Health care in Australia

Sunday 30 June, 2013

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On this page: Types of health insurance ι Paying for treatment ι Medication and the PBS ι Reviewers


This page provides a general overview of the health care system in Australia. It includes information about:

  • the difference between public and private health care
  • how to pay for health care in and out of hospital
  • medication and the Pharmaceutical Benefits Scheme.

Types of health insurance

Public (Medicare)

The Australian Government provides health care insurance to citizens and permanent residents of Australia through Medicare. Under Medicare, you can receive free inpatient treatment in a public hospital. However, you can't choose your own doctor and you might have to wait for some services. Medicare also provides benefits for outpatient services, such as visits to GPs and specialists, but it doesn't cover dental, ambulance and private home nursing services.

Private

Private health insurance is a contract between you and an insurance company where you pay the company to cover your medical expenses. The amount you pay (the premium) and what's covered depends on your policy. As a privately insured patient, you can choose your own doctor, and you can choose to be treated in a private or public hospital. However, private health insurance may not cover all your costs, so there may be some out-of-pocket fees. 

Everyone's entitled to be treated as a public patient in a public hospital. If you have private insurance, you can choose to be treated in a private facility, or as a private patient in a public hospital.

Paying for treatment

You have a right to know whether you’ll have to pay for treatment and medication and, if so, what the costs will be. There may be fees you hadn’t considered – for instance, if you have surgery as a private patient, there will be fees for the hospital stay and the anaesthetist. Your doctors must talk to you about likely out-of-pocket expenses before treatment or before you go to hospital. This is called informed financial consent.

Medicare sets fees for medical services, called the schedule fee. Some specialists charge more than the schedule fee. They may, for example, set their fees according to the Australian Medical Association’s list of fees. The difference between the schedule fee and the higher doctor’s fee is called the gap fee.

Tips

  • Ask your health care provider for a written quote for fees. If you receive a bill far higher than the original quote, you can show the written quote and only pay that amount.
  • Even if you have private health insurance, you don’t have to use it – you can choose to be treated as a public patient in a public hospital.
Before being admitted to hospital, ask:
  • your doctor for an estimate of their fees (and if there will be a gap), who else will care for you, and how you can find out their fees
  • your health insurer what the gap cover will be – search for ‘gapchecklist’ on the www.privatehealth.gov.au website for a list of detailed questions
  • the hospital if there are any extra treatment and medication costs.

Fees for services in hospital

If you’re treated as a public patient, Medicare pays for your care and treatment while in hospital, and follow-up care from your treating doctor.

For a private patient in a public or private hospital, Medicare pays 75% of the schedule fee for services and procedures that your doctor provides. Your doctor can choose whether to charge more than the schedule fee. If your doctor charges more than the schedule fee, your insurer may cover the gap or you may have to pay the difference.

Patients with private insurance will also be charged for hospital accommodation and items such as operating theatre fees and medicines. Private health insurance may cover some or all of these costs, depending on the policy.

Some private health insurance funds will only pay benefits for services at certain hospitals. Check with your fund.

Fees for out-of-hospital services

A lot of cancer care is delivered outside hospital, such as when you see your oncologist or GP in their rooms for a consultation, and when you have tests, such as x-rays and pathology.

Some doctors bulk-bill for their services, which means they bill Medicare directly, accepting the Medicare benefit as full payment. Other doctors charge a consultation fee, which means you pay the account at the time of the consultation and claim the benefit through Medicare.

Medicare pays 100% of the schedule fee for GP visits and 85% of the schedule fee for visits to specialists.

What if I can’t afford treatment?

If treatment is too expensive for you, there are a number of options:

  • Ask if costs are negotiable – some doctors may reduce the fees.
  • If you’re treated as a private patient, ask your private hospital specialist if they can treat you at a public hospital. Keep in mind that you may have to wait longer.
  • Inquire about paying in instalments or for more time to pay your bill. Check if your doctor charges interest.
  • Ask your doctor if they charge more than the schedule fee.
  • Private patients can consider switching to a doctor who charges less.
  • Ask your GP to refer you to a doctor in the public system. 

Medicare Safety Net

The Medicare Safety Net subsidises costs once your expenses exceed a certain amount (called the threshold).

Individual patients are automatically registered for the program. You can contact Medicare to register as a family or couple and combine your medical costs so you're more likely to meet the threshold sooner.

Medication and the PBS

Many drugs and medications – especially chemotherapy drugs – are expensive. The Australian Government’s Pharmaceutical Benefits Scheme (PBS) subsidises the cost of more than 2,600 prescription medicines.

On the PBS, concession card holders (e.g. people with a Seniors Health Card or Health Care Card) and veterans receive discounts on prescriptions. You can get PBS medication even if you're treated privately.

The PBS Safety Net helps you afford medication covered by the scheme. Once you pay a certain amount for medicine, the rest of your prescriptions that year will be discounted or free. Occasionally, a doctor may prescribe a medicine that's not on the PBS. Prescriptions for these medicines are known as private prescriptions and they may cost more. Private health insurance may cover some or all of the cost of a private prescription.

Tips

  • Ask if your hospital or treatment centre charges a fee for chemotherapy drugs, and check whether you'll have to pay any costs.
  • If you have private health insurance, ask if you have to contribute to the cost of chemotherapy drugs.
  • Some doctors prescribe only drugs that are on the PBS to help patients afford treatment. Ask your doctor for every option – including private prescriptions – so you can make an informed decision about what you’d prefer.
  • Keep a record of your PBS medication on a form available from the pharmacy. Take the form with you each time you fill a prescription for a PBS medicine and your pharmacist can record it.
"I hit my PBS Safety Net 3–4 months into the year, then I paid nothing else because I’m a pensioner. I have a chemist who helps me keep track." — Jonathan

Reviewers: Sondra Davoren, Senior Legal Advisor, Cancer Council Victoria; Neil Brebner, Team Leader, Cancer Care Support Team, Wide Bay Hospital and Health Service, QLD; Angela Cotroneo, Acting Team Leader & Counsellor, Psycho Oncology Service, Sydney Cancer Centre, Royal Prince Alfred Hospital, NSW; Louisa Fitz-Gerald, National Pro Bono Manager, Cancer Council NSW; Val Goodwin, Cancer Counselling Service, Cancer Council QLD; Carol Hargreaves, Cancer Information Consultant, Cancer Council NSW; Lahna Hosken, Helpline Consultant, Cancer Council QLD; Dan Kent, Consumer; Dr Deborah Lawson, Legal Policy Advisor, McCabe Centre for Law and Cancer, VIC; Amy Parker, Helpline Consultant, Cancer Council QLD; and Sarah Penman, Pro Bono Case Manager, Cancer Council NSW.
Updated: 30 Jun, 2013