What Are Out of Pocket Expenses?

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Out-of-pocket costs are the additional charges beyond Medicare and health insurance coverage for medical services.
Private health insurance doesn't mean healthcare is free; you still need to pay for some of the costs.
How much you’ll pay depends on your treatment, your level of private health, Medicare coverage and hospital patient type
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Out-of-pocket costs are the additional charges beyond Medicare and health insurance coverage for medical services.
Private health insurance doesn't mean healthcare is free; you still need to pay for some of the costs.
How much you’ll pay depends on your treatment, your level of private health, Medicare coverage and hospital patient type

DOES HAVING AN INSURANCE POLICY WITH A HEALTH FUND MEAN ALL YOUR HEALTHCARE COSTS ARE FREE? NOT QUITE - YOU’LL STILL HAVE SOME OUT-OF-POCKET COSTS.

Australia has a pretty great healthcare system with Medicare, but that doesn’t mean healthcare is free.

Even with a private health insurance policy, you still need to pay some of the costs of your medical services. These costs are called out-of-pocket costs.

An out-of-pocket cost refers to the additional amount you may need to pay for a medical service beyond what is covered by Medicare and your private health insurer.

It would be great if private health insurance or Medicare fully paid for all your medical needs - but unfortunately, that’s not how it works.

In this guide, we’ll shed some light on why out-of-pocket costs exist, what you might pay out of pocket costs for, and how you can reduce your out of pocket expenses.

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When You Might Pay Out of Pocket Expenses

If you receive treatment as a public patient at a public hospital, you won't be charged anything for your medical treatments. The costs are typically covered by the government.

Costs for many private treatments are also fully covered by Medicare and private health insurers.

However, it's important to be aware that if you choose to have medical treatment as a private patient in a private or public hospital, there may be out-of-pocket costs involved. These costs can include:

  • Doctors and Health Care Providers: When receiving medical treatment as a private patient, you may incur charges from doctors or other health care providers that go beyond what is covered by Medicare and private health insurers. These charges can vary depending on the specific provider and the nature of the treatment.
  • Hospital Charges: As a private patient, you may be responsible for certain hospital charges, such as accommodation fees and theatre fees. These charges contribute to the overall cost of your hospital stay and are typically not fully covered by Medicare and private health insurers.

In addition to hospital-related costs, you may also encounter out-of-pocket expenses for medical services outside of a hospital setting. For instance:

  • Appointments and Diagnostic Tests: If you undergo medical services, such as appointments with specialists or diagnostic tests, outside of a hospital, there may be out-of-pocket costs associated with these services. These costs can vary depending on the specific service and the provider you visit.
  • Private Hospital Accident and Emergency Department: Should you require medical attention at a private hospital's accident and emergency department, there may be out-of-pocket costs involved. These costs are separate from the fees associated with public hospital emergency departments and may vary depending on the nature of the emergency treatment.

How Much Out of Pocket Will You Pay?

When it comes to out-of-pocket costs, there are several factors that can influence what you may need to pay. Let's take a look:

  1. Charges and Fees: The amount you're charged for medical services can vary depending on the healthcare provider. Keep in mind that different providers may have different fees for the same service, which can impact your out-of-pocket costs.
  2. Treatment Location: Whether you receive treatment in a hospital or outside of it can also affect your expenses. Costs for hospital treatments and services may differ from those received outside of a hospital setting.
  3. Medicare Coverage: The coverage provided by Medicare plays a role in determining your out-of-pocket expenses. Medicare benefits might not cover the full cost of certain treatments, leaving you responsible for the remaining amount.
  4. Hospital Patient Type: If you're treated at a hospital, whether you're classified as a public or private patient can make a difference. The billing structures for public and private patients may vary, which can impact the costs you incur.
  5. Private Health Insurance Coverage: Having private health insurance can influence your out-of-pocket costs as well. The level of coverage offered by your insurance policy determines how much of your medical expenses are covered.
  • The potential costs associated with your treatment
  • The timing and method of payment for these costs
  • Exploring different medical treatment options and their associated expenses using practical tips

It's important to remember that private health insurance can only cover doctor's fees for hospital treatments. The specific coverage and reimbursement amounts can vary between insurance providers.

