Do I Need Medical Insurance?

[JetBlast]

Hello,

I have recently arrived in Australia on a 489 and can get medicare under the reciprocal agreement. I understand this doesn't cover:

• medicines that aren’t in the Pharmaceutical Benefits Scheme
• Pharmaceutical Benefits Scheme medicines for In Vitro Fertilisation (IVF)
• care planned before you got to Australia
• care for Assisted Reproductive Technology (ART)
• private hospital care
• public hospital care as a private patient
• ambulance travel
• dental care unless it’s in the Chronic Disease Management scheme
• care from a physiotherapist, occupational therapist, speech therapist, eye therapist, chiropractor, podiatrist or psychologist unless it’s in the Chronic Disease Management scheme
• acupuncture unless it’s from a doctor
• glasses and contact lenses
• hearing aids and other devices
• prostheses
• costs someone else is responsible for - for example an insurer, employer or government agency
• care that isn’t clinically essential
• cosmetic surgery
• checks for life insurance or superannuation or to join a friendly society
• home nursing

If I go to a public hospital as a public patient everything else is covered under Medicare. This is similar to the NHS (ambulance is probably the biggest difference).  When I get a PR the list above is reduced eg: prostheses & physiotherapist

I understand that if I go to a doctor that bulk bills it's all covered by Medicare. If I go to one that doesn't do bulk billing I have to pay the gap between the doctors actual fee and schedule fee. This shouldn't be huge amount anyway. If the doctor refers me to a specialist can this be done via public so I don't pay?

Assuming I am happy to go all public and I know the above list isn't covered and happy to pay for them - Do I actually need private cover?  Is there anything I might have missed please?

Thanks

[Quoll]

Not quite.  You are entitled to pay the same as Australians for "necessary" medical care.  That doesnt mean everything that could happen - for example if your kid wants his tonsils out that's elective.  You want your gall bladder out, that's elective.  You need a knee replacement, that's elective.  You need a procedure as a cancer screen, that my be elective - it's whatever the schedule says it is, not whether you think it's necessary or not.

Most specialists are private unless you choose to wait some time - there was an article in the Canberra Times last year which said the public wait to see a urologist was 6 years!  You generally can pay around the $100-120 mark for a specialist "gap".

Medicare is a co-pay system so the expectation is that Aussies will pay around $35 per visit to a GP.  Of all the Aussies I know, none are hell bent on getting a bulk billing doctor as are all the new migrants on here who seem to think that they should get free health care because that's the way it is with the NHS.  Bulk billing was designed as a safety net for those who would struggle to pay the co-payment but it seems to be being exploited by the factories which churn patients through, usually with little continuity of care.  Medicare is not the NHS

In all states you need to watch out for ambulance cover - some states have it as part of your power bill but in the states which require independent insurance you had better be sure your health care policy has it covered because it can be eye waveringly expensive.

Other catch 22 is that if you have something that is elective and you are expected to go home to get it fixed, once you are no longer resident in UK you will have to pay for it there too.  No matter if you are a citizen - you have to actually be resident in UK for treatment.

[Marisawright]

6 hours ago, JetBlast said:

Hello,

I have recently arrived in Australia on a 489 and can get medicare under the reciprocal agreement. I understand this doesn't cover:

• ...

If I go to a public hospital as a public patient everything else is covered under Medicare.

True, but notice one of the things not covered is "care that isn't clinically essential". 

The interpretation of "clinically essential" relies on whether it would be safe for you to fly home and have treatment in your own country.  If the answer is yes, then it's not essential and it's not covered.  The fact that you won't be covered by the NHS either is not their problem. 

In practice, I have a sneaky suspicion that hospitals are not that rigorous and if you present with a medical issue, they may not always check your status before giving treatment. But personally, I wouldn't rely on that!

[JetBlast]

I am struggling to find a definition of clinically essential on the website. What source did you use please?

[Marisawright]

28 minutes ago, JetBlast said:

I am struggling to find a definition of clinically essential on the website. What source did you use please?

http://www.health.gov.au/internet/budget/publishing.nsf/Content/budget2017-factsheet17.htm

[shaunfreo]

7 hours ago, JetBlast said:

Hello,

I have recently arrived in Australia on a 489 and can get medicare under the reciprocal agreement. I understand this doesn't cover:

• medicines that aren’t in the Pharmaceutical Benefits Scheme
• Pharmaceutical Benefits Scheme medicines for In Vitro Fertilisation (IVF)
• care planned before you got to Australia
• care for Assisted Reproductive Technology (ART)
• private hospital care
• public hospital care as a private patient
• ambulance travel
• dental care unless it’s in the Chronic Disease Management scheme
• care from a physiotherapist, occupational therapist, speech therapist, eye therapist, chiropractor, podiatrist or psychologist unless it’s in the Chronic Disease Management scheme
• acupuncture unless it’s from a doctor
• glasses and contact lenses
• hearing aids and other devices
• prostheses
• costs someone else is responsible for - for example an insurer, employer or government agency
• care that isn’t clinically essential
• cosmetic surgery
• checks for life insurance or superannuation or to join a friendly society
• home nursing

