5 Best Health Insurance Plans for Cosmetic Surgery in Australia
Not all surgery is about aesthetics. If you’re recovering from an accident, illness, or congenital issue, reconstructive procedures can be essential, not elective.
In this guide, you will learn:
- ✅ What’s the Difference Between Cosmetic and Reconstructive Surgery?
- ✅ Reconstructive Surgery and the Medicare Benefits Schedule
- ✅ Why Cosmetic Surgery Is (Almost) Never Covered
and much, much more!
What’s the Difference Between Cosmetic and Reconstructive Surgery?
Cosmetic surgery changes appearance and is elective, like facelifts or liposuction. Since it doesn’t treat a medical issue, it’s usually not covered by Medicare or private health insurance.
Reconstructive surgery, on the other hand, repairs damage from illness, injury, or birth conditions, like breast reconstruction after cancer or fixing a cleft palate. These are often covered under the Medicare Benefits Schedule (MBS) with the right hospital policy.
Some procedures can be both. For example, a nose job to improve breathing might be covered, but one done purely for looks won’t be. Coverage depends on the medical purpose behind the surgery.
Reconstructive Surgery and the Medicare Benefits Schedule
In Australia, Medicare doesn’t cover cosmetic surgery. But it might help with reconstructive surgery if the procedure is medically necessary and listed on the Medicare Benefits Schedule (MBS).
This is the government’s list of procedures that qualify for rebates. It doesn’t matter how common the surgery is or how skilled your surgeon is. You’ll pay the full cost if the procedure isn’t listed. To qualify for Medicare support, your surgery must:
- Fix something caused by trauma, disease, or congenital disability.
- Restore function, reduce pain, or prevent further problems.
- Be recommended by your specialist or treating doctor.
- Have an MBS item number (this is non-negotiable).
- Be done in a hospital if it’s on the “inpatient only” list.
- Have proper documentation – your claim can be rejected without it.
- Not having anything done only to improve appearance.
You don’t need to guess which surgeries qualify because the MBS item numbers are public, and your doctor usually confirms it during pre-approval.
Updated MBS Rules (Late 2024 / Early 2025)
In March 2024, Medicare removed rebates for several plastic and reconstructive surgeries performed outside hospitals. If your surgery is done in a clinic instead of a hospital, it might no longer be eligible, even if reconstructive.
This was done to improve clinical safety, but it catches some patients off guard. Some new procedures were added too, including:
- Tattooing of nipple/areola post-breast reconstruction.
- Complex wound reconstruction after trauma.
Revisions to earlier reconstructive surgeries that failed or caused complications
Common Reconstructive Surgeries That Are MBS-Approved
| 🔎 Procedure | MBS Item Number | When It’s Covered |
| 1️⃣ Breast reconstruction after cancer | 45585 / 45589 | After mastectomy or lumpectomy, includes flap or implant-based reconstruction |
| 2️⃣ Abdominoplasty (tummy tuck) after weight loss | 30177 | When skin folds cause infections or hygiene issues, not cosmetic issues |
| 3️⃣ Skin grafts for burns or trauma | 45000+ | If required for wound healing or coverage of exposed tissue |
| 4️⃣ Cleft lip or palate repair | 45715 / 45716 | For children and adults - includes staged surgical correction |
| 5️⃣ Facial fracture repair | 45735 / 45736 | Following accidents, sports injuries, or other trauma |
| 6️⃣ Eyelid reconstruction (all layers) | 45614 | For functions like eyelid closure or protection of the eye |
| 7️⃣ Nose surgery (septoplasty) | 41671 / 41672 | Covered only if it improves breathing, not for aesthetic reasons |
| 8️⃣ Scar revision surgery | 45520+ | Covered when scarring limits mobility, causes pain, or results from prior surgery |
| 9️⃣ Breast reduction | 45523 | If breast size causes chronic pain or spinal issues |
| 🔟 Correction of congenital deformities | Multiple | Including ear reshaping for congenital malformation (not cosmetic reshaping) |
What You Still Need to Cover
Medicare only pays part of the fee, even if your surgery is on the MBS. Here’s what you must still pay:
- Any amount your surgeon charges above the MBS rebate.
- Anaesthetist and assistant fees (if they’re not part of the gap scheme).
- Hospital excess (depends on your private policy).
- Travel, if you live regionally or your procedure requires relocation.
- Revision surgery if something goes wrong and it’s not deemed urgent.
- Non-covered items like compression garments, implants not listed, or private room upgrades.
