9 Things You Must Know About Health Insurance

1. 9 Things You Must Know About Health Insurance
Source: www.privatehealth.gov.au
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2. 1. Health Care System
Medicare
Medicare is the basis of Australia's health care system and covers many health care costs. You can choose whether to have Medicare cover only,
or a combination of Medicare and private health insurance. Citizens and most permanent Australian residents are eligible for Medicare. The
Medicare system has three parts: hospital, medical and pharmaceutical.
Private Health Insurance
Private health insurance cover is generally divided into hospital cover, general treatment cover (also known as ancillary or extras cover) and
ambulance cover.
Ambulance
Ambulance cover may be available separately, combined with other policies, or in some cases is covered by your state government.
Many people don’t know enough about health insurance!
Take the guesswork out and ask for professional advice.

3. 2. Medicare hospital
Under Medicare you can be treated as a public patient in a public hospital, at no charge, by a doctor appointed by the hospital. You can choose to
be treated as a public patient, even if you are privately insured.
As a public patient, you cannot choose your own doctor and you may not have a choice about when you are admitted to hospital.
Medicare hospital does not cover:
 private patient hospital costs
 medical and hospital costs incurred overseas
 medical and hospital services which are not clinically necessary, or surgery solely for cosmetic reasons
 ambulance services

4. 3. Medicare medical
When you visit a doctor outside a hospital, Medicare will reimburse 100% of the Medicare Benefits Schedule (MBS) fee for a general
practitioner and 85% of the MBS fee for a specialist. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.
Medicare provides benefits for:
 consultation fees for doctors, including specialists
 tests and examinations by doctors needed to treat illnesses, such as x-rays and pathology tests
 eye tests performed by optometrists
 some other items under certain circumstances
Medicare does not cover:
 examinations for life insurance, superannuation or memberships for which someone else is
 ambulance services
 most dental examinations and treatment
 most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services
 acupuncture, glasses/contact lenses, hearing aids
 home nursing

5. 4. Medicare pharmaceutical
Under the Pharmaceutical Benefits Scheme (PBS) you pay only part of the cost of most prescription medicines purchased at pharmacies. The
rest of the cost is covered by the PBS. You must present your Medicare card to obtain this benefit.
The amount you pay varies with the medicine, up to a standard maximum. People with concession cards have a lower maximum payment.

6. 5. Hospital cover
With private health insurance hospital cover you have the right to choose your own doctor, and decide whether you will be treated at a public or
a private hospital that your doctor attends. You may also have more choice as to when you are admitted to hospital.
Private health hospital cover insures you against some or all of the additional costs of being a private patient in either a public or private hospital.
Medicare will cover 75% of the Medicare Benefits Schedule (MBS) fee for associated medical costs. Provided you have the appropriate private
health insurance policy, your health fund will cover the remaining 25% of the MBS fee.
What may not be covered?
The health insurance policy you buy will have some limitations on hospital treatment, which might include:
 Exclusions - specific services that are not covered at all
 Restrictions - services that are covered to a limited extent, which means you will have greater out-of-pocket expenses
 Benefit limitation periods - which pay reduced benefits on one or more services for a set period of time after the waiting period, then
pay full benefits after this period
 Surgery or hospital treatment that Medicare does not pay a benefit for - Medicare pays a benefit on all medical services necessary to
maintain your health, but does not cover optional treatments such as elective cosmetic surgery
 Long stay patients - If you are in hospital for more than 35 days in succession, you will be regarded as a long stay or nursing home type
patient, unless your doctor specifies otherwise.

7. 6. Extras cover
General treatment cover (also called ancillary cover or extras cover) provides insurance against some or all costs of treatment by ancillary health
service providers. The extent of your cover depends on the type of policy you select and may include services such as:
 dental treatment
 chiropractic treatment
 home nursing
 podiatry
 physiotherapy, occupational, speech and eye therapy
 glasses and contact lenses
 prostheses
What may not be covered?
Nearly all services covered under general treatment are only covered to a limited extent. There are various limits that may apply, for example a
limit per service, per year, or lifetime limits. Some services may not be covered at all.

8. 7. Ambulance cover
Medicare does not cover the cost of emergency or other ambulance services. You can organise cover for this service as part of your hospital or
general treatment plan, or as a stand-alone cover.
The options for ambulance cover vary depending on what State you live in.
You’ll need to check the details of your cover because some only cover ground travel, while others include air and sea ambulance services. And
depending on your level of cover, your policy may include some out of pocket expenses – like a co-payment. Co-payments let you keep the cost
of your policy down, but mean you to pay some of the costs, if you need an ambulance.
For young couples or families on a good general health conditions who don’t want or can’t afford private health insurance, a combination of
Medicare and Ambulance membership would be very good and cost effective emergency strategy.

9. 8. Overseas student health cover
This type of cover assists international students to meet the costs of medical and hospital care they may need while in Australia.
OSHC policies assist to cover the cost of hospital and medical treatment.
Benefits are also paid for ambulance services but only limited benefits for pharmaceuticals apply. You may face significant out of pocket costs if
you need treatment with pharmaceuticals, particularly oncology (cancer) treatment which can costs tens of thousands of dollars.
OSHC does not pay for general treatment (ancillary, or extras cover) such as dental, optical or physiotherapy. If you require cover for these
treatments, you may take Extra OSHC provided by an OSHC provider or general treatment cover with any Australian private health insurer. You
can also choose to supplement OSHC with other insurance such as international travel insurance.
Only a small number of registered health insurers offer OSHC. If your visa status or Medicare eligibility changes at any time, inform your
insurer as soon as possible to find out whether your level of cover is still suitable. When your student visa expires, then you are no longer
eligible to hold OSHC. You can then swap over to a residents' cover or to an Overseas Visitors Health Cover plan.

10. 9. Overseas visitor health cover
Unlike Australian citizens who can use the public health system Medicare, to cover their medical and hospital expenses, overseas visitors who
hold temporary visas aren't generally eligible to use Medicare.
Visitors from the United Kingdom, Sweden, Belgium, Finland, Italy, Malta, the Netherlands, Slovenia, the Republic of Ireland and New Zealand
have a reciprocal health care arrangement with Australia and can receive immediate necessary treatment in the public health system but aren't
otherwise entitled to benefits.
Every OVHC policy will differ in costs, eligibility and benefits. However, most policies should cover you for medically-required hospital
admissions and a portion of doctor's fees.
In addition to cover for hospital and medical expenses, you can also purchase General Treatment cover. General Treatment cover pays benefits
towards the services of health care providers in private practice such as dentists, optometrists and physiotherapists. Insurance can cover part of
these costs, though you would still need to cover part of the fees yourself.

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