Paying for healthcare

Victoria’s healthcare system includes many types of healthcare providers and insurers (both public and private). Your healthcare costs depends on the kind of treatment you are getting, whether you have private health cover and what government services you are eligible for. Some of your medical fees are covered by Medicare and some are covered by your private health insurer (if you have one), while you will have to pay for the rest out of your own pocket.

All medical practitioners (doctors and specialists) and healthcare providers have different rates and payment models. To make sure you do not get unexpected bills, before any appointments, ask your doctors and healthcare providers what you will be charged for each service, what is covered by Medicare and what is included in your healthcare plan.

Medicare

Medicare is Australia’s national public health insurance scheme. For people who have a Medicare card, it usually covers:

• free or subsidised treatment by healthcare providers, such as doctors, specialists, optometrists and in specific circumstances, dentists and other allied health practitioners
• free treatment and accommodation as a public patient in a public hospital
• a portion (75%) of the Medicare Schedule fee for services and procedures if you are a private patient in a public or private hospital. This does not include hospital accommodation, and items such as theatre fees and medication
• some healthcare services in certain countries.

Medicare covers the cost of all in-patient medication in public hospitals. If you choose to be admitted into a private hospital, you or your health insurer (depending on your healthcare plan) will be billed for all medication.

Private health insurance

Australia’s healthcare system is funded by Medicare and the private health insurance industry. While Medicare pays for the bulk of Australia’s healthcare costs, private health insurance plans offer you more control over your treatment and help with medical costs that are not covered by Medicare.

Some of the services that are not covered by Medicare include:

• dental care
• ambulance cover
• allied health services
• prostheses.

The two main types of health plans that health insurers offer are:

• general cover, which covers medical and allied health costs, such as dental, chiropractic and home nursing
• hospital cover, which covers doctors’ fees and hospital expenses, such as accommodation and theatre fees.

All Australians and most permanent residents are entitled to free healthcare in public hospitals, but if you want to choose your own doctor or the hospital you are treated at, or you would like your own room, you will need private health insurance.

To reduce the strain on the Medicare system, the Australian Government provides tax advantages for those who take out private health insurance.

Pharmaceutical Benefits Scheme for medication

The Pharmaceutical Benefits Scheme (PBS) is the government program that provides affordable medication to all those people covered by Medicare. The scheme subsidises a wide range of approved prescription medication.

If you and your family spend a lot on medication over the course of a year, it may be worth talking to your pharmacist about the PBS Safety Net. Once you and your family have spent a certain amount within a given year (the threshold amount is revised yearly), the scheme will provide a discount on all further medication or, in some cases, supply it free of charge.

You are entitled to extra discounts through the PBS if you have:

• an Australian Seniors Health Card
• a Health Care Card
• a Pensioner Concession Card
• a Department of Veterans' Affairs (DVA) Gold, Orange or White Card.

Whether you have a health care card or not, you will still receive medication through the PBS. How much you pay and how much is covered by the PBS depends on whether you have a concession card or if you have reached the PBS Safety Net.

When buying your medication from a pharmacy, you can ask for a generic brand. These medications have the same active ingredients and are approved by the Therapeutic Goods Administration (TGA).

If your medication is not yet on the list of approved PBS medications, you will be required to pay the full price. In these instances, every pharmacy will charge a different price, so it is a good idea to shop around if you would like the cheapest.

National Disability Insurance Scheme (NDIS)

The National Disability Insurance Scheme (NDIS) is a new government scheme designed to give people easy access to disability support. Although still in the early stages of the rollout, the scheme aims to take a more personalised, life-long approach to disability support.

NDIS staff work with the changing needs, goals and lifestyles of each person with a disability by offering advice and referrals, and help with accessing community services.

Hospital payments

Victorian public hospitals provide free treatment and accommodation for a public patient in a public hospital, for Australian citizens and permanent residents, through the Medicare scheme.

