Transitioning from the ADF and getting to know the ins and outs of the healthcare system can be daunting. This may be your first time getting to know Medicare and the public health system and which costs you are liable for when seeing a doctor, going to the pharmacy or being admitted to hospital.

1. Do I need, and can I get Medicare?

Medicare provides access to a range of medical services, lower cost prescriptions and free care as a public patient in a public hospital. Whether you choose to sign up to health insurance or not, you will need to register for Medicare.

All permanent residents of Australia are eligible for Medicare. If you are single, have never had Medicare before and are separating, you must register with Medicare to access benefits.

If your family already has Medicare you can add yourself to the family Medicare card. In either case, you can register prior to separation but you can’t access benefits until you leave the ADF.

For more information, or to sign up visit https://www.humanservices.gov.au/customer/subjects/medicare-services

Things to know about Medicare

Doctors

When seeing a doctor, Medicare usually covers 85% of the Medicare Benefit Schedule (MBS) Fee for general practitioners and specialist out of hospital services (some GP’s may bulk bill which will mean the MBS fee is fully covered).

Other doctors may charge more than the MBS Fee, it’s your responsibility to pay the difference which is not claimable through a health insurance fund.

Prescription Medicines

The Pharmaceutical Benefits Scheme (PBS) subsidises the cost of medicine. To be eligible, the medicine must be listed on PBS. If this is the case, you may pay up to $31.60 (effective 01/01/2024) and Medicare pays the rest (indexed annually). If a medicine is not on PBS, health insurance can assist with these costs.

Going to Hospital

Medicare covers 100% of the hospital costs when you are admitted to a public hospital as a public patient. As a public patient, the hospital will choose the doctors and specialists who treat you.

In this case, Medicare pays 100% of costs, including after-care by the treating doctor or hospital. It is worth remembering however, that waiting lists apply in the public system and can be significant.

Public Hospital as a private patient

If you choose to be admitted to a public hospital as a private patient you must give your consent to be treated as a private patient.

If you are asked to use your health insurance in a public hospital you should ask:

• Can I choose my own doctor?
• Can I have a private room?
• Will all my costs be covered?
• Will electing to be a private patient get me admitted quicker?
•You have a right to be treated as a public patient if the answer is ‘no’ to any of these questions even if you have health insurance.

Private Hospital

You may also wish to choose to be admitted to a private hospital in which case:

You can choose your doctor or specialist, and:

• Medicare pays 75% of MBS fee for your doctor
• You are responsible for paying the balance of the doctor’s total fee; and
→ Accommodation
→ Theatre
→ Intensive care
→ Medical Devices and Human Tissue Products
→ Pharmaceutical costs

If you have private health insurance, your health fund will pay all or most of the costs not covered by Medicare.

Out of Pocket hospital expenses

Any admission to hospital may result in out of pocket hospital expenses.

It is worth noting the following:

• The majority of out of pocket costs relate to doctors’ fees
• Health funds have agreements with hospitals and doctors that determine the benefit available to you. There are three types of these arrangements:
→ No Gap contracts (Doctor/hospital cannot opt in or out)
→ Gap Cover Schemes (Doctors can opt in/out)
→ Gap Medical (Legislated requirement for minimum payment in absence of contract or Gap Cover Scheme)

Benefits of the Private Health system

Joining a private health insurance fund protects you and your family against unexpected health issues and gives you the freedom to make choices in your healthcare as well as offering the following benefits:

• Choose your doctor and gain access to the best healthcare in Australia
• Cut down waiting times. Wait times in public hospitals in Australia have more than doubled since the year 2000.
• Get covered for more. Medicare doesn’t cover you and your family for important healthcare services you may need such as ambulance, dental, physiotherapy and optical.
• Help reduce the burden on the public health system. Health care is a huge cost on the government and your membership helps reduce the strain on the public system.
• Tax benefits. There are several tax benefits to having private health insurance including claiming the private health insurance rebate, avoiding the Medicare Levy Surcharge and Saving long-term on Lifetime Health Cover.