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Healthcare standards are high in Australia, and residents have a wide choice of doctors and hospitals. Therefore you can select the level of healthcare you require according to how much you need, how much you are ready to pay, and what quality of service you can afford. It is therefore critical to be upfront with your doctor to know in advance how much you are to be charged, even if you are eligible for Medicare. See National Health Service for Expats in Australia
If you are happy with basic healthcare, it is possible to rely solely or mainly on public funds, as the Government will mostly or fully reimburse your healthcare costs. If not, you will need to pay out of your own pocket.
Public vs. Private
Most healthcare providers in Australia are private, though there are public hospitals as well. You can choose to be admitted to a public hospital as a private patient or choose to go to one even if you are privately insured. Public hospitals are run by state/territory governments in cooperation with the federal government. There may be long waiting lists and, as a public patient, you will have no choice over which doctor you see. In emergencies you will need to go to a public hospital, as few private hospitals have emergency departments. See Health Emergencies for Expats in Australia
To find a hospital (public or private) in your local area, click here.
If you are not eligible to Medicare, you can equally consider public and private hospitals, as you will be a private patient anyway. What you should actually do depends on your needs, the facilities available in your local area, and the likely charges.
If you are eligible to Medicare, clinically necessary public hospital services are normally free. This is because the public hospital charges you only the applicable MBS fee, which is 100% paid or refunded by Medicare through bulk billing (see below). In a private hospital, Medicare pays only 75% of the MBS fee. The remaining 25% is called a “gap expense” whereas the Medicare payment is a “Medicare benefit”. However, a doctor is free to charge you more than the MBS fee for whatever commercial reasons. In that case, the difference between what you are charged and the Medicare benefit is called an “out-of-pocket expense”.
Ann is eligible to Medicare and goes to a private doctor. The doctor charges $120 for his consultation, the applicable MBS fee is $100, and the Medicare benefit for this consultation is paid at a rate of 75%.
Ann will face a gap expense of $100-$75 = $25 and an out-of-pocket expense of $120-$75 = $45.
Gap and out-of-pocket expenses are designed to be substantially lower than the actual cost for a consultation, except for services not covered by Medicare benefits. In addition, they can be further covered by the Government in certain circumstances (e.g. safety nets, See National Health Service for Expats in Australia). Therefore, the actual price to pay when you go private may be nil or very low, without prejudice to the benefits of circumventing choice restrictions and waiting times at public hospitals.
Typically, a consultation with a general practitioner (GP) is subject to a 100% Medicare benefit. If your doctor charges you no more than the MBS fee, and sends the invoice directly to Medicare (bulk billing), you may have nothing to pay at all. Bulk billing is made possible with your Medicare card.
A consultation with a specialist attracts 85% Medicare benefit, unless the service is not within the scope of Medicare. See National Health Service for Expats in Australia You need GP referral to qualify for the Medicare benefit.
If you are unclear whether Medicare covers the specialist treatment you are looking for, check the current Medicare Benefits Schedule. See National Health Service for Expats in Australia A general treatment cover may supplement Medicare with regard to out-of-hospital care. See Health Insurance for Expats in Australia
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