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Private Health Insurance / Medicare / Out of Pocket Expense

Private Health Insurance / Medicare / Out of Pocket Expense

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Old May 15th 2012, 6:50 am
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Angry Private Health Insurance / Medicare / Out of Pocket Expense

Being new to Australia, I'm seeking some advice on health insurance based on my recent experiences, any help much appreciated.

Arrived in Perth in Nov 2011, and soon after took out private health insurance through HBF (top hospital/essential standard) for the family. This I assumed was the same as private cover in th UK.

Anyway a few months later, I hurt my back lifting some furniture, as a typical bloke, I didn't bother going to the GP, thought it would just fix itself. Week and a half later, back was still hurting, and if anything was getting worse, so off I went to the GP, who prescribed me some heavy painkillers, a sick note, and told me to rest it out for a week.

A few days later, after waking up in the morning, I felt this incredible pain down the right leg, like a bolt of lightning. I managed to scramble to the GP, who insisted I undergo an x-ray to determine the problem. X-ray done, I returned back to the GP, X-ray didn't show anything negative and so he implied it could be sciatica - back disc pushing against the sciatic nerve, causing the pain. He suggested a CT scan to confirm. CT scan done and returned to the GP, who confirmed it was the disc/nerve problem. He asked if I had private health insurance, which I confirmed and said it was with HBF, he then referred me to a neurologist stipulating I may need surgery.

Needless to say this freaked me out big time, and before I went down that route I wanted a second opinion, so I went to see another GP taking my X-ray and CT scans with me. This GP came to the same conclusion, asked whether I had private cover, and then referred me to a neurologist - the same specialist.

Armed with two referrals, I called up the specialists reception, who asked again if I had private cover, and then made an appointment, unfortunately the earliest slot was 3 months away.

Up until this point I hadn't paid a dime, apart from the prescriptions. The two GPs, X-ray and CT scan were covered by bulk billing.

Whilst waiting for the consult, I undertook weekly physio, which was covered half by HBF, the other half I had to pay, $60 -$29 (HBF) = $31 my pocket.

Well before my appointment with the neurologist, my back and leg pain where almost gone, partially because of the physio, and partially my body just fixing itself.

Anyway the appointment came and I thought I best go to see what the specialist had to say about it. I must have been in the consult for a maximum of 10min. When I came out the receptionist asked for payment for the consultation. $300 for 10min....doesn't equate. Anyway I paid and she gave me a receipt to take to Medicare for rebate.

Ok I thought, Medicare will cover the cost, but I have to pay upfront? So I took the receipt to Medicare who gave me a $100 as that's what they said is the scheduled fee.

Ok I thought, so that's we're the private health insurance comes in to play and pays back the difference....wrong! According to HBF, as it was an out-patient service it's not covered by the insurance, and now im out of pocket by $200 which is a considerable amount!

So what's going on here? I thought by taking out the insurance and paying the high premiums I'd be covered for these situations?

And what happens in the future? Me and the wife are getting older and as such will experience such ailments more often, the GPs can only do so much before they refer you to a specialist? Does that mean we have to pay out each time we go see a specialist?

I also discovered, that even as an in-patient, there maybe costs associated with the attaining doctor, anaesthetist, and services like pathology, radiology etc.. What's the point of the health insurance if it doesn't cover this? Is it so I get to the front of the queue? If that's the case I'd rather wait for public hospital than pay a ton of premium, knowing that I may have to pay ontop anyway!

Please can someone clear up this situation with some real life examples, as the insurance companies just seem to baffle me with jargon!

Thank you very much!

Last edited by grapii; May 15th 2012 at 7:02 am.
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Old May 15th 2012, 8:44 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by grapii
Being new to Australia, I'm seeking some advice on health insurance based on my recent experiences, any help much appreciated.

Arrived in Perth in Nov 2011, and soon after took out private health insurance through HBF (top hospital/essential standard) for the family. This I assumed was the same as private cover in th UK.

