Breast reduction surgery health insurance
Breast reduction surgery is partially covered by Medicare and may be covered by private health insurance.
Key takeaways
- Medically necessary breast reduction can be covered by Medicare and private hospital cover.
- Depending on the situation, public surgery wait times could be over a year or more.
- Even with private health cover, out of pocket costs could be seveal thousand dollars.
How much does breast reduction surgery cost?
The cost of a breast reduction varies depending on the type and reason for the surgery. In the private system, without insurance, a unilateral breast reduction $10,000. This surgery is normally done on a healthy breast after a cancer is removed from the other breast, to even them up. A bilateral breast reduction can cost closer to $15,000 - these surgeries are done for a range of other medical reasons.
If you have private hospital insurance that covers breast surgery, you'll be able to get some of that private surgery covered. According to Medical Costs Finder, the typical out of pocket payment is around $1,000 for unilateral procedures, but around $8,400 for bilateral procedures.
Does Medicare cover breast reduction surgery?
Medicare will cover medical breast reduction surgery in a public hospital, so you won't have anything to pay out of your own pocket. Unfortunately, breast reduction is often categorised in one of the lower priority surgery categories, so you could be waiting over a year for surgery. The medical reasons for your surgery could affect your prioritisation category.
How does private health insurance cover breast reduction?
Breast surgery is covered under Bronze tier hospital policies. If you are covered and need surgery it will cover some, but not all, or your treatment costs. Exactly how much you'll have to pay for your breast reduction will depend on the reason for the surgery, whether or not it is unilateral or bilateral, as well as your private health fund's gap payment arrangements.
To reduce your our of pocket costs, you should call your health fund before the surgery is booked in. This will let them explain how the gap payment works, and if there are any ways you can reduce the gap, such as getting the work done at one of their agreement hospitals.
In order to receive cover for the procedure, Medicare will need to deem it medically necessary. Breast reduction surgery conducted for purely cosmetic purposes isn't covered by your health fund.
It’s also worth noting that any health problem that needs to be alleviated by breast reduction surgery will likely be classed as a pre-existing condition by your health fund, so you will need to serve a 12-month waiting period before you will be eligible to receive any benefits.
Signs that a breast reduction might be right for you
Medical reasons for breast reduction surgery include:
- Back pain and backaches
- Neck pain
- Shoulder pain
- Migraine headaches
- Shortness of breath
- Numbness in the hands and fingers
- Skin irritations
If you suffer from any of the above symptoms, breast reduction surgery could be beneficial for you.
However, the procedure does come with a number of risks attached and it’s important that you’re aware of them before going under the knife.
What’s involved in breast reduction surgery?
Breast reduction surgery, which is also commonly referred to as reduction mammaplasty, involves cutting and removing excess fat and glandular tissue from the breast, repositioning the nipple and areola higher on the breast and removing the excess skin. This makes the breasts smaller and lighter. The aim of the surgery is to produce breasts of a size and shape that are in proportion to the rest of the patient’s body.
However, it’s worth pointing out that it is recommended that you wait until your breasts are fully developed and childbirth and breastfeeding have been completed before undergoing the procedure. Your ability to breastfeed following breast reduction surgery may be harmed and changes to your breasts while pregnant can also alter the results of previously completed surgery.
Finder survey: Which conditions have Australians made a hospital claim for?
| Response | Female |
|---|---|
| Breast surgery | 1.72% |
Source: Finder survey by Pure Profile of 1006 Australians, December 2023
Making a claim
If you’re planning on undergoing breast reduction surgery and need to know whether you’ll be covered, you’ll first need to find out whether the procedure will be deemed medically necessary by Medicare and therefore eligible for a benefit.
You will also need to provide details of the procedure to your health fund to determine whether or not you are eligible for cover. This usually involves filling out a medical estimate form with information on your surgeon, anaesthetist, procedure (including MBS item numbers) and the hospital where you will be treated. Your fund will then be able to tell you whether or not you will be covered and to what level.
Frequently asked questions about breast reductions
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