For many people, a cancer diagnosis is the start of a long and often complicated journey through the health care system. Navigating through this system can be challenging, particularly when you are dealing with the physical and emotional effects of cancer.

This page and subsequent pages, outline what you can reasonably expect of the health care system and your treatment team. It also includes some basic information about insurance and workplace rights, and practical issues such as paying for treatment, finding a specialist and accessing community services.

This information is about working in partnership with your health care providers and taking an active role in your care, if you wish to do so. This doesn’t mean you are making demands of your treatment team – rather, it’s about feeling comfortable asking questions and ensuring your needs are met.

Health care in Australia

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

• the differences between public and private health insurance
• how to pay for health care in and out of hospital
• medicines and the Pharmaceutical Benefits Scheme (PBS).

Types of health insurance

Public (Medicare)

Medicare is insurance provided by the government that gives citizens and permanent residents of Australia access to medical and hospital services. It is also available to people who meet certain other requirements (e.g. some overseas visitors).

Under Medicare, you are entitled to free inpatient treatment in a public hospital, even if you have private health insurance. However, you can’t choose your own doctor and you might have to wait for treatment. Medicare also provides benefits for outpatient services, such as visits to general practitioners (GPs), specialists and optometrists, but it doesn’t cover dental (with exceptions), ambulance or private home nursing services.

Public dental services

Free or subsidised dental care is available to people who meet certain eligibility criteria, for example, you may need to hold a particular concession card. Visit your state or territory health department’s website for information.

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 is 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 hospital or as a private patient in a public hospital. See public or private treatment.

Visit privatehealth.gov.au for a detailed list of hospital, specialist and pharmaceutical services covered by Medicare and private health insurance.

Paying for treatment

You have a right to know whether you will have to pay for treatment and medicines and, if so, what the costs will be. There may be fees you hadn’t considered – for example, if you have surgery as a private patient, there will be fees for your stay in hospital and for the anaesthetist.

Your doctors must talk to you about likely out-of-pocket expenses before treatment starts. This is called informed financial consent. For more information order a free copy of Cancer and Your Finances or call Cancer Council 13 11 20.

Medicare Benefits Schedule (MBS)

Medicare sets fees for medical services. The list of fees is called the Medicare Benefits Schedule (MBS). Some doctors charge more than the Schedule fee. The difference between the Schedule fee and the doctor’s fee is called the gap fee.

Before being admitted to hospital, you should 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 what their fees will be
• your private health fund (if you belong to one) what costs they will cover and what you’ll have to pay. Some funds only pay benefits for services at certain hospitals
• the hospital if there are any extra treatment and medicine costs.

Fees for services in hospital

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

For private patients in a public or private hospital, Medicare pays 75% of the Schedule fee for services and procedures that your doctor provides. If your doctor charges more than the Schedule fee, your health fund may pay the gap fee or you may have to pay it yourself. You 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 your policy. You may also have to pay an excess to your health fund, depending on the type of hospital cover you have.

Fees for out-of-hospital services

A lot of cancer care is delivered outside hospital, such as consultations with your oncologist, surgeon or GP, and tests, such as blood tests, x-rays and scans.

Some doctors bulk-bill for their services, which is when they bill Medicare directly and accept the Medicare benefit as full payment. This means you don’t pay anything. Other doctors charge a consultation fee, which means you pay the account at the time of the consultation and claim the benefit through Medicare. You can often make this claim when you pay the bill – the doctor’s receptionist can process it through EFTPOS.

Medicare pays 100% of the Schedule fee for GP visits and 85% of the Schedule fee for visits to specialists – you pay the extra 15% of the specialist’s fee. If the doctor charges above the Schedule fee, you will pay a gap fee on top of the 15%.

Keeping costs in check

• Ask your health care provider for a written quote for fees. If you receive a much higher bill, you can show them the quote and only pay that amount.
• Even if you have private health insurance, you don’t have to use it – you can be treated as a public patient in a public hospital to reduce your out-of-pocket costs. Before you are admitted, the hospital will ask whether you would like to be treated as a private or public patient.

What if I can’t afford treatment?