Fees for medical treatment in private hospitals are partly covered by Medicare and private health insurance companies. You can choose to be admitted as either a public or private patient in a public hospital. Having private health insurance does not mean you cannot choose to be a public patient in a public hospital.

For public patients, Medicare covers the costs of all emergency department and outpatient services, doctors’ and specialists’ fees, hospital accommodation, theatre fees and in-hospital medicines.

Private patients in public hospitals still have their primary healthcare costs covered by Medicare, but their hospital accommodation, theatre fees and doctors’ fees are not. These are either covered by the patient or by their private health insurance.

Services that are not clinically necessary are not covered by Medicare. These include TV, internet and other optional services that are offered by the hospital.

Paying to see a doctor

Visits to a general practitioner (GP) in Victoria are covered, either partly or fully, by Medicare. The decision about how much is covered is left up to each doctor or clinic. There are also different prices for long consultations. Medicare reimburses doctors for consultations at a prescribed rate. If a doctor wishes to charge more than the prescribed rate, those extra charges will be passed on to you.

Bulk-billing

Bulk-billing means that the full cost of the consultation is covered by Medicare. The doctor will bill Medicare directly for the consultation, rather than you.

Some doctors bulk-bill all the time, some bulk-bill on certain days, or for certain hours of the day, while others do not bulk-bill at all. To avoid unexpected out-of-pocket expenses, it is important to call ahead to find out if your doctor will be able to bulk-bill you at the time of your appointment.

Children, pensioners and health care card holders are often bulk-billed. However, there is no standard practice across Victoria. For specific information, check your clinic’s website or ask when making your appointment.

Paying to see a specialist

Specialists’ fees vary a great deal and will depend on whether you access the services in a public hospital or at a private clinic or hospital.

The fee structure of individual specialists may also impact on the cost, as does your eligibility for reimbursement or bulk-billing, or access to private health cover.

Ask your doctor and specialist how much it will cost upfront and if there are likely to be any further costs. You may also want to ask if the specialist:

• works within the public or private healthcare system
• bulk-bills via the Medical Benefits Scheme (MBS)
• requires gap payments
• has a payment plan
• accepts your private health cover.

The MBS allows specialists to provide services within public hospitals to both public and private patients. If you see a specialist as a public patient, the hospital can bulk-bill the specialist’s services through Medicare, which makes it free to public patients. If you have private health insurance and wish to be a private patient, you can choose your own specialist.

Paying to see a dentist

How much you pay for public dental healthcare depends on your situation and the type of treatment you need. You may be able to get treatment for free or there may be a cost involved. See the Dental Health Services Victoria (DHSV) website for current fees.

Free dental treatment

Free public dental treatment is available for:

• Aboriginal and Torres Strait Islander people
• homeless people and people at risk of homelessness
• refugees and asylum seekers
• children and young people aged 0–17 years who are health care or pensioner concession card holders or dependents of concession card holders
• all children and young people up to 18 years of age who are in out-of-home care provided by the Department of Health
• all youth justice clients up to 18 years of age in custodial care
• registered clients of mental health and disability services, supported by a letter of recommendation from their case manager or staff of special developmental schools
• those receiving care from undergraduate dental students
• those experiencing financial hardship.

Child Dental Benefits Schedule (CDBS)

The Commonwealth Child Dental Benefits Schedule (CDBS) provides up to $1,000 per child in dental benefits over a two-calendar-year period for children aged from two to 17, in families receiving Family Tax Benefit A.

Private dentists

Private dentists and dental health professionals set their own fees, which can vary depending on the dentist and the type of treatment required.

However, the cost of dental treatment can be offset if you take out dental insurance, which is offered under many private health insurance policies or as an extra.

The two main types of dental insurance are:

• general dental, which usually covers cleaning, removal of plaque, x-rays and smaller fillings
• major dental, which usually includes cover for orthodontics (braces), wisdom teeth removal, crowns, bridges and dentures.

Emergency dental care

Emergency dental services are available at the Royal Dental Hospital of Melbourne and at community dental clinics across Victoria. The cost of treatment will depend on your situation and the type of treatment you need. You may be able to get emergency treatment for free or there may be a cost involved.

