Confused about how health insurance works

[TandT]

Hi everyone

We've just moved to Australia with my partner's work on 457 visas. His work arranged private health insurance for both of us before we came, and we've got a copy of this policy but it doesn't go in to any detail of how the process works and I haven't been able to find out. I take regular medication so at some point will need to register with a GP here and start getting more medication. The insurers are aware of all the medication and told us it would be covered. As we already have health insurance does anyone know:

1. Do we need to get Medicare cards as well? (I don't think we do but could be wrong)

2. When I go to the GP and get medication, how do the appointment fees and prescription fees work - do I pay them upfront and then claim back from the insurance provider? Or is there some other system for paying through health insurance? Do I need to take a copy of the health insurance with me to register with a GP?

If anyone could enlighten me I'd be really grateful. I have tried googling for this information but just seem to get bogged down in information about Medicare. 

[Marisawright]

You don't need to register with a GP, you just choose a doctor.  If you don't like that doctor, you go somewhere else next time until you find one you like.

Your best plan is to get the policy from your employer, then ring up your insurance company and ask them how their claim process works. 

For all health insurance, you just pay for everything upfront and then send in a claim form.   With some insurers, you can present your membership card at the GP's office and they will put it through a machine that processes your claim immediately and pays the doctor direct - but that's not every insurer and it's not every practitioner.

If you were a UK resident prior to arriving in Australia, you are entitled to reciprocal cover and therefore you're entitled to a Medicare card (which is valid only for essential medical treatment and not for elective or pre-existing conditions).  

[VERYSTORMY]

You should certainly register with Medicare asap as insurance doesn't cover everything - even the very best won't and also there can be gaps between what the insurance pays and what you are charged and this can be a LOT of money. 

Also, a Medicare card is an important piece of ID that can be used for lots of things

[TandT]

Thank you both. So we need to get Medicare cards, thanks for clarifying. I'm a little confused about the Medicare levy but I'll do some more reading around that. It seems a bit old fashioned that you have to go and wait in a centre to apply for a Medicare card during office hours (here in Adelaide, not sure if it's how it works state-wide) - not a problem for me but a pain for my partner and anyone else who works 9-5. 

I'll try and contact the insurance company too. As it was all arranged for us and we had no direct contact with the insurers (we just had to complete some questionnaires for partner's employer who dealt with insurer) I feel we're a bit in the dark about what exactly is covered and so on so I'll need to look in to it anyway.

Good point about the ID - we are finding I need something more than what I have ID-wise for applying to rent a property. 

Edited August 22, 2018 by TandT

[Guest The Pom Queen]

Hi @TandT we have private health but we are still liable for our medications unless they aren’t on PBS then Bupa will pay something towards them. 

‘To save paying Drs fees see if you can find one that Bulk Bills.

 

[Marisawright]

On 22/08/2018 at 16:34, TandT said:

I'll try and contact the insurance company too. As it was all arranged for us and we had no direct contact with the insurers (we just had to complete some questionnaires for partner's employer who dealt with insurer) I feel we're a bit in the dark about what exactly is covered and so on so I'll need to look in to it anyway.

Yes, you certainly will, since there's no way you can use claim on the health insurance unless you have the details!

[Quinkla]

Health insurance works by you paying thousands of dollars a year to an insurance company and then if you need hospital inpatient treatment they will give you back about $20, leaving you to pay hundreds yourself. If you get extras cover, the same will apply for physiotherapy, dental treatment or medical devices. 

[SWMOY04]

On ‎24‎/‎08‎/‎2018 at 17:29, The Pom Queen said:

Hi @TandT we have private health but we are still liable for our medications unless they aren’t on PBS then Bupa will pay something towards them. 

‘To save paying Drs fees see if you can find one that Bulk Bills.

 

What's Bulk billing @The Pom Queen?

[Bulya]

26 minutes ago, SWMOY04 said:

What's Bulk billing @The Pom Queen?

Bills the govt not you 

[unzippy]

You don't have to pay after seeing a Doctor.  The Doctor claims the money directly from Medicare.

