Health care in Australia

Public health care

The Australian Government provides free or subsidised medical care and hospital services through Medicare. This is known as a “universal health care system”. If you have a current Medicare number, you have the right to receive free treatment as a public patient in a public hospital (even if you have private health insurance).

Public hospitals often provide a wider range of services than private hospitals, including:

• emergency departments
• specialist surgical and medical units
• allied health services.

If you are being treated as a public patient in a public hospital:

• you can’t choose your doctor or any other member of your health care team at the hospital
• you might have to wait longer for treatment than a private patient.

Cancer care delivered publicly includes:

• consultations with your oncologist or surgeon
• cancer treatments (e.g. surgery, chemotherapy, radiation therapy)
• tests such as blood tests, x-rays and imaging scans
• some allied health services (usually in outpatient clinics).

It’s important to remember that both public and private patients have the same access to public hospital services.

Private health care

Some people prefer to be treated as a private patient so they can choose their own doctor, and may not have to wait as long for treatment. You can be treated as a private patient in both public and private hospitals and health services. The cancer care services listed under public health care are also offered in the private sector.

Fees – Doctors, service providers and hospitals in the private sector can set their own fees. Some people pay for private health insurance to help cover the extra cost of treatment as a private patient in hospital. If a health service provided in a private hospital is on the Medicare Benefits Schedule, Medicare covers 75% of the schedule fee for some services and private health insurance may cover at least 25%. Many doctors charge more than the schedule fee. Your health insurer may cover some or all of this cost; you will have to pay any costs not covered (gap payment).

You will also be charged for hospital accommodation, operating theatre fees and medicines. Private health insurance may cover some or all of these costs, depending on your policy.

Discuss costs – Before being admitted to hospital as a private patient, it’s helpful to ask:

• your doctor for a written estimate of their fees (and if there will be a gap), who else will care for you (e.g. an anaesthetist or surgical assistant), 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.

Health funds may make arrangements with some doctors about gap payments. Using the doctors and hospitals that take part in your health  insurer’s medical gap scheme can help reduce out-of-pocket costs.

Public hospitals – If you choose to be treated as a private patient in a public hospital, it is usually arranged on admission. However, if you have been admitted to hospital through the emergency department, an administration officer may come to your bedside to ask if you want to be treated as a private or a public patient.

You don’t have to decide straightaway. You may like to first talk to your health fund or a patient liaison officer at the hospital.

Many people treated privately are surprised that they have to pay additional costs not covered by Medicare or their private health fund. It is  important to ask about out-of-pocket costs before treatment.

What is Medicare?

The Australian Government provides free or subsidised medical and hospital services through Medicare to Australian citizens and permanent  residents, and people who meet certain requirements (e.g. visitors from some other countries). The government sets fees for the medical services it subsidises, which are listed on the Medicare Benefits Schedule (MBS). The fees are known as schedule fees and the Medicare benefit for out-of-hospital services is usually 85–100% of that schedule fee.

Bulk-billing – Some GPs and specialists accept the Medicare benefit as full payment for a service, and you will not have to pay anything. This is called bulk-billing. Many doctors do not bulk-bill, so you will have to pay the difference between the Medicare benefit and the consultation fee. You may be able to find doctors who bulk-bill their services, by visiting Health Direct.

Many doctors charge more than the schedule fee. The difference between the schedule fee and the doctor’s fee is called a “gap payment”. Note that private health insurance does not help cover the gap fee for doctors’ consultations in the community (only in hospitals). If a health service is not listed on the MBS, you will have to pay the whole fee.

What Medicare covers – It covers hospital care when admitted as a public patient to a public hospital, and visits to GPs, specialists and optometrists. Medicare may cover the cost of certain medical supplies (e.g. breast prostheses, stoma supplies). There are also programs to help with the cost of other services, such as visits to a psychologist or allied health professionals. Talk to your GP to see if you are eligible.

What Medicare doesn’t cover – It doesn’t cover ambulance services (funding and costs vary according to the state or territory in which you live and may be covered by your private health insurance), dental care (with exceptions), private home nursing services, and other services.

Medicare Safety Nets

This program can help reduce how much you have to pay for some out-of-hospital services. Once your out-of-pocket costs add up to a certain amount (called the threshold) during a calendar year, Medicare will pay you a higher benefit for some services until the end of that year.

Individuals with no dependants do not need to register for Medicare Safety Nets as Medicare automatically keeps a total of your expenses. Couples and families, however, must register for Medicare Safety Nets, even if you are all listed on the same Medicare card. For details, visit Medicare or call them on 132 011.

Private health insurance

Some people choose to take out private health insurance to help cover their future health care expenses. The amount you pay (the premium) and the health services covered vary depending on the company and the type of policy you select.