Complementary medicine costs

A Medicare rebate is available on some complementary medicine (CM) therapies, including chiropractic care and acupuncture. Ask about Medicare rebates when you book your appointment.

Some CM therapies may also be partly covered by your private health insurance. Check your policy or speak with your health insurer about what you are covered for. There is often a limit on the number of visits you can claim in a year, or on the total amount refunded.

Some universities and CM training organisations offer discounted treatments by supervised final-year students, such as the osteopathy clinic at Victoria University. Search online for CM training colleges in your area.

Emergency medical care

Medical treatment in public emergency departments is free to all public patients. When you arrive you will be asked if you want to be admitted as a public or a private patient.

If you choose to be admitted as a private patient, your primary healthcare costs will still be covered by Medicare but your hospital accommodation, theatre fees and doctors’ fees will not. These costs will be billed to you or your private health insurance provider.

Although most emergency medical treatment is performed in public hospitals, there are a limited number of private emergency departments in Victoria. Emergency departments in private hospitals operate on a user-pays model. In an emergency, ambulances will always transport you to a public hospital unless you specify otherwise.

Ambulance and medical transport services

Ambulance and other emergency services are not covered by Medicare unless you are a concession or health care card holder. Ambulance cover is available as an option through most private health funds or as a subscription through each state’s ambulance service.

The Victorian Patient Transport Assistance Scheme (VPTAS) may provide financial help if you live in rural and regional Victoria and need to travel long distances to access specialist services. Check the VPTAS website to check your eligibility and apply for assistance.

Aged care services

As with many other parts of the health system, you will be required to contribute to your aged care expenses if you can. However, you will always be given the care you need, whether you can afford it or not.

If you are on a low income and have limited assets, you may be eligible for help through a Home Care Package (if you are still living at home) or the Aged Care Home Financial Hardship Assistance scheme.

Home and Community Care program

The Home and Community Care (HACC) program is Victoria’s main program for providing in-home help to frail older people and carers. The range of home care options includes lifestyle help, household help, personal care, home maintenance, home modification and nursing care.

To be eligible for HACC, you must be aged 65 years or over (50 years or over for Aboriginal and Torres Strait Islander people).

Before you can start receiving these home care services, you will have a basic assessment to work out what sort of help and how much you need, and what it may cost. What you pay depends on your income, and the type and number of services you want.

For information on the HACC program or agencies in your area, contact the Commonwealth Respite and Carelink Centre on 1800 200 422 (free call) or your local council.

Community help

For older people still living independently at home, there is a range of supports available outside the home. You may have come out of hospital recently or are looking for somewhere to go for daytime activities or support. Options for respite care are available for you and your carer, if you have one, and day services provide opportunities to increase independence and to socialise.

Centre-based care is care available to older people in a centre, rather than in their home. This type of care involves structured group activities that encourage positive ageing and wellbeing. Centre-based care also offers a range of meals, day therapy, social support, respite for carers and overnight care.

Call My Aged Care on 1800 200 422 for help finding information about services in your local area and what you need to do to receive them.

Residential aged care

If you need more help at home than your family, carers or home services can provide, it is a good idea to consider residential aged care. Residential aged care facilities provide older people with continuous supported care, and are funded and regulated by the Australian Government.

The Aged Care Assessment Service assesses your needs, decides if you are eligible, and then provides approval for a place in a residential aged care facility.

Financial support

The Victorian Government provides financial assistance and subsidised healthcare services to Victorians in need. You may be eligible for a range of free and subsidised services if you spend a lot of money on medical expenses or if you hold a concession card or health care card. Contact Medicare or ask your doctor for more information about costs.

Services covered by the state and federal government’s healthcare assistance schemes include dental health, eye care, ambulance travel, chronic disease management, sexual health and aged care.

Where to get help

• Your GP (doctor)
• Pharmacist
• Healthcare provider
• Medicare