Without bulk billing, you go see a doctor and pay, medicare then remiburses you some time later.

Very wasteful system imo.

 

https://www.humanservices.gov.au/individuals/services/medicare/medicare-bulk-billing

 

[Marisawright]

37 minutes ago, unzippy said:

You don't have to pay after seeing a Doctor.  The Doctor claims the money directly from Medicare.

Without bulk billing, you go see a doctor and pay, medicare then remiburses you some time later.

Very wasteful system imo.

 

https://www.humanservices.gov.au/individuals/services/medicare/medicare-bulk-billing

 

Most doctors today claim the basic fee direct from the government and you only pay the extra

[SWMOY04]

thanks guys...

it helps...but only a little... could you expand more on this? I'm afraid I'm slow at times...

so far I get that bulk billing is to do with the GP billing the govt...so does this mean I pay something still? where does insurance factor in? where does medicare fit in? where do reimbursements come in?

I'm sorry to bug, but its coz the information has come back a bit disjointed for me. 

[unzippy]

4 minutes ago, SWMOY04 said:

thanks guys...

it helps...but only a little... could you expand more on this? I'm afraid I'm slow at times...

so far I get that bulk billing is to do with the GP billing the govt...so does this mean I pay something still? where does insurance factor in? where does medicare fit in? where do reimbursements come in?

I'm sorry to bug, but its coz the information has come back a bit disjointed for me. 

It's a disjointed system!

 

Medicare basics - https://www.privatehealth.gov.au/healthinsurance/whatiscovered/medicare.htm

Health insurance basics - https://www.privatehealth.gov.au/healthinsurance/

ANd then maybe the most useful reading - http://www.abc.net.au/news/2018-07-09/private-health-insurance-do-i-need-it/9633430

For whatit's worth, I'm only considerng it to offset my tax bill...

[Toots]

15 minutes ago, unzippy said:

It's a disjointed system!

It does have lots of faults but we shouldn't whinge about it because before Medicare, it was not that uncommon for people to avoid using health-care services because of the cost, or for people to experience serious financial hardship when they did.  The better off always had health insurance.

[Marisawright]

19 minutes ago, SWMOY04 said:

thanks guys...

it helps...but only a little... could you expand more on this? I'm afraid I'm slow at times...

so far I get that bulk billing is to do with the GP billing the govt...so does this mean I pay something still? where does insurance factor in? where does medicare fit in? where do reimbursements come in?

Unlike the NHS in the UK, Medicare in Australia doesn't employ any GP's. They all either work for themselves.  The doctors decide what they want to charge for their services, just like any other business person.

However, Medicare won't pay the doctor that amount.  The government has decided a set fee for each service and that's the amount that can be claimed,  no more.

If a doctor decides he's happy to accept the set fee, then when you go to see him, you just present your Medicare card and he sends the bill straight to the government.  Some doctors are happy to do this because although they're only getting a set fee, they save a lot on admin costs.

When I first came to Australia, it was very common for doctors to bulk bill.  I don't know whether it's doctors getting greedier, or whether the govt hasn't increased the set fee for a while, but I notice more and more doctors aren't content to bulk bill.  

If you go to a doctor who doesn't bulk bill, then it depends how up to date their systems are.  You will either have to pay the full cost of the consultation and then submit a claim to Medicare OR (more common these days), the doctor will swipe your card and claim the set fee straight from Medicare, then you pay just the difference.  The difference is called "the gap".

"The gap" is not covered by health insurance.  Health insurance mainly exists to cover you for treatment outside the public system.  Most Australians take it for granted that if they need specialist treatment, they'll go to a private specialist rather than waiting to see someone in a public hospital. In fact, it's so taken for granted that if a GP refers you to a specialist, he won''t even ask if that's what you want. 

[SWMOY04]

WOW thanks @Marisawright... this makes a lot of sense now. thanks again

[DeeTowers]

To give you some other context I have had 2 spinal surgeries in the last year and was refereed to a Neurosurgeon who does not work in the public system - most don't but if they do there will be a long wait.

