Throughout your life, you may face health issues that require the type of attention and treatment that only a specialist doctor can provide (e.g. an immunologist if you have a certain allergy). In these cases, you’ll be referred to one usually by your GP or another medical professional.
Depending on who you’re seeing and the treatment and tests you require, you could face out-of-pocket costs.
Let’s break down how Medicare and health insurance may cover specialist treatment – and when you may need to dip into your savings.
When you’re treated as a private patient in a private or public hospital, Medicare automatically rebates some of the cost of your treatment providing it’s listed on the Medicare Benefits Schedule (MBS)
The MBS is a list of item numbers assigned to medical services; each item has an assigned cost that the government deems reasonable. Medicare will rebate 75% of the cost that’s listed on the schedule for that item.
For treatment outside of hospital like dialysis or rehabilitation, you may be able to get a Medicare specialist rebate of 85% of the MBS cost.
If you find your cover isn’t suitable for your treatment, or if you don’t have a policy, try comparing health insurance with our handy tool.
With our free tool, you can select which treatments and services you’d like covered in your policy. From there, we provide you policies from some of Australia’s top insurers, so you can easily compare features, cover options, excesses and premiums.
Consider coverage early as waiting periods may apply.
The amount you need to pay in total for your treatment depends on:
Keep in mind that the cost of your treatment will depend heavily on your specialist – they can set a fee they believe is suitable for their services.
As such, it’s crucial you ask your specialist and any additional specialists to participate in your health fund’s gap cover program, check that the treatment is included in your health insurance product, and know all possible out of pocket costs before booking or agreeing to your treatment.
Other costs to be aware of
When you use your hospital policy for treatment, you may need to pay an excess. An excess is an amount you agree to pay when you are admitted to hospital. If you elect to pay more for your excess, it will lower your policy premiums.
You might need to pay your excess every time you go to hospital or as a once-off in a membership period– it depends on your policy and insurer.
Also keep in mind that you may also need to pay a co-payment. A co-payment is where you agree to pay a certain amount of money for each day you’re in hospital.
If your specialist charges more than the Medicare Benefits Schedule (MBS) fee.
Some specialists charge a higher fee for their services than what’s listed on the MBS. As such, Medicare and your health insurer’s contributions towards your bill might not cover all expenses. This leaves you to pay the rest – the gap – out of pocket.
If you’re seeing a specialist out of hospital.
When you’re receiving out-of-hospital specialist care, Medicare might not always provide a rebate. This is where extras health insurance may help. This type of policy can provide cover for certain specialist treatment that Medicare doesn’t cover.
Depending on the type of extras policy, you could be covered for visits to:
When you claim on your health insurance policy.
Depending on your policy and insurer, you may need to pay an excess or co-payment.
Be treated at Partner or Agreement hospital.
Ask your health fund for their list of partner or agreement private hospitals. At these hospitals, your insurer has negotiated and agreed to the amounts to be charged and will than cover those costs related to:
If you choose to go to a private hospital that isn’t a partner or agreement hospital with your insurer, you may face higher out-of-pocket expenses for your treatment.
Public hospitals, on the other hand, are typically treated as agreement hospitals by your insurer. So, if you want to be treated as a private patient in a public hospital, your out-of-pocket fees are likely to be less than being in a private hospital.
Be treated by a partner or gap cover agreement specialist.
Once you know what you need to be treated for, speak to your health insurer, ask for their list of partner or gap cover agreement specialists for your required treatment. These are specialists that have previously participated in ‘gap cover’ agreements with that fund.
Seeing one of these specialists can reduce the likelihood of being severely out of pocket for fee’s charged above the scheduled fee for that procedure. It’s important to discuss the fee’s that they will be charging and request that they participate in your funds gap cover to reduce your out of pocket expenses.
Don’t forget that multiple specialists might see you during your treatment. Ensure you’re clear about who will be involved in your care and ask specialist to be seen by those who will also participate in the gap cover arrangement.
Tip: Specialists can choose, on a case-by-case basis, whether they’ll participate in a gap cover agreement with your health fund. So, make sure you ask them during your consultation.