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. It is likely that you will have some out-of-pocket costs.

You can get hospital cover as well as cover for extras such as dental, optical and physiotherapy treatments. After you take out a policy, there will usually be a waiting period before you can claim benefits. For a general list of what Medicare and private health insurance covers in Australia, visit PrivateHealth.gov.au.

Informed financial consent

You have a right to know if you have to pay for treatment and medicines and, if so, what the costs will be. Before treatment starts, your doctors and other health care providers must talk to you about the likely fees that you will have to pay (called out-of-pocket costs). This is called informed financial consent.

You can ask for this information to be put in writing, so you can refer to it during your treatment. There may be costs associated with your treatment that 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, as well as the fees for the surgical procedure.

In some instances, such as in the case of an emergency, it is not possible to give informed financial consent before medical care. In such cases, your consent should be obtained as soon as possible afterwards.

Exploring medical costs

Understanding all treatment costs may play a role in your decision to use public or private services. It may be helpful to visit the Australian  Government’s online tool Medical Costs Finder, which is a general guide to the typical fees, private health insurance contributions and out-of-pocket costs for medical services in your area. The Medical Costs Finder covers services provided in and out of hospital.

Also see PrivateHealth.gov.au for a general list of what Medicare and private health insurance cover. If you have private health insurance, you will need to contact your health fund to find out what costs are covered in your policy.

Ways to manage health care costs

• Ask your health care provider for a written quote outlining their fees. If you receive a much higher bill, show them the quote and ask why the bill is higher.
• Ask your GP to refer you to a doctor in the public health system.
• Consider switching to a doctor who charges lower fees (if you are a private patient).
• Ask to be treated as a public patient in a public hospital, even if you have private health insurance.
• Talk to your doctor about treatment options. Some newer treatments can be very expensive and may not offer greater benefits than traditional approaches. Ask your doctor if other treatments might be as effective but cost less.
• Find out if you can pay in instalments or have more time to pay your bill. If your health care provider agrees, check if you will be charged interest.
• Ask your doctor if they would consider reducing their fees if you can’t afford treatment.
• Ask your GP if they can give you a long-term referral to your specialist at the end of your treatment. This is known as an “indefinite referral”. It may save you time and money if you require follow-up over several years (standard GP referrals are valid for 12 months and specialist referrals are valid for 3 months). Note, an indefinite referral is not valid for new or unrelated conditions, and it’s important to visit your GP if you have any health concerns and for regular check-ups.

Download our booklet ‘Cancer and Your Finances’

Medicines and the PBS

Many drugs used to treat cancer are expensive. The Pharmaceutical Benefits Scheme (PBS) covers all or part of the cost of many prescription  medicines for people with a current Medicare card. Medicines that you buy from a pharmacy without a prescription (over-the-counter medicines) are generally not covered by the PBS.

Concession cards and allowances

Some PBS medicines are cheaper for people with a Pensioner Concession Card, Commonwealth Seniors Veteran Card, Health Care Card or  Department of Veterans’ Affairs Health Card. You will need to show your card to the pharmacist when you get your prescription filled. People who receive some 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 on medicines each year (the  threshold). When you reach the 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). For details, call 1800 020 613 or visit The Pharmaceuticals Benefits Scheme.

Generic medicines

Your pharmacist may ask if you would like a generic brand of your prescribed medicine because it will be cheaper. Generic medicines contain the same active ingredients and meet the same high standards of quality, safety and effectiveness set by the Therapeutic Goods Administration, which regulates medicines sold in Australia. It is your choice whether to buy the generic or original brand.

Non-PBS prescriptions

Doctors may prescribe a medicine that is not on the PBS. This is called a private prescription. You will need to pay the full price for these medicines  and it will not count towards the PBS Safety Net. If you have private health insurance, it may cover some or all of the cost of a private prescription.  Check with your insurer.

You may also be able to access medicines that are not on the PBS by joining a clinical trial through a compassionate access scheme.

Paying for medicines

• Public patients in public hospital do not pay for most drugs as the cost is covered by the PBS. Ask your treatment team if you have to contribute to the cost of your drugs (there may be a cost for some oral chemotherapy drugs).
• If you choose to be treated as a private patient, you may have to contribute to the cost of chemotherapy drugs. Check with your doctor and health fund before starting treatment.
• Some doctors only prescribe 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. You may also be able to get some drugs at a reduced cost on compassionate grounds (these are called compassionate access schemes). Ask your doctor if this might be an option for you.
• You usually have to pay for medicines you take at home. Keep a record of your PBS medicines on a Prescription Record Form, available online or from your pharmacist, so you know when you’ve reached the PBS Safety Net threshold.