Anyway a few months later, I hurt my back lifting some furniture, as a typical bloke, I didn't bother going to the GP, thought it would just fix itself. Week and a half later, back was still hurting, and if anything was getting worse, so off I went to the GP, who prescribed me some heavy painkillers, a sick note, and told me to rest it out for a week.

A few days later, after waking up in the morning, I felt this incredible pain down the right leg, like a bolt of lightning. I managed to scramble to the GP, who insisted I undergo an x-ray to determine the problem. X-ray done, I returned back to the GP, X-ray didn't show anything negative and so he implied it could be sciatica - back disc pushing against the sciatic nerve, causing the pain. He suggested a CT scan to confirm. CT scan done and returned to the GP, who confirmed it was the disc/nerve problem. He asked if I had private health insurance, which I confirmed and said it was with HBF, he then referred me to a neurologist stipulating I may need surgery.

Needless to say this freaked me out big time, and before I went down that route I wanted a second opinion, so I went to see another GP taking my X-ray and CT scans with me. This GP came to the same conclusion, asked whether I had private cover, and then referred me to a neurologist - the same specialist.

Armed with two referrals, I called up the specialists reception, who asked again if I had private cover, and then made an appointment, unfortunately the earliest slot was 3 months away.

Up until this point I hadn't paid a dime, apart from the prescriptions. The two GPs, X-ray and CT scan were covered by bulk billing.

Whilst waiting for the consult, I undertook weekly physio, which was covered half by HBF, the other half I had to pay, $60 -$29 (HBF) = $31 my pocket.

Well before my appointment with the neurologist, my back and leg pain where almost gone, partially because of the physio, and partially my body just fixing itself.

Anyway the appointment came and I thought I best go to see what the specialist had to say about it. I must have been in the consult for a maximum of 10min. When I came out the receptionist asked for payment for the consultation. $300 for 10min....doesn't equate. Anyway I paid and she gave me a receipt to take to Medicare for rebate.

Ok I thought, Medicare will cover the cost, but I have to pay upfront? So I took the receipt to Medicare who gave me a $100 as that's what they said is the scheduled fee.

Ok I thought, so that's we're the private health insurance comes in to play and pays back the difference....wrong! According to HBF, as it was an out-patient service it's not covered by the insurance, and now im out of pocket by $200 which is a considerable amount!

So what's going on here? I thought by taking out the insurance and paying the high premiums I'd be covered for these situations?

And what happens in the future? Me and the wife are getting older and as such will experience such ailments more often, the GPs can only do so much before they refer you to a specialist? Does that mean we have to pay out each time we go see a specialist?

I also discovered, that even as an in-patient, there maybe costs associated with the attaining doctor, anaesthetist, and services like pathology, radiology etc.. What's the point of the health insurance if it doesn't cover this? Is it so I get to the front of the queue? If that's the case I'd rather wait for public hospital than pay a ton of premium, knowing that I may have to pay ontop anyway!

Please can someone clear up this situation with some real life examples, as the insurance companies just seem to baffle me with jargon!

Thank you very much!

Sorry but this is basically how it works here.

You pay medicare, and have private health but there is still a gap.

Sounds easy, dont have private health. Great in a emergency situation (accident etc) will have to see you, fix you up at that level, but much of the ongoing care may still be user pays anyway.

Over a basic income limit ( limits all changing too, so I wont quote them). if you dont have private, you will pay a extra medicare levy for not having it. So you cant win.

I wouldnt rely on the medicare system, the wait times are often simply too long. Cancer treatments, eye surgery, heart surgery, how long do you have to wait?

If your out of pocket is over $2000, you can start to claim a 20% tax refund, but only on the out of pocket, not the whole lot.

Medicare has a safety net for prescriptions, it used to be about a $1000 then you got it cheaper.

You really will have to check all figures, it all changed (for the worse of course) in the budget.

Speak to your health fund, they can offer a list of providers who charge that particular fund members less, so less of a gap.

Were a family of 4, health cover now 300 a month, tax penalty if we dont pay it. But study your fund, for eg, our twice yearly dental checkups are fully paid by the fund so that alone is about $1600 a year! for 4 people, it does pay back too.
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Old May 15th 2012, 9:19 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

I literally dont understand Medicare or Private at all, and how you get refunds.

