How does health insurance cover brain surgery?

Compare brain treatment for public and private health insurance

Patient being scanned

To make health insurance for brain treatment as stress-free and simple as possible, we've put together a brain surgery guide. You can get cover with Medicare and private health insurance; check out which is the right option for you.

What would be considered a brain treatment?

Brain disorders generally include any conditions or disabilities that affect your brain. These can be conditions that are caused as a result of illness, traumatic injury or genetics. Brain treatment can include:

  • Treatment for brain injuries. Brain injuries often result from blunt trauma which can affect your brain tissue, nerves and neurons. This can range from blood clots and concussions to strokes and the swelling of the skull (cerebral edema). Depending on the type of injury you have, brain treatment can include medication, rehab and surgery. Rehabilitation can include speech and language therapy, physical therapy and psychiatry.
  • Treatment for brain tumours. Brain tumours can be cancerous and non-cancerous. The type of treatment you need will depend on factors such as the size of the tumour, your age and health condition. Treatments can include surgery, chemotherapy and radiation therapy.
  • Treatment for neurodegenerative diseases. Neurodegenerative diseases usually cause your brain to deteriorate over time. Because there's no cure for neurodegenerative diseases, surgery is less common though other treatments including medication can help.

When might you need brain treatment?

Common reasons for brain surgery include:

  • Blood clots
  • Cerebral edema
  • Strokes
  • Concussion
  • Primary brain tumours
  • Metastatic (secondary) brain tumors

In some cases, you might need surgery for Alzheimer's disease, Parkinson's disease or Huntington's disease, though other forms of treatment are much more common. If you experience severe headaches, seizures, numbness in your arms or legs, changes in personality or changes in your hearing, speech or vision, you may have a brain injury and require treatment.

How does medicare cover treatment for the brain?

Medicare will usually cover the cost of staying and being treated as a public patient in a public hospital. You generally won't be able to choose your own doctor or choose when you want to undergo brain treatment or surgery. This is because public waiting times are normally longer as they're busier, so you don't have the same flexibility as you would with private health care.

Medicare will also pay a benefit towards seeing a specialist, such as a neurosurgeon. The neurosurgical consultation structure consists of an initial consultation (Medicare Benefits Schedule no. 6007) and four categories of subsequent consultations. These categories relate to both the length of consultation time and the complexity of what is being discussed. You will generally be reimbursed between 75% and 85% of the medical fee. Prices can be broken down into four tiers:

  • Level 1. 6009 - Fee: $44.35 Benefit: 75% = $33.30, 85% = $37.70
  • Level 2. 6011 - Fee: $88.25 Benefit: 75% = $66.20, 85% = $75.05
  • Level 3. 6013 - Fee: $122.20 Benefit: 75% = $91.65, 85% = $103.90
  • Level 4. 6015 - Fee: $155.60 Benefit: 75% = $116.70, 85% = $132.30

Medicare also provides cover for deep brain stimulation, which is sometimes required for Parkinson's disease or for treating tremors or dystonia. Because there are so many different types of brain treatment, you should consult your local Medicare office to find out exactly what you're covered for.

How does private health insurance cover treatment?

You can get private health insurance for brain and nervous treatment with all bronze tier hospital policies. Hospital treatment includes investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system. Chemotherapy, radiotherapy and immunotherapy for cancer generally come under a separate service but are also included in all bronze policies. Waiting periods may apply and vary depending on the surgery though you will get to choose the doctor of your choice and treatment is generally very quick.

Costs generally range from around $85 a month for bronze tier health insurance which covers you for 18 clinical categories. Bronze tier policies are tailored specifically to those who want the basics and cover for more unlikely, but potentially serious problems like brain cancer.

Quotes from Finder Partners for brain treatment

Brand Policy Benefit Excess Price Apply
ahm logo Starter Bronze Brain and nervous system – Stroke, brain or spinal cord tumours, head injuries, epilepsy and Parkinson's disease $500 $86.80 Go to Site
Medibank logo Medibank Bronze Everyday Brain and nervous system – Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system $500 $83.40 Go to Site
HCF health insurance HCF Hospital Bronze Plus Brain and nervous system – Stroke, brain or spinal cord tumours $500 $91.60 Go to Site
nib helath insurance logo Bronze Hospital Plus Brain and nervous system – Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system $500 $89.48 Go to Site
Bronze Hospital Brain and nervous system – Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system $500 $85.89 Go to Site

Prices are based on a single person in Sydney earning less than $90,000.

Things to know about public vs private

If you go to a public hospital for treatment, surgery often involves a team of doctors. It is also likely you will stay in a shared room, unless your condition means you need a private room. Sometimes, your surgery is postponed if a patient is in a more critical condition than you. This is because hospital beds are generally in short supply, so patients that need them the most will get priority. You won't be able to choose the specialist that treats you if you are treated in a public hospital. Medicare will pay some benefits towards out-of-hospital care you might need, such as rehabilitation, though you will probably have some out-of-pocket expenses.

Even if you don't have private health insurance, you can still choose to be treated privately. If you choose to be admitted as a private patient, you will:

  • Choose which specialist doctor you want to treat you
  • Receive follow-up care from a specialist doctor in their private room after you leave the hospital
  • Have access to a private room, where available
  • Likely be eligible to transfer to a private hospital for further treatment or for follow-up care

While you have access to these services without private health insurance, the costs will be considerable. Private health insurance helps ensure your out-of-pocket expenses are kept to a minimum. It can cover you for all of the above and more.

Compare more options

Ready to compare? Simply pop your details in and hit search policies. To make sure brain treatment is covered, you can select brain and nervous system (and chemotherapy, if you also want that included) from the side bar, which will filter your options.

Picture: GettyImages

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