Medicare have codes and set fees for each procedure and rebates you 75% or 85% for that procedure depending on your status - Your private health fund is there to cover the remaining 25/15% gap - However a specialist can charge whatever they like so for example my first surgery my surgeon charged over $7500, I got about $2800 back from medicare and my private health fund. Also there was the anaesthetist, assistant surgeon, etc... who all charge their own fees - so after claiming back from medicare and from my private health fund I was still out of pocket just over $9500 for one procedure - not to mention the many CT scans too!!

My private health fund did pay fully for a private hospital room, the theatre, intensive care etc... for a one off excess of $450.

Due to the severity of my spinal symptoms, waiting was not an option - 2 weeks later and procedure number 1 was done. 

8months later I did it all again..... I have spent a lot of money but I have had the best Neurosurgeon and team look after me and have not had to wait in crippling conditions for the procedures. If I was in the UK I would still be waiting for my first procedure on the NHS.

It took ages for me to get my head around it all as I had private healthcare in the UK which covered everything with no extra out of pocket expenses - the whole medicare/health fund/Gap thing took some understanding to say the least!

 

[Marisawright]

12 minutes ago, DeeTowers said:

To give you some other context I have had 2 spinal surgeries in the last year and was refereed to a Neurosurgeon who does not work in the public system - most don't but if they do there will be a long wait.

That's the common belief, but I suspect some of it is the health funds (and the government) trying to scare us all into getting private health insurance.

For instance, I lost my voice and was referred to a private throat specialist.  He was a horrible man, but he diagnosed a possible cancerous growth and was about to book me in for an op.  He asked me what health fund i was in and when I said I didn't have health insurance, he said, "In that case I'll refer you to the public system".  I didn't trust or like him, so although I thought it would mean a long wait, I decided to take the referral.  Only three weeks later, I saw a doctor at Randwick Hospital. He diagnosed a fungal infection and I was right as rain in a couple of days.

Another example - I had a spinal fusion, too, and I also went to a private neurosurgeon.  I'm very happy with the result even though I was out of pocket almost $10,000.  However, just a few months later, my friend's father had exactly the same op on the public system.  He waited four weeks, and it cost him absolutely nothing.

So, while I'm sure there are long waiting lists in the public system for some things, it's by no means true for everything.

[DeeTowers]

2 minutes ago, Marisawright said:

That's the common belief, but I suspect some of it is the health funds (and the government) trying to scare us all into getting private health insurance.

For instance, I lost my voice and was referred to a private throat specialist.  He was a horrible man, but he diagnosed a possible cancerous growth and was about to book me in for an op.  He asked me what health fund i was in and when I said I didn't have health insurance, he said, "In that case I'll refer you to the public system".  I didn't trust or like him, so although I thought it would mean a long wait, I decided to take the referral.  Only three weeks later, I saw a doctor at Randwick Hospital. He diagnosed a fungal infection and I was right as rain in a couple of days.

Another example - I had a spinal fusion, too, and I also went to a private neurosurgeon.  I'm very happy with the result even though I was out of pocket almost $10,000.  However, just a few months later, my friend's father had exactly the same op on the public system.  He waited four weeks, and it cost him absolutely nothing.

So, while I'm sure there are long waiting lists in the public system for some things, it's by no means true for everything.

That's really interesting to hear - it was my doctor that said it would be quicker and gave me 3 neurosurgeon names to choose from so I did my research and went with the best but all 3 their admin staff said they were private only.

I am glad I had it done quickly when I did but it would have been interesting to know if I had done it public how long I would have had to wait. I know I will need more at some point so will keep that in mind - thank you!

Glad you are ok and the throat thing was not a growth! How wrong could he have been - yikes!

Like i said it took me ages to understand it all, perhaps I never will ha ha! 

All the best!

[Marisawright]

16 minutes ago, DeeTowers said:

That's really interesting to hear - it was my doctor that said it would be quicker

I think even the doctors have been sucked into believing it...