Im registered for both however!
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Old May 15th 2012, 9:28 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by jad n rich
If your out of pocket is over $2000, you can start to claim a 20% tax refund, but only on the out of pocket, not the whole lot.
Soon to change as a result of last week's budget:

Means testing and reducing the net medical expenses rebate by increasing the threshold to $5K and reducing the rebate percentage to 10% (down from 20%) (Means testing thresholds- $84K single or $168K family)

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Old May 15th 2012, 9:29 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by Tramps_mate
I literally dont understand Medicare or Private at all, and how you get refunds.

Im registered for both however!
Me neither. Also have both.
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Old May 15th 2012, 9:32 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by OzSheila
Soon to change as a result of last week's budget:

Means testing and reducing the net medical expenses rebate by increasing the threshold to $5K and reducing the rebate percentage to 10% (down from 20%) (Means testing thresholds- $84K single or $168K family)


Woww!!

I knew things had got even worse but that stinks!!
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Old May 15th 2012, 9:42 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by jad n rich
Woww!!

I knew things had got even worse but that stinks!!
Yep. Going to finish paying off son's braces ($7K) before June 30. Trouble is Stage 2 of his treatment (at the end of the year) involves a temporary plate and I dont know how much this is going to set me back. Stage 3 in another few years I have been told will be about $10K in todays prices.

Youngest son still to be determined whether he needs braces.

Waiting to hear back from accountant as to whether we can pre-pay health insurance for next year to avoid reduction in rebate.
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Old May 15th 2012, 9:56 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by OzSheila
Yep. Going to finish paying off son's braces ($7K) before June 30. Trouble is Stage 2 of his treatment (at the end of the year) involves a temporary plate and I dont know how much this is going to set me back. Stage 3 in another few years I have been told will be about $10K in todays prices.

Youngest son still to be determined whether he needs braces.

Waiting to hear back from accountant as to whether we can pre-pay health insurance for next year to avoid reduction in rebate.

We had one kids braces, partners eye operation and my 3 crowns, total about 20K over 2 years. The out of pocket was around $9000. That bit of tax back helped.

This government is stupid beyond belief. How many people are going to try and cram back into medicare for many things with all these increases in private health .

But I suppose the government is confident that wont happen, the bloody wait lists are often years.
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Old May 15th 2012, 10:21 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

@OP - Private health insurance has two components:
1. Private hospital cover
2. Extras cover

1. Is for inpatient treatment at a private hospital, private day hospital or private patient at a public hospital only. You sometimes have a gap and you should check the private insurers website to see if they have gapcover preferred hospitals and/or doctors.

2. Is for ancillary health services like dental, optical etc

So to confirm private health insurance has nothing to do with private doctors outside hospital. Medicare chips in a bit for private specialists (and the second consultation is no where near as expensive) but you either pay the gap or ask your GP to be referred to a public specialist like the NHS.

Similar to the NHS the wait time depends on the speciality and the public hospital. You can see details for the wait times for the specialities at your local hospitals here: http://www.myhospitals.gov.au/

Similar to the NHS some wait times for elective surgery are long and some are acceptable so I would not dismiss it out of hand as many are happy with their treatment and some are not. In my experience urgent cases like cancer etc often get fantastic treatment through the public system.

If you are using public hospitals and don't have private insurance you always have the option of occasionally skipping the elective surgery queue by paying as a private patient at a public hospital. This works out for some cheaper than paying private premiums.

Last edited by fish.01; May 15th 2012 at 10:24 am.
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Old May 15th 2012, 10:26 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Yes Grapii, it's a nightmare here.
As an example, I have Synvisc (synovial fluid) injected into my knee every 12 months due to osteoarthritis. I've only had it once in this country but cost of orthopaedic surgeon was $165 - rebate under $100 (can't remember exactly). I also had to buy the medicine - $300 ish which was not covered at all by medicare or health fund. We pay top everything! Also, have to pay for Dr. referral $65 (get $35 back).

