Although obesity is related to many complications such as hypertension, heart failure, pre-diabetes, type 2 diabetes, osteoarthritis, sleep apnoea and many others, the Medicare benefits are a fraction of the total cost of surgery, and procedures/surgeons are not easily available through the public hospital system (sometimes not at all). This is why the majority of weight loss surgery in Australia is done through the private system, typically funded through health fund policies.Â
What health insurance policy covers weight loss surgery?Â
From April 2020, hospital insurance coverage is now classified into four categories; Gold, Silver, Bronze, and Basic. Weight loss surgery is covered within the Gold tier of hospital insurance coverage (though this should be checked with your own provider as it can differ). Some ‘Extras’ policies cover weight management programs such as discounted gym memberships or subscriptions to consulting programs like Jenny Craig.
Typically you will have a waiting period of approximately 12 months before you are eligible to be able to claim for weight loss surgery through your Gold tier private health insurance. In comparison, you may only have a couple of months to wait for your Extras cover to kick in, which could be a positive step in the right direction in terms of weight loss.Â
What are the out-of-pocket costs of weight loss surgery with health insurance?
Even with sufficient health insurance for weight loss surgery to support the gap between Medicare subsidies and the total procedure cost or clinic fee, typically the patient will still have some out-of-pocket expenses, depending on the level of coverage from their provider, the complexity of the procedure and their chosen clinic. Each clinic and insurer are different, so it’s best to ensure you have thoroughly done your research before booking your surgery date.  Â
‘No-Gap’ Bariatric Surgery
As there is a difference between Medicare payments and medical charges there can be expenses in addition to what the health fund pays and what the patient will have to cover. The ‘Gap Costs’ indicate the amount that patients have to pay to undergo treatment. Calculation of the Gap Costs depends on the complexity of the surgery performed and the time it takes. For weight loss surgery we offer ‘No-Gap’ surgery, however, patients are charged a Clinic fee – this contributes toward the expenses of running a bariatric clinic and allows us to provide your follow-up care without charging above the Medicare rebate for up to three years after surgery.Â
Does it matter what private health fund I am with if I need weight loss surgery?Â
In short, the answer is no; we accept all health funds at Upper GI Surgery and the majority of clinics are the same. However, you will need to ensure that you are eligible for the weight loss surgery type recommended to you by your bariatric surgeon or bariatric specialist. The following are the item numbers for the main weight loss surgery procedures:Â
Sleeve Gastrectomy – 31575
Gastric Bypass – 31572
Gastric Band – 31569
If you would like to know more about weight loss surgery eligibility, procedure options, costs or follow-up you can download our free Bariatric Surgery Guide or contact our clinic on (02) 9553 1120 to make an appointment.Â
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