are payable towards the medical fees?
- Will there be any gap payments?
At the end of your conversation, they should be able to give you a clear understanding of what costs they will pay, and what you may need to pay yourself.
Private Health Insurance Cover Explained
Your Private Health Insurance will typically cover some hospital and theatre fees associated with your surgery.
HOSPITAL FEES: If your procedure is included under your hospital policy and you’re treated in a hospital that has an agreement with your insurer, your Private Health Insurance will generally cover the hospital accommodation costs according to the insurer’s agreement with the hospital.
However, you may still have to pay an excess or copayment, depending on your policy.
THEATRE FEES: The same applies to your theatre fees. There is no universal Medicare or Private health insurance percentage. The benefits you can expect will depend on:
- your level of hospital cover
- whether your procedure is included in your policy
- whether the hospital has an agreement with your insurer
- the hospital’s charges
- any applicable excess or copayment
Whether the hospital is contracted with your insurer also makes a difference. At a contracted hospital, the insurer’s agreement can mean the patient has no hospital gap or a known, limited gap. At a non-contracted hospital, the patient may face substantially higher out-of-pocket costs.
Your Initial Consultation
The first step in determining whether you may be eligible for Medicare and private health insurance benefits is to book an appointment with Dr Eddy Dona in his Sydney-based rooms.
During your consultation, you can discuss your physical concerns and objectives, and Dr Dona can thoroughly assess you and determine whether your proposed surgery meets the relevant Medicare criteria.
If applicable MBS item numbers are identified, we’ll include them in your surgical quote. You can then contact your Private Health Insurer, as outlined above, to confirm whether your policy provides benefits for the procedure and what costs it may cover.
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