If I go to a public hospital as a public patient everything else is covered under Medicare. This is similar to the NHS (ambulance is probably the biggest difference).  When I get a PR the list above is reduced eg: prostheses & physiotherapist

I understand that if I go to a doctor that bulk bills it's all covered by Medicare. If I go to one that doesn't do bulk billing I have to pay the gap between the doctors actual fee and schedule fee. This shouldn't be huge amount anyway. If the doctor refers me to a specialist can this be done via public so I don't pay?

Assuming I am happy to go all public and I know the above list isn't covered and happy to pay for them - Do I actually need private cover?  Is there anything I might have missed please?

Thanks

 

19 minutes ago, JetBlast said:

I am struggling to find a definition of clinically essential on the website. What source did you use please?

It is difficult to give a definitive answer, to some extent you will only know what isn't when you are told something isn't covered,  but from a medical perspective it would be treatment which is urgently required, if treatment was not given could cause further complications, disabilities, or worst case scenario a threat to life.

In my experience of hospitals I have worked in  as Marisa says they were not that diligent in checking, but there are certainly more checks on eligibility undertaken now so it is potentially more risky.

Basic cover insurance is not that expensive and would certainly be cheaper than forking out for treatment that was not covered, 

[JetBlast]

5 minutes ago, Marisawright said:

http://www.health.gov.au/internet/budget/publishing.nsf/Content/budget2017-factsheet17.htm

I can't see where that defines what is "clinically essential".

[Marisawright]

10 minutes ago, JetBlast said:

I can't see where that defines what is "clinically essential".

You've just had a reply from someone who has actually worked in hospitals, telling you how it works in practice - I'd say that is far more important than anything you can find on a website.  

However, the wording I'm looking at is "Australian taxpayers will no longer subsidise treatments that can wait until the visitor returns home or for which the visitor can pay while they are here."

Edited May 17, 2019 by Marisawright

[Skani]

I suspect that "clinically essential" is at the discretion of the medical practitioner and will depend on how stressed the public resources are in your location at the time.  

Another factor to consider is that you will be taxed a Medicare Levy Surcharge if you earn over a certain amount and do not have private hospital insurance.   Details are here:

https://www.privatehealth.gov.au/health_insurance/surcharges_incentives/medicare_levy.htm

Depending on your family situation and income it may make financial sense to take out private hospital cover at least.

[Amber Snowball]

I’ll just chime in with ambulance cover. If you do need to buy cover separately ie as in Victoria, don’t rely on your private health insurance. Those policies will only cover ‘life threatening ‘ incidents. So essentially you would have needed to stop breathing. If a member of the public calls an ambulance for you, in a helpful way, and you didn’t actually want or need it, you will still be liable to pay for it. 

Get the cover from the ambulance themselves, in Victoria it was $50 odd for a single person, covers any and all ambulance calls you might make. Don’t get caught up with a health insurance company quibbling over how at risk your life was!

[NicF]

3 hours ago, Amber Snowball said:

I’ll just chime in with ambulance cover. If you do need to buy cover separately ie as in Victoria, don’t rely on your private health insurance. Those policies will only cover ‘life threatening ‘ incidents. So essentially you would have needed to stop breathing. If a member of the public calls an ambulance for you, in a helpful way, and you didn’t actually want or need it, you will still be liable to pay for it. 

Get the cover from the ambulance themselves, in Victoria it was $50 odd for a single person, covers any and all ambulance calls you might make. Don’t get caught up with a health insurance company quibbling over how at risk your life was!

My health insurance paid for an ambulance in a situation that wasn’t life threatening.  My son had fallen over on his way home from school and hurt his knee.  He refused to move (he is autistic and doesn’t do pain very well) and a kind parent called an ambulance for him.  Definitely not life threatening but still covered as it was still classed as an emergency.  What you do have to watch for though is often health insurance will only cover one amublance call in a year and don’t cover none emergency amublance transport, ie transport between hospitals.  Here in SA ambulance cover from SA ambulance covers all amublance transport and is also pretty cheap.

[Amber Snowball]

6 hours ago, NicF said:

My health insurance paid for an ambulance in a situation that wasn’t life threatening.  My son had fallen over on his way home from school and hurt his knee.  He refused to move (he is autistic and doesn’t do pain very well) and a kind parent called an ambulance for him.  Definitely not life threatening but still covered as it was still classed as an emergency.  What you do have to watch for though is often health insurance will only cover one amublance call in a year and don’t cover none emergency amublance transport, ie transport between hospitals.  Here in SA ambulance cover from SA ambulance covers all amublance transport and is also pretty cheap.