[Guest The Pom Queen]

Also don’t settle on the price given by one specialist. For example the op on Hubby neck was going to cost him $500 which was the gap fee. His neurologist then told him one of his colleagues had to operate on a lady who had the same op done in Victoria, not only had he messed her spine up but his gap fee was $28,000

[Bulya]

We’ve both had major ops (aneurism, TKR) including ambulance transport, with more X-rays, CT Scans, ultrasounds, medication, GP and specialist visits than either of us could possibly remember and haven’t paid a single solitary cent.  Personally had two lots of X-rays and a CT Scan in the last fortnight and an ultrasound booked for next week, all at zero cost.  Can’t see the value in private health insurance tbh 

[Guest The Pom Queen]

10 minutes ago, Bulya said:

We’ve both had major ops (aneurism, TKR) including ambulance transport, with more X-rays, CT Scans, ultrasounds, medication, GP and specialist visits than either of us could possibly remember and haven’t paid a single solitary cent.  Personally had two lots of X-rays and a CT Scan in the last fortnight and an ultrasound booked for next week, all at zero cost.  Can’t see the value in private health insurance tbh 

I was told to take private insurance out by my GP in Cairns and it was the best thing I did. I get to choose the best surgeons for the job from all of Australia. When the public system told me they would basically have to remove a part of me, I found one of only two surgeons in Australia who were doing a new kind of operation and although I need an op every 3 months to manage it this was the best thing I did. 

‘I have found the public system is a get them in and get them out as fast as possible attitude. For me I try every alternative there is before agreeing to them.

I spent 4 weeks in hospital 3 weeks ago, including 1 week in ICU, 3 operations, 5 CT/MRI’s, 2 lots of treatment which cost $25,000 each one, blood tests every day, 4 X Rays, and 5 different specialists, 3 of which saw me everyday for 4 weeks and I didn’t pay a penny. I dread to think what the bill would have come to for that stay. So for me private definitely is the best. If I rang my specialist now (I have mobiles for all of them) and said Paul this is happening, I would be admitted within the hour in my own room, treatment started, bloods done and MRI’s done with the results back the same day.

[Bulya]

15 minutes ago, The Pom Queen said:

I was told to take private insurance out by my GP in Cairns and it was the best thing I did. I get to choose the best surgeons for the job from all of Australia. When the public system told me they would basically have to remove a part of me, I found one of only two surgeons in Australia who were doing a new kind of operation and although I need an op every 3 months to manage it this was the best thing I did. 

‘I have found the public system is a get them in and get them out as fast as possible attitude. For me I try every alternative there is before agreeing to them.

I spent 4 weeks in hospital 3 weeks ago, including 1 week in ICU, 3 operations, 5 CT/MRI’s, 2 lots of treatment which cost $25,000 each one, blood tests every day, 4 X Rays, and 5 different specialists, 3 of which saw me everyday for 4 weeks and I didn’t pay a penny. I dread to think what the bill would have come to for that stay. So for me private definitely is the best. If I rang my specialist now (I have mobiles for all of them) and said Paul this is happening, I would be admitted within the hour in my own room, treatment started, bloods done and MRI’s done with the results back the same day.

Up there probably different.  Here public access the same specialists and facilities as private except for the hospital bed.  

[Guest The Pom Queen]

24 minutes ago, Bulya said:

Up there probably different.  Here public access the same specialists and facilities as private except for the hospital bed.  

It’s the time frame that can be for ages. An example being I was referred by a private specialist to a Professor who is based at the PAH and is the only one in Australia who can help  that’s because he studied overseas and although he isn’t fully versed with my condition as it’s rare (Without going in to too much detail my organs are shutting down so I have different specialists for each part and then one overall specialist who organises everything) he is the only one who has any knowledge at all. Now I’ve seen him twice and I’ve now been waiting to see him since January, now don’t get me wrong I’ve had to cancel multiple appointments with him as I’ve been in my own hospital, but it’s around 3 - 4 months between each new date, which for my condition is a long time.

 I suppose it really depends what’s wrong with you. Hubby and my sons are on the policy it’s a family policy and since we took it out there is only Rob who has used it once and the boys never.