My dentist has quoted me $7k for crowns etc and the maximum I will get back is $2400. So you either pay up or lose your teeth - to be fair I did have this situation one summer back home recently - the NHS dentist would have pulled the tooth out but I told him to temporary fill it and I got it root filled and crowned in Jakarta.

When I arrived here my Aussie neighbour told me if I was ever in an accident/emergency to say I didn't have private cover and then would get free treatment instead of having to top up the payment out of my own pocket.
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Old May 15th 2012, 10:30 am
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Any dental work like crowns and braces would get done in the UK. My Dentist told me he has patients that see him once a year when they holiday back in the UK..

I told him he should move to Oz in that case!!
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Old May 15th 2012, 10:39 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by Penny45

When I arrived here my Aussie neighbour told me if I was ever in an accident/emergency to say I didn't have private cover and then would get free treatment instead of having to top up the payment out of my own pocket.

It works to some extent, but once they have fixed up the immediate emergency they can just shuffle you back into the private system. FIL and SIL both had medical emergencies stabilised but to actually cure it they had to go private or wait.......

OP With the claiming on medicare or private, everything has an item number, the funds know exactly what the other one will pay for. Usually if medicare have paid their tiny refund on an item the private fund wont touch it.

Last edited by jad n rich; May 15th 2012 at 10:44 am.
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Old May 15th 2012, 10:43 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by Penny45
...
When I arrived here my Aussie neighbour told me if I was ever in an accident/emergency to say I didn't have private cover and then would get free treatment instead of having to top up the payment out of my own pocket.
It's your right to use public specialists/hospitals whenever you want. Just tell GP, ambulance or whoever that you want to use public system. One of my sisters has had various issues over the years from elective things to chronic conditions to urgent cancer treatment. All was done on public in good time with top specialists and ongoing care - and she paid nought. So while it can be bad it can also be very good ... similar to the NHS I expect.
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Old May 15th 2012, 10:53 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by fish.01
@OP - Private health insurance has two components:
1. Private hospital cover
2. Extras cover

1. Is for inpatient treatment at a private hospital, private day hospital or private patient at a public hospital only. You sometimes have a gap and you should check the private insurers website to see if they have gapcover preferred hospitals and/or doctors.

2. Is for ancillary health services like dental, optical etc

So to confirm private health insurance has nothing to do with private doctors outside hospital. Medicare chips in a bit for private specialists (and the second consultation is no where near as expensive) but you either pay the gap or ask your GP to be referred to a public specialist like the NHS.

Similar to the NHS the wait time depends on the speciality and the public hospital. You can see details for the wait times for the specialities at your local hospitals here: http://www.myhospitals.gov.au/

Similar to the NHS some wait times for elective surgery are long and some are acceptable so I would not dismiss it out of hand as many are happy with their treatment and some are not. In my experience urgent cases like cancer etc often get fantastic treatment through the public system.

If you are using public hospitals and don't have private insurance you always have the option of occasionally skipping the elective surgery queue by paying as a private patient at a public hospital. This works out for some cheaper than paying private premiums.
some private funds also have drs/surgeons who have gap cover ie the fund covers the gap but some surgeons/anaesthetiststs etc decide this means they can earn more by putting an extra charge on top so make sure you discuss all this with your fund and with your doctor before hand find out exactly what is covered and what isn't.
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Old May 15th 2012, 10:59 am
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Default Re: Private Health Insurance / Medicare / Out of Pocket Expense

Originally Posted by Tramps_mate
Any dental work like crowns and braces would get done in the UK. My Dentist told me he has patients that see him once a year when they holiday back in the UK..

I told him he should move to Oz in that case!!
Well this was the NHS dentist in Bridgend, he was from Zimbabwe (or as he insisted in calling it Rhodesia). I did get treated as an NHS patient though as the receptionist insisted that 'all the immigrants get free treatment so you should too'!!!

Originally Posted by jad n rich
It works to some extent, but once they have fixed up the immediate emergency they can just shuffle you back into the private system. FIL and SIL both had medical emergencies stabilised but to actually cure it they had to go private or wait........
Luckily, have never needed any emergency treatment that was just the advice given.
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