Private Health Insurance For Weight Loss Surgery

Obesity can become a multifaceted, long-standing medical issue. While genetics play a role, the rise in body weight among both adults and children over the last two decades can be primarily attributed to decreased physical activity and shifts in dietary habits brought about by changes in food preparation and consumption patterns.

Considering weight loss surgery isn’t a decision that’s made lightly. If you feel like you’ve exhausted all of your options, it’s important to know the costs and risks associated with this type of surgery.

Weight loss surgery isn’t always covered by Medicare, so this guide takes you through the ins and outs of health insurance for weight loss surgery.

Am I eligible for weight loss surgery?

In order to qualify for weight loss surgery covered by Medicare and private health insurance, patients must meet specific medical requirements. 

Does Body Mass Index (BMI) play a role?

Your Body-Mass Index (BMI) assesses your body composition based on your height and weight measurements. As stated in the Medicare MBS guidelines, clinically severe obesity is generally characterised by a BMI of 40 or higher, or a BMI of 35 or higher in combination with other significant medical co-morbidities or obesity-related diseases, such as diabetes. Obesity-related conditions can include:

• Cardiac ailments

• Excess weight

• Respiratory conditions like asthma

• Sleep apnea

• Osteoarthritis 

BMI values may vary among different population groups due to variations in body proportions, which can impact your percent of body fat distribution. Consequently, diverse ethnic groups may face significant health risks even at a BMI below the 35-40 range specified in the definition. According to the MBS, the decision to proceed with obesity surgery is ultimately based on the clinical judgement of the surgeon.

What types of weight loss procedures are available in Australia?  

In Australia, there are four primary types of weight loss surgeries available. These procedures are commonly performed in the country and, when medically necessary,  can be covered by appropriate private hospital insurance. Let's take a closer look at each of them:

1. Gastric Sleeve Surgery (Sleeve Gastrectomy): This surgery involves the removal of a significant portion (around 70% to 80%) of the stomach. By transforming the stomach from a large bag into a small tube, it enforces lifelong control over food volume. After the surgery, patients physically cannot consume more than what the remaining tube can hold. It's important to note that this procedure is irreversible.

2. Lap Band Surgery (Gastric Banding): With this procedure, a silicone band is utilized to restrict a section of the stomach, making it much smaller. Unlike gastric sleeve surgery, the stomach remains intact and functional, making the procedure reversible. The reduced-size stomach pouch limits the amount of food that can be consumed.

3. Roux-en-Y Gastric Bypass (Gastric Bypass Surgery): This surgery involves the creation of a small pouch at the top of the stomach, which is then connected to a loop of the small bowel. The remaining part of the stomach is disconnected from the intestines but remains inside the body. Gastric bypass surgery is commonly recommended for individuals with a BMI over 50, those with type 2 diabetes, and those who experience gastric reflux.

4. Duodenal switch surgery, also known as biliopancreatic diversion with duodenal switch (BPD-DS), is a surgical procedure designed to help individuals achieve significant weight loss. It is considered a complex and highly effective bariatric surgery option for those struggling with obesity.

IMPORTANT NOTE: Health insurers don’t cover this procedure in Australia as yet. It’s not used often, and is fairly new.

These weight loss surgery options offer different approaches to achieve significant weight loss and improve overall health. It's important to consult with a medical professional to determine the most suitable procedure based on your individual circumstances.

Is weight-loss surgery covered by Medicare?

Patients are covered by Medicare for bariatric surgery, as long as they fulfil the necessary medical criteria requirements. The current Medicare Medical Benefits Scheme (MBS) includes weight loss surgery, also known as Bariatric Procedures, which fall under Items 31569 to 31581, along with the associated anaesthesia item 20791. These specific items within the MBS assist you in accessing surgical treatment for clinically severe obesity, accompanied by the necessary anaesthesia services or similar.

It can be covered by Medicare, but there are specific requirements to qualify for cover. Medicare only covers your weight loss surgery if it’s determined to be medically necessary, rather than for cosmetic or lifestyle reasons. 

Eligibility criteria include: 

• having a BMI of 35 or higher.

• being severely overweight for a minimum of five years.

• having a co-morbidity that poses a significant health risk (such as sleep apnea, diabetes, heart disease, osteoarthritis, or high blood pressure).

• demonstrating unsuccessful attempts at other medically supervised weight loss methods.

•  ruling out other underlying causes for obesity, such as glandular issues. 