Why Cosmetic Surgery Is (Almost) Never Covered
There’s a reason Medicare and most health insurers don’t cover cosmetic surgery. It’s not just about the cost but also how the system defines “healthcare.” If a procedure is done for appearance only, it’s elective. In Australia, elective = excluded.
But the line between cosmetic and reconstructive surgery isn’t always obvious, and that’s where it can be challenging.
The Key Reasons It’s Not Covered
Most cosmetic procedures:
- Don’t treat a diagnosed medical condition.
- They aren’t required to improve function, mobility, or comfort.
- They aren’t considered necessary for mental health under the current MBS guidelines.
- Can’t show clinical evidence of harm or impairment without the surgery.
- Don’t meet the “medically necessary” definition under private hospital cover.
- They are performed by specialists who often charge outside MBS limits.
Moreover, if it has no MBS item number, which means Medicare pays nothing.
What Cosmetic Procedures Are Always Excluded?
| 🔎 Procedure | Covered? | Why Not |
| 1️⃣ Breast augmentation (implants) | None | Cosmetic unless post-traumatic or post-cancer |
| 2️⃣ Liposuction | None | Not covered unless for lymphedema (rare) |
| 3️⃣ Facelift/neck lift | None | Purely aesthetic |
| 4️⃣ Tummy tuck (no skin issues) | None | Covered only after massive weight loss with medical impact |
| 5️⃣ Rhinoplasty (for shape only) | None | Only covered if the breathing function is affected |
| 6️⃣ Eye bag removal (blepharoplasty) | None | Covered only if vision is impaired |
| 7️⃣ Botox/fillers | None | Not medically necessary |
The “Gray Zone” Cases That Confuse Everyone
Some procedures look cosmetic, but might be covered if you meet strict criteria:
- Breast reduction: Covered if you have chronic pain, rashes, or spinal issues.
- Abdominoplasty: Covered only after massive weight loss + documented skin infections.
- Nose surgery: Covered if it treats breathing obstruction (septoplasty), not just reshaping.
- Scar revision: Covered if scarring affects function or causes persistent pain.
It all comes down to documentation. You need proper referrals, photos, and specialist notes. Even then, your insurer might still request a second opinion.
Why You Should Always Check Your Fund First
Health funds vary; some spell out exclusions clearly, others hide them in policy documents. Even when a procedure sounds reconstructive, the fund could flag it as cosmetic based on the referral wording or provider code. Before committing:
- Ask if the procedure has an MBS item number.
- Confirm if your surgeon participates in Access Gap.
- Get the full out-of-pocket estimate.
- Make sure the surgery is being done in an approved setting.
Finally, ask your insurer in writing, not over the phone.
5 Best Health Insurance Plans for Cosmetic Surgery in Australia
HIF Gold Top Plan
HIF doesn’t mess around with their hospital cover. Their Gold Top plan is one of the few that spells out what’s included (and more importantly, what’s not). If you need reconstructive surgery, this policy gives you a straight path to coverage without dancing around the fine print.
The plan includes every hospital category eligible for Medicare rebates, meaning you’re covered if your procedure has an MBS item number. It’s not marketed as anything fancy; it covers most Australian needs.
The Details That Matter
Here’s what the Gold Top policy gives you when reconstructive surgery is required:
- It covers every clinical category on the MBS list, including plastic and reconstructive surgery.
- You can choose a specialist, so you’re not stuck with whoever’s on a provider list.
- AccessGap Cover helps cut the fee difference between what Medicare pays and what your surgeon charges.
- There’s no excess charge for your kids if you’re on a family plan.
- All surgeries must be done in a hospital, but there is no cover for in-clinic or day procedure centres.
- Ambulance cover is included, but you must pay $50 per trip.
This isn’t just a “Gold by name” plan; it covers what matters when you recover from illness, trauma, or surgery.
What the Plan Covers (Reconstructive-Relevant Categories)
| 🔎 Benefit Area | Included | Notes |
| 1️⃣ Plastic and reconstructive surgery | Yes | Must be medically necessary and MBS-listed |
| 2️⃣ Cancer-related surgery | Yes | Breast reconstruction and related procedures |
| 3️⃣ Skin repair after trauma/burns | Yes | Requires a hospital setting and proper documentation |
| 4️⃣ Surgically implanted devices | Yes | Includes prostheses linked to approved surgeries |
| 5️⃣ Dental surgery | Yes | Hospital-only, must hold Extras for full benefit |
| 6️⃣ Weight loss follow-up surgery | Yes | Abdominoplasty is only indicated if the clinical need is documented |
| 7️⃣ Cleft palate or congenital repairs | Yes | Must meet medical necessity and age criteria |
Know Before You Sign
Gold Top doesn’t hide its limits like any plan, but you must still know what to expect. The most common hiccup is out-of-pocket costs when your surgeon charges above the MBS fee and isn’t in the AccessGap network.