That was good.

probably the advice should be “read the small print!”

[JetBlast]

Thanks for the replies everyone. I am not trying to pick holes or anything I just want to be certain in my mind.

Question - If for example I get cover for the ambulance in SA and have an accident in QLD. What would happen? Would I not be covered or is there some kind of cross state agreement please?

[NicF]

6 hours ago, JetBlast said:

Thanks for the replies everyone. I am not trying to pick holes or anything I just want to be certain in my mind.

Question - If for example I get cover for the ambulance in SA and have an accident in QLD. What would happen? Would I not be covered or is there some kind of cross state agreement please?

SA ambulance have an option where you can cover yourself with them for interstate ambulance.  It costs a little bit more than the cover for just in the state but not that much more.

[Jessica Berry]

We always get our money's worth from our 'extras' cover and feel it is good value.  We keep a spreadsheet every year and are always quids in, often getting back double or triple our premiums, but we are also smart with how we use it!  As with everything you need to look at your own circumstances and whether it is right for you.

I thought it might be useful to add on a link I started on Poms in Adelaide back in 2015.  The information is still relevant so might be worth having a read through.

https://www.pomsinadelaide.com/topic/41327-guide-on-dental-costs/

[rammygirl]

We self insure.  So far our costs have been far lower than we would have paid in premiums, especially when you take into account any gap payments. 

I am happy with that.  If we end up paying for something then I reckon we will still be in front.  We do have ambo cover though as hubby cycles a lot and you never know! It is cheap enough.

It is what we did in the UK.  Paying for private when we chose to and going with the NHS when we didn’t. 

Dentists in the UK aren’t free nowadays either, unless you are on benefits or pregnant!  The rules for orthodontists are tighter now so treatment which isn’t for severe alignment is now not covered. 

 

[Amber Snowball]

If I had stayed in Australia I would probably have cancelled my private health insurance tbh. I didn’t use it enough to make it worthwhile and the premium just kept rocketing. 

You definitely need to be sure you want/need it and will use it to get the best value.

[Marisawright]

25 minutes ago, Amber Snowball said:

If I had stayed in Australia I would probably have cancelled my private health insurance tbh. I didn’t use it enough to make it worthwhile and the premium just kept rocketing. 

You definitely need to be sure you want/need it and will use it to get the best value.

Don’t forget the OP is coming on a 489 visa, not PR

[I❤️??]

Hi all, 

We are soon moving to WA on pr visas. My Qn is: are we eligible for all Medicare benefits even if we are looking for work?

thanks

[Marisawright]

54 minutes ago, I?? said:

Hi all, 

We are soon moving to WA on pr visas. My Qn is: are we eligible for all Medicare benefits even if we are looking for work?

thanks

If you have a PR visa then you are always fully covered by Medicare whether you are working or not.

[JetBlast]

On 17/05/2019 at 07:11, Quoll said:

Not quite.  You are entitled to pay the same as Australians for "necessary" medical care.  That doesnt mean everything that could happen - for example if your kid wants his tonsils out that's elective.  You want your gall bladder out, that's elective.  You need a knee replacement, that's elective. 

 

On 17/05/2019 at 12:33, Marisawright said:

True, but notice one of the things not covered is "care that isn't clinically essential". 

The interpretation of "clinically essential" relies on whether it would be safe for you to fly home and have treatment in your own country.  If the answer is yes, then it's not essential and it's not covered.  The fact that you won't be covered by the NHS either is not their problem. 

In practice, I have a sneaky suspicion that hospitals are not that rigorous and if you present with a medical issue, they may not always check your status before giving treatment. But personally, I wouldn't rely on that!

I have had a minor "elective" procedure done on medicare. The doctor said it needed doing so It got done. I could have flown home but didn't. I suspect this is all because of genuine people coming to Australia with an existing health condition and getting it treated here.

Anyway - based on the Medicare Levy Surcharge I will be getting insurance anyway as it will be cheaper in the long run.

Edited July 5, 2019 by JetBlast

[Jessica Berry]

On 05/07/2019 at 13:22, JetBlast said:

 

Anyway - based on the Medicare Levy Surcharge I will be getting insurance anyway as it will be cheaper in the long run.

Have you found employment? I am sure you are aware the Medicare Levy Surcharge is only payable if you go over the threshold, $90,000 for a single and $180,000 for families.  If you haven't started working yet or will start in a few months, depending on your salary you may not go over the annual threshold.  Just thought I would mention it in case other people are reading and they are not aware of the thresholds.

https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-surcharge/