Health Care in Australia

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Medicare

Under the Medicare scheme, patients receive:
  • free treatment as a public patient in a public hospital
  • free or subsidised treatment by doctors in a general practice
  • subsidies on some treatments by participating specialists, optometrists and dentists

In-hospital Services

If you are treated in a public hospital as a Medicare patient, you do not pay for treatment by the attending physician, or for services or accommodation provided by the hospital. You are, of course, subject to any prioritisation and waiting periods that exist and you are not able to choose which doctors or specialists treat you.

You can opt to be treated as a private patient, either in a private hospital or in a public hospital. In that case, you can choose who treats you. Medicare pays 75% of the Medicare Schedule Fee for treatment, but does not cover the hospital accommodation or services such as theatre fees.

Out-of-hospital services

Medicare provides benefits towards many medical costs, including:
  • Doctors' Consultation Fees at GPs and some specialists
  • Pathology Tests including cholesterol and other blood tests, pap smears etc.
  • Radiology including x-rays, ultrasound imaging, MRI, CT and PET scans
  • Eye Tests by an optometrist (optician) - one test every two years
  • Some Surgical Procedures performed by doctors and approved dentists

What Medicare Does Not Cover

The following are some of the services that Medicare does not cover. For these, the patient either pays the full cost or their private health fund (if they have one) covers part or all of the cost:
  • Ambulance - the good news is the paramedic won't check your private health cover before agreeing to help you, but be warned, you will receive a bill if you need an ambulance.
  • Dental - routine examinations and treatment
  • Optical - the cost of glasses and contact lenses
  • Hearing Aids
  • Physiotherapy, Chiropractic, Osteopathy
  • Podiatry
  • Acupuncture

Bulk Billing

Some doctors 'bulk bill' Medicare, in which case you don't pay anything and the doctor accepts the standard Medicare benefit amount.

Other doctors charge more than the Medicare benefit and the patient has to pay the difference (known as 'out-of-pocket' expenses).

Doctors sometimes operate bulk billing for certain patients only; for example pensioners, Heath Care Card holders, or children.

Medicare Schedule Fees

Medicare benefits are based on a schedule of fees set by the government, but medical practitioners can charge more (often much more) than those fees.

It is the individual doctor, not the government, who decides whether to bulk bill or not. In practice, the socio-economic profile of an area largely determines whether a doctor bulk bills; in many suburbs they do not, so patients are often left with substantial out-of-pocket expenses to pay.

Note that private health funds do not pay benefits to your Medicare out-of-pocket expenses.

The Medicare Gap

For a visit to a General Practitioner, the amount that Medicare pays (the Medicare Benefit) is usually 100% of the Medicare Schedule Fee.

But for many other out-of-hospital services, like a consultation with a specialist, the Medicare benefit is 85% of the schedule fee. The difference, which the patient pays of course, is called the 'Medicare Gap'.

Out-of-pocket Expenses

As mentioned above, many doctors charge more than the Medicare Schedule Fee, so even if Medicare are paying 100% of the schedule fee, it can still be much less than the doctor charges you. The difference is called 'out-of-pocket' expenses.

See What Medicare Costs for examples.

Medicare Safety Net

The Medicare Safety Net is a policy which can provide additional financial assistance for individuals or families who make high gap payments in a financial year.

For 2012 the Medicare Safety Net Threshold is set at $413.50. This means that as soon a family unit has paid gap payments totalling $413.50 in a financial year, they will start getting back 100% of the Medicare rebate instead of 85%.

Medicare Safety Net Extension

Even when the Medicare Safety Net kicks in and you get the full Medicare rebate, you can still be paying substantial gap payments. When your gap payments total

For 2012 the Medicare Safety Net Threshold is set at $413.50. This means that as soon a family unit has paid gap payments totalling $413.50 in a financial year, they will start getting back 100% of the Medicare rebate instead of 85%.

Pharmaceutical Benefits Scheme (PBS)

The Pharmaceutical Benefits Scheme provides funding to reduce the cost of many prescription medicines. In order to qualify for the subsidy, the medicine must be prescribed by a doctor and must be on the PBS list of medicines.

The PBS does not usually cover the full cost of medicines that your GP prescribes. When you collect your medicine from the pharmacy, you will have to pay a script charge. Low-income families can apply for a concession card, thus reducing the amount they pay for medicines.

There is also something called the Pharmaceutical Benefits Safety Net, which provides additional help for people who spend a lot on medicines, reaching the PBS Safety Net Threshold in a given financial year.

Health Care Card

Individuals or families on a low income may qualify for a health care card - a concession card that gives them automatic subsidies on many medicinal treatments and drugs.

Enrolling in Medicare

One of the first things that permanent residents need to do when they arrive in Australia is to enrol in Medicare and get a Medicare Card. Do this in person at a Medicare Service Centre.

Registering with a Doctors Surgery

You can register with any General Practice and see any doctor you like, provided they have the capacity to take you on.

There appears to be very little integration of patient records between surgeries currently, although this should be about to change, with the introduction of Personally Controlled Electronic Health Records (PCEHR5) in July 2012.

Resources

1Dept of Human Services - Medicare.
2MBSonline - Medical Benefits Schedule.
3Department of Health and Ageing
4National E-health Transition Authority - information about PCEHR.
5Australian Medical Association
6Dept of Human Services website - Medicare Safety Net