That can surprise you, especially with procedures involving multiple specialists or anaesthetists. Also note:
- You must wait 12 months if the condition is pre-existing.
- Your excess options range from $500/$1000 to $750/$1500, depending on your premium.
Some niche surgeries (e.g., podiatric reconstructions) could trigger high out-of-pocket fees because they’re partly excluded or under-rebated.
Our Insights
If you want full MBS coverage, access to top surgeons, and don’t want to navigate three tiers of half-baked policies, HIF’s Gold Top plan is the best you can get because it’s practical; if you’re going through something that needs reconstructive support, practical always wins.
St. Lukes Health Hospital Plans
St. Lukes Health focuses on practical, full-spectrum coverage for hospital treatment. Their Gold Hospital plan offers real support where it matters most: in medically necessary procedures backed by Medicare.
If your surgery is on the MBS and has clinical backing, this policy supports it without added complications or unclear exclusions.
It’s not just surface-level cover, either. The plan includes support for hospital-based procedures across all 38 required categories, which means it doesn’t cherry-pick in terms of surgery.
It also offers the best support for regional or public hospital use than many other funds, which matters more than most people realise when they face recovery time.
Where It Counts Most
Covers plastic and reconstructive surgery if the procedure is MBS-listed and clinically justified.
- Breast reconstruction post-cancer is included without needing to fight through exception clauses.
- Access to private and day hospitals across Australia is built into the plan.
- Excess-free hospital stays apply to dependents under your policy.
- You can access full theatre and accommodation benefits in contracted hospitals.
- Ambulance services are covered, although local state rules may affect how it’s billed.
There’s no fluff, only straight access to surgical categories that matter when your situation is medical, and not cosmetic.
Reconstructive Procedures Covered by St. Lukes Gold Plan
| 🔎 Procedure | Covered | Notes |
| 1️⃣ Breast reconstruction after mastectomy | Yes | Standard inclusion under cancer-related surgical care |
| 2️⃣ Skin grafts and trauma repairs | Yes | Must be inpatient and meet Medicare medical necessity |
| 3️⃣ Scar revisions (functional impact) | Yes | Requires specialist referral and supporting documentation |
| 4️⃣ Abdominoplasty after major weight loss | Yes | Covered if skin fold causes hygiene or health complications |
| 5️⃣ Cleft lip or palate repair | Yes | Covered for eligible children and adults |
| 6️⃣ Prostheses and surgical implants | Yes | Must be approved and linked to hospital-based procedures |
| 7️⃣ Joint reconstructions and tendon repair | Yes | Included under orthopaedic surgical categories |
| 8️⃣ Dental surgery (hospital only) | Yes | Requires Extras cover to avoid full out-of-pocket billing |
Key Conditions and Limits
Every policy has its boundaries. With St.Lukes Gold, most are straightforward, but you should keep these in mind:
- A standard 12-month wait applies for pre-existing conditions.
- Excess options start at $500 and scale up to $1000, depending on your selection.
- Podiatric surgery is limited. Hospital fees may be covered, but the surgeon’s charges usually aren’t unless they’re an Access Gap participant.
- Like most funds, St.Lukes won’t cover cosmetic versions of any listed procedure. If your surgeon bills it as aesthetic, you won’t get reimbursed.
Our Key Takeaways
There’s no complicated tier structure to figure out. If your situation involves trauma recovery, cancer reconstruction, or congenital repair, and the procedure is listed on the MBS, St. Lukes will likely support you.
That makes this plan worth a deeper look if you want clear access without second-guessing what’s excluded.
Phoenix Health
Phoenix Health’s Gold Complete Hospital plan is the highest level of cover the fund offers, and it delivers on medically necessary reconstructive surgery.
It includes all clinical categories required by law for Gold-tier policies. It is more useful because it supports hospital-based procedures without forcing members to navigate a maze of hidden exclusions.
This plan is useful if you need complex surgical care in a private setting and want predictable access to approved hospitals and theatre services.
What You Can Expect From the Policy
It covers all medically necessary reconstructive surgery listed on the MBS.
- Includes breast surgery linked to cancer or trauma, including follow-up stages like implant replacement.
- AccessGap is available if your specialist participates – this can drastically reduce your out-of-pocket cost.
- Offers unlimited ambulance cover, with a $50 co-payment per callout.
- Full hospital accommodation and theatre fees are included if you use contracted providers.