You have some options if treatment is too expensive:

• If your doctor charges more than the Schedule fee, ask if they will consider an exception in your case.
• Ask if costs are negotiable – some doctors may agree to reduce their fees.
• Find out if you can pay in instalments, or ask for more time to pay your bill. Check if you will be charged interest.
• 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 out-of-hospital costs, such as medical appointments and tests, once your expenses exceed a certain amount (called the threshold). There are different thresholds depending on your circumstances. Once you reach the threshold, you may receive a higher Medicare benefit for eligible expenses for the rest of the calendar year.

Individual patients do not need to register for the Medicare Safety Net as Medicare automatically keeps a total of your expenses. You can contact Medicare to register as a family or couple and combine your medical costs so you are more likely to meet the threshold sooner. See more information about the Medicare Safety Net and registering as a family or couple.

Medicines and the PBS

Many drugs – especially chemotherapy drugs – are expensive. The Australian Government’s Pharmaceutical Benefits Scheme (PBS) subsidises the cost of many different prescription medicines for people with a current Medicare card.

Concession cards and allowances

Some PBS medicines are cheaper for people with the following cards:

• Pensioner Concession Card
• Commonwealth Seniors Health Card
• Health Care Card
• Department of Veterans’ Affairs health card.

You will need to show your eligible card to the pharmacist when you get your prescription filled.

People who receive certain Centrelink payments may be eligible for a Pharmaceutical Allowance, which can help to cover the costs of prescription medicines.

PBS Safety Net

The PBS Safety Net further reduces the cost of PBS medicines once you or your family have spent a certain amount. When you reach the Safety Net threshold, your pharmacist can give you a PBS Safety Net card, and your prescription medicines for the rest of the year will be discounted, or free if you have an eligible concession card.

Generic medicines

You can ask your pharmacist to supply you with a generic brand of your prescribed medicine if one is available. Generic medicines contain the same active ingredients as more expensive brands. The medicine may look different, but it meets the high standards of quality, safety and effectiveness set by the Therapeutic Goods Administration, which regulates medicines sold in Australia.

Non-PBS prescriptions

Doctors may prescribe a medicine that is not on the PBS. Prescriptions for these medicines are known as private prescriptions. They may cost more than PBS medicines and they do not count towards the PBS Safety Net. Private health insurance may cover some or all of the cost of a private prescription. Check with your insurer.

Paying for medicines

• Ask if your hospital or treatment centre charges a fee for chemotherapy drugs and whether you will have to pay.
• If you have private health insurance, ask whether you have to contribute to the cost of chemotherapy drugs.
• Some doctors prescribe only PBS medicines to make treatment affordable. Ask your doctor for every option – including private prescriptions – so you can make an informed decision about your treatment.
• Keep a record of your PBS medicines on a Prescription Record Form, available from your pharmacist. Take the form with you each time you get a prescription filled, so the pharmacist can record it.

Key points

• There are two types of health insurance: public (Medicare), which is provided by the government; and private, which is a contract between you and an insurer to cover certain medical expenses.
• Your treatment team should talk to you about how much treatment and medicines will cost. This is called informed financial consent.
• Some doctors charge more than the Medicare Benefits Schedule fee for services. Your health fund may pay the difference (gap fee) or you may have to pay it.
• If you’re treated as a public patient, Medicare pays for your care and treatment in hospital, and for follow-up care from your doctor.
• For private patients in a public or private hospital, Medicare pays 75% of the Schedule fee for services and procedures.
• A lot of cancer care is delivered outside hospital, e.g. visits to your doctors and some tests. Medicare pays 100% of the Schedule fee for GP visits and 85% of the Schedule fee for visits to specialists out of hospital. The remaining 15% is paid by you.
• Once your expenses reach a certain amount (threshold), the Medicare Safety Net subsidises costs.
• The Australian Government’s Pharmaceutical Benefits Scheme (PBS) subsidises the cost of many prescription medicines.
• The PBS Safety Net helps with the cost of medicines. Once you reach a certain threshold, your prescriptions for the rest of the year will be discounted or free.

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