Additionally, a team of healthcare professionals must assess and approve you as a suitable candidate for the surgery before granting approval. If you meet the criteria and receive approval for weight loss surgery, Medicare will cover some of the costs. However, even if you undergo treatment in a public hospital, you may still face substantial out-of-pocket expenses. It's important to note that each of the three weight loss surgeries mentioned earlier may qualify for Medicare subsidies.

Will my private health insurance policies cover weight loss surgery?

In addition to Medicare, private health cover can cover some of your costs for weight loss surgery. In Australia, there are four tiers of hospital cover: 

• Basic.

• Bronze.

• Silver.

• Gold.

Only the most expensive option, gold cover, covers weight loss surgery. A gold-tier hospital policy may cover some of the following aspects of your hospital stay for medically necessary weight loss surgery and subsequent care: 

• Private hospital accommodation fees 

• Theatre fees 

• Doctor, bariatric surgeon and anaesthetists' fees 

• Diagnostic tests conducted in a hospital setting, such as X-rays, CT and MRI scans 

• Medications provided whilst you’re an inpatient 

• Fees for post-op visits by psychologists, dietitians or lifestyle advisors whilst you’re still an in-patient in hospital

It's important to note that there may still be some out-of-pocket expenses and certain procedures that won’t be covered by your gold hospital cover. For example, you may be required to pay a portion of your surgeon's and your anaesthetist's fees if they charge more than the Medicare Benefit Schedule (MBS) fee for the service, which is known as a 'gap' payment. Other areas which may not be covered include: 

• Hospital cover excess: an amount you have to pay each time you make a claim on your health insurance policy. This can range from zero to $750, depending on the policy you decide to buy 

• Co-payment fees: a co-payment fee is an amount you are required to pay with some hospital cover policies for each day you remain in hospital. This amount can vary but is usually around $100 a day, capped at $700.

• Skin reduction surgery: this is surgery (often performed after the initial weight-loss surgery) which aims to remove excess skin .

• Muscle tone surgery: sometimes additional surgery is also required (once a considerable amount of weight has been lost) to tighten up loose muscles to regain muscle control.

Your specific costs may vary depending on your recommended surgery. Contact your insurer to check the specific terms and conditions pertaining to weight loss surgery. Different insurers have varying policies and requirements in this regard.

What does weight loss surgery cost?

The cost of weight loss surgery in Australia varies depends on a variety factors, such as: 

• the specific procedure chosen;

• whether you've been approved for Medicare-funded surgery;

• whether you have your surgery as a public or private patient.

• Surgeon consultation fees.

• Surgical assistant fees.

• Hospital fees.

• Anaesthetist’s fees.

• Prescribed medications.

• After surgery care plan.

Additionally, the complexity of the surgery, the number of surgeons or bariatric specialists required, the presence of other health issues, and the need for additional support services following the surgery can impact your overall cost. 

It's worth mentioning that there is no standard cost for weight loss surgery. However, the approximate average costs for an individual without private health insurance, accurate as of February 2023, are as follows:

• Gastric sleeve surgery: starting from $20,000.

• Gastric banding: ranging from $12,000 to $18,000.

• Gastric bypass surgery: ranging from $15,000 to $20,000.

Without private cover, you may face expenses ranging from $12,000 to $18,000, even after your Medicare rebate. With your gold-tier hospital cover, a significant portion of these expenses may be covered by your health insurance. 

With your health insurance, your costs can be reduced to somewhere between $3,000 to $8,000.

Medicare may provide a modest contribution towards your surgical costs, if you’re approved for this. The contribution from the Medicare Benefits Schedule (MBS) typically falls within the range of approximately $1,000 to $1,500 for weight loss procedures. The specific amount depends on the applicable MBS codes associated with the performed procedure.

Medicare vs Private health insurance for weight loss surgery:

The costs below include hospital stays and associated fees (such as accommodation, theatre, or medical devices). Your private health funds covers all or most of this, though you may need to pay an excess or co-payment.

Are the hospital waiting times for weight loss surgery long?

Bariatric surgery in the public system is predominantly considered an elective procedure, which means that you can face significant waiting times. It’s not uncommon for patients to wait for two to three years or even longer. In Victoria, the waiting period for bariatric surgery currently exceeds five years.

While the waiting times can be lengthy, it's essential to consult with healthcare professionals to discuss all available options and develop your personalised plan towards your long-term health and wellbeing.

Are there alternatives to weight loss surgery? 

Weight loss surgery is a significant decision, and it may not be suitable or feasible for everyone. There are alternative options available if you’re seeking weight loss solutions that are less invasive, such as:

• Gastric Balloon: This non-surgical procedure involves the insertion of a balloon into the stomach for a period of approximately six months. The balloon occupies space within the stomach, leading to a sensation of fullness and reducing food intake.