- Child dependents on family plans aren’t charged hospital excess.
This is one of the few funds where the hospital benefits extend well beyond the basics, without layering it in “extras” language.
Reconstructive Procedures Covered by Phoenix Health
| 🔎 Procedure | Covered | Notes |
| 1️⃣ Plastic and reconstructive surgery | Yes | Requires clinical need and a valid MBS item number |
| 2️⃣ Breast reconstruction after cancer | Yes | Covered as part of post-treatment surgical care |
| 3️⃣ Skin grafts and wound repair | Yes | Includes burns, trauma, or post-operative correction |
| 4️⃣ Scar revision for function | Yes | Must impact mobility, comfort, or healing |
| 5️⃣ Cleft lip and palate repair | Yes | Must meet medical necessity and age criteria |
| 6️⃣ Dental surgery (hospital only) | Yes | Requires Extras for full coverage of related specialist fees |
| 7️⃣ Weight loss-related skin surgery | Yes | Must show impact on hygiene or physical health |
| 8️⃣ Joint or tendon reconstruction | Yes | Covered under general orthopaedic care |
| 9️⃣ Surgically implanted prostheses | Yes | Linked to approved in-hospital procedures |
| 🔟 Cosmetic-only versions of any of these | None | If the goal is aesthetic only, no benefit is paid |
A Few Things to Watch
Phoenix Health’s coverage is decent, but as with any policy, there are limits you need to consider before booking surgery:
- You must serve a 12-month waiting period for anything pre-existing.
- You can choose excess levels ($500, $750, or $1000) depending on your premium.
- Podiatric surgery is limited. Hospital fees may be covered, but many surgeons bill outside the scheme.
Even if your surgery is listed on the MBS, the doctor’s fees could exceed the rebate if they don’t participate in AccessGap.
Our Insights
Phoenix Health doesn’t oversell this policy, but what it offers holds up. If your surgery is clinically necessary and done in the hospital, and you have the right documentation, the Gold Complete plan covers much more than just the basics.
Overall, it’s a reliable option if you want real surgical support without combing through layers of vague wording.
Onemedifund All-in-One Policy
OneMediFund doesn’t split coverage into a dozen hospital tiers. There’s one plan, and it’s Gold. That makes this insurer unusual in a landscape full of upgrade charts and confusing feature limits.
If your surgery is medically necessary, hospital-based, and has an MBS item number, this plan will include it.
The simplicity works in its favour. To understand exclusions, you don’t need to guess which tier includes what or dig through footnotes. If it’s on the Medicare Benefits Schedule and you meet the clinical criteria, there’s a high chance you’re covered.
What’s Included That Matters
Plastic and reconstructive procedures are included if they meet Medicare’s rules.
- Breast surgery after cancer is supported without extra hurdles.
- Full hospital accommodation and theatre fees are part of the standard benefit.
- There’s no ambulance waiting period, and the cover includes emergency and non-emergency transport.
- AccessGap is available, and it works if your specialist participates.
- Extras aren’t bundled in, and dental or optical care must be added separately.
OneMediFund is ideal if you don’t want to micromanage plan upgrades to access what should be standard care.
What’s Covered Under Reconstructive Support
| 🔎 Procedure | Covered | Notes |
| 1️⃣ Plastic and reconstructive surgery | Yes | Must be listed on the MBS and performed in a hospital |
| 2️⃣ Breast reconstruction after cancer | Yes | Standard inclusion |
| 3️⃣ Skin grafts or wound healing surgery | Yes | Trauma, burns, or post-operative correction |
| 4️⃣ Scar revision (non-cosmetic) | Yes | Must impair mobility or cause pain |
| 5️⃣ Dental surgery (in hospital) | Yes | Requires Extras for specialist fees |
| 6️⃣ Joint and tendon repairs | Yes | Included under orthopaedic cover |
| 7️⃣ Surgically implanted prostheses | Yes | Must relate to a listed inpatient procedure |
| 8️⃣ Cleft lip and palate repair | Yes | Based on age and medical necessity |
| 9️⃣ Weight-loss related skin surgery | Yes | Requires documentation of medical complications |
| 🔟 Cosmetic procedures (elective) | None | Not covered, regardless of setting |
What You Should Watch For
OneMediFund does a lot right, but every policy has conditions worth understanding upfront:
- Waiting periods apply, which means 12 months for anything considered pre-existing.
- Depending on what you’re comfortable paying, you can choose a $250 or $500 excess.
- Surgeon fees above the MBS rebate won’t be covered unless they’re in the AccessGap network.
- Extras are optional and not part of the base hospital plan, so you must add those separately if needed.