• Endoscopic Gastric Sleeve: This non-surgical procedure aims to reduce the size of the stomach using an endoscope. It is a less invasive approach compared to a full sleeve gastrectomy but offers similar benefits in terms of weight loss.

• Vagal Blockade (vBlocK): In this alternative method, a device is surgically implanted beneath the skin. The device emits electrical pulses that help block hunger signals transmitted through the vagus nerve. This helps to regulate appetite and control food intake.

These non-surgical options offer viable alternatives to weight loss surgery, allowing you to explore less invasive methods to achieve your health goals. Always consult with your healthcare professional to determine the most suitable approach based on your individual circumstances.

Frequently Asked Questions:

Which health funds cover weight loss surgery?

If your weight loss surgery is deemed medically necessary, most health funds cover you under gold tier hospital cover. As long as your medical procedure meets the requirements of the MBS, you can claim your hospital costs and specialist’s fees.

What BMI do I need for weight loss surgery?

The BMI requirement for weight loss surgery varies, but generally, a BMI of 40 or higher, or a BMI of 35 or higher with obesity-related health issues, is often considered for eligibility.

Can weight loss surgery kill you?

Like any surgical procedure, weight loss surgery carries risks, but when performed by experienced surgeons in appropriate healthcare settings, the chances of serious complications or fatalities are relatively low. However, you need to consider that general anaesthesia is riskier for people with a high BMI and/or diabetes.

How long does weight loss surgery last?

Gastric bypass and other bariatric surgeries can provide long term weight loss. The amount of weight you lose depends on the type of surgery and your change in lifestyle habits. It may be possible to lose half, or even more, of your excess weight within two years.

What is the safest form of weight loss surgery?

For many people, the best option for weight loss surgery is gastric sleeve surgery. This allows you to lose a lot of weight while still absorbing nutrients. And you will produce fewer hormones that make you hungry but really, the safest option for you is best determined between yourself and your medical care team.

Can I use my super for weight loss surgery?

If you are undergoing laparoscopic sleeve gastrectomy or laparoscopic gastric bypass surgery, and you have inadequate means of funding the surgery, it's possible to apply to the ATO for access to your superannuation on compassionate grounds. The amount of super you can withdraw is limited to what you reasonably need.

Many weight loss surgery clinics and specialists offer payment plans as well.

Can those with diabetes have weight loss surgery?

Yes - in fact it’s often recommended as an important part of managing diabetes.

Diabetes is a complex and severe chronic health condition associated with a heightened risk of:

• cardiovascular diseases.

• kidney disease.

• vision loss.

• limb amputation.

• chronic non-healing wounds. 

The increasing prevalence of Type II diabetes in Australia is part of the obesity epidemic affecting most of us or people we love.

Metabolic surgery has long been acknowledged for its ability to reverse Type 2 diabetes and prevent individuals with pre-diabetes from progressing to Type 2 diabetes. While bariatric surgery cannot reverse or directly impact the autoimmune factors underlying Type 1 diabetes, the hormonal, receptor, and metabolic effects resulting in weight loss can help improve diabetes control and reduce medication usage in those with type 1 diabetes.

The duration of diabetes and insulin use prior to surgery affects the likelihood of achieving complete remission, making early intervention through weight loss surgery important for achieving better health outcomes for you.

Sources

Dr. Phil Locke

Health.Gov - Metabolic Obesity Service

Health Direct

Mayo Clinic

Advanced Obesity Surgery

Sydney Bariatric Clinic

Diabetes Australia

Bariatric Surgery Source, Weight Loss Surgery Australia, 2021, https://www.bariatric-surgery-source.com/weight-loss-surgery-australia.html#

Chris Stanley is the sales & operations manager of health insurance at Compare Club. With extensive experience and expertise, Chris is a trusted leader known for his deep understanding of health insurance markets, policies, and coverage options. As the sales & operations manager of health insurance, Chris leads a team of dedicated professionals committed to helping individuals and families make informed decisions about their health insurance needs.

Meet our health insurance expert, Chris Stanley

Chris's top health insurance tips

• 1

  Australia’s public health system is world-class, but wait times for public hospitals can be long, inconvenient - and leave you living in constant pain while you wait.

• 2

  An appropriate private health insurance policy can speed up your surgery, relieving your pain sooner.

• 3

  Family health cover means your children are covered under the same policy as you.

• 4

  Many health insurance policies come with a 12-month waiting period for pregnancy-related cover, so it’s a good idea to get a family policy organized well before starting your family. This means your child will be covered from birth until at least their early twenties (depending on which health fund you select).