Podiatric surgery has limited benefits. Accommodation is covered, but surgeon fees usually are not.
Our Takeaway
This plan is clear, predictable, and doesn’t waste your time with upgrades that should be baseline. If you’re planning or preparing for reconstructive surgery and want the confidence of knowing it’s in or out, OneMediFund’s approach is straightforward.
RT Health Gold Optimum Plan
RT Health’s Gold Optimum Hospital plan for members who want full hospital cover without gaps in critical areas.
It doesn’t bury reconstructive surgery under vague terms or optional tiers; if your procedure is listed on the MBS, clinically justified, and done in the hospital, it’s covered. That applies whether you’re recovering from cancer, trauma, or major illness.
It’s also one of the few policies providing practical support for rural patients. If you need to travel more than 200km for surgery, the plan includes transport and accommodation cover (something many funds still overlook).
Where the Cover Delivers
Reconstructive surgery is included as long as it’s medically necessary and listed on the MBS.
- Breast reconstruction post-mastectomy is fully covered under cancer-related care.
- Joint and tendon repairs are included under general surgical access.
- RT Health participates in Access Gap – many in-network doctors will bill with reduced or no gap.
- Travel and accommodation are supported for long-distance medical trips over 200km.
- Prostheses are covered if they’re on the approved no-gap list.
You must ensure your procedure is performed in a contracted hospital. If it isn’t, none of the benefits will be paid.
What RT Health Covers for Reconstructive Support
| 🔎 Procedure | Covered | Notes |
| 1️⃣ Plastic and reconstructive surgery | Yes | Must be medically necessary and MBS-listed |
| 2️⃣ Breast reconstruction after cancer | Yes | Included under surgical cancer care |
| 3️⃣ Skin repair from burns or trauma | Yes | Requires inpatient admission and medical documentation |
| 4️⃣ Scar revision affecting function | Yes | Not covered for appearance-only purposes |
| 5️⃣ Joint or tendon reconstruction | Yes | Covered under general orthopaedic categories |
| 6️⃣ Surgically implanted prostheses | Yes | Must be from the approved device schedule |
| 7️⃣ Dental surgery (in hospital) | Yes | Requires Extras for full dental fee cover |
| 8️⃣ Weight-loss follow-up surgery | Yes | Requires evidence of skin fold complications |
| 9️⃣ Congenital correction surgery | Yes | Subject to age and condition-specific approval |
| 🔟 Cosmetic-only procedures | None | Not covered, regardless of where or why they’re done |
A Few Things to Know Upfront
There’s a lot to like in this policy, but some conditions are worth flagging before you go ahead with any major treatment:
- A 12-month waiting period applies to any pre-existing condition.
- Hospital excess is fixed at $750 and applies per admission, even for day surgeries.
- The policy doesn’t pay for outpatient consultations or diagnostics
- Not all doctors participate in the Access Gap.
- If your surgery happens in a non-contracted hospital, you’ll pay the entire bill yourself.
Other exclusions include hospital television, private room upgrades by choice, and non-PBS medications.
Our Key Takeaways
RT Health’s Gold Optimum plan is one of the more transparent policies for medically necessary hospital care. It does exactly what it claims to, and if you’re navigating post-trauma recovery or cancer-related reconstruction, that kind of clarity matters.
In Conclusion
Overall, Cosmetic surgery rarely gets the green light from insurers, but reconstructive procedures can only if you meet the criteria.
That means hospital admission, medical necessity, and a valid MBS item number. The tricky part is the details: not all doctors bill within the schedule, and not all policies cover every hospital.
Before committing, confirm the classification of your surgery, understand the costs beyond rebates, and check everything in writing. Insurance doesn’t erase the bill, but the right plan can make essential recovery more accessible (and far less financially stressful).
Frequently Asked Questions
Does health insurance ever cover cosmetic surgery?
No. It won’t be covered if the goal is to change appearance alone, even under Gold-tier plans.
What if the surgery is for medical or psychological reasons?
You’ll need clear medical evidence showing that the surgery is necessary for function or health. Insurers won’t accept stress or self-esteem alone as a reason.
Is breast reconstruction after cancer considered cosmetic?
No. It is classified as reconstructive and usually covered if you meet policy and Medicare conditions.
Will private insurance pay for a nose job if I can’t breathe properly?
Yes, if it’s for a function, like correcting a deviated septum. Not if it’s just for shape.
Are there out-of-pocket costs even if I’m covered?
Yes. You’ll pay the difference if your surgeon charges above the MBS fee or isn’t in your fund’s gap scheme.