To gain a clear understanding of your costs, it's a good idea to discuss the following aspects with your doctor, hospital, and health insurer:

Costs For Services Outside Hospital

When it comes to out-of-hospital medical services, there are various types of treatments and appointments that fall into this category. These may include:

  • GP or specialist appointments
  • Diagnostic imaging
  • Pathology
  • Radiation or chemotherapy
  • Dialysis
  • Rehabilitation

If a particular out-of-hospital service is listed on the Medicare Benefits Schedule (MBS), Medicare will contribute towards the cost as follows:

  • For most services, Medicare will pay 85% of the MBS fee.
  • For GP appointments, Medicare covers 100% of the MBS fee.

It's important to note that Medicare generally doesn't provide benefits for out-of-hospital services that are not listed on the MBS, such as physiotherapy and podiatry.

When you receive an out-of-hospital service covered by the MBS, your out-of-pocket costs will depend on the difference between the fee charged by your doctor and the Medicare benefit provided by the government.

In most cases, doctors directly bill Medicare for the Medicare benefit. If the service is not bulk-billed, you will be responsible for paying the difference between the Medicare benefit and the total fee. Typically, this involves paying the entire fee upfront and subsequently claiming the Medicare benefit.

It's worth noting that private health insurers cannot cover out-of-hospital Medicare services. However, they may offer coverage for services that Medicare doesn't, such as physiotherapy and other allied health services not included in the MBS.

Costs for in-Hospital Services

When it comes to in-hospital services, the cost structure varies depending on your patient status. Here's what you need to know:

Public Patient in a Public Hospital:

If you have a Medicare card and receive treatment as a public patient in a public hospital, you won't incur any out-of-pocket costs. This means that the hospital services are covered by Medicare, ensuring you receive the necessary care without having to pay directly.

Private Patient in a Public or Private Hospital:

However, if you choose to be treated as a private patient in either a public or private hospital, there may be out-of-pocket costs involved. As a private patient, you have the option to access additional services and benefits but may be responsible for certain expenses not covered by Medicare or your private health insurance.

It's essential to carefully review your health insurance policy and consult with the hospital and health insurer to understand the specific costs you may be responsible for as a private patient.

Remember, as a public patient in a public hospital with a Medicare card, you can receive treatment without incurring any out-of-pocket costs. However, if you opt for private treatment, it's important to be aware of potential expenses that may arise.

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Other Fees You May Pay as a Private Patient

When you receive medical services as a private patient in a public or private hospital, it's important to be aware of potential costs associated with doctors and other health providers. Here's what you should know:

Services Covered:

As a private patient, you may need to pay for various services provided by doctors and health providers, including surgeons, assistant surgeons, anaesthetists, other specialists, and medical imaging, pathology, or diagnostic tests.

Insurance Coverage:

If you have private hospital insurance that covers the specific medical service, your insurer is required to pay at least 25% of the Medicare Benefits Schedule (MBS) fee, ensuring a portion of the cost is taken care of.

The Gap Payment:

However, it's common for doctors and health providers to charge fees higher than the MBS fee for services provided to private patients. This difference between the MBS fee and the actual charge is known as the "gap." Unless the doctor has a gap arrangement with your insurer, you may be responsible for paying the gap out of your own pocket.

Gap Arrangements:

To help alleviate the burden of out-of-pocket costs, many doctors and insurers have gap arrangements in place. These arrangements aim to reduce or eliminate the gap payment by either fully covering it or significantly reducing the amount you need to pay.

Hospital Charges You May Face as a Private Patient

When receiving treatment as a private patient in a hospital, it's important to be aware of potential hospital charges that you may need to pay. These charges can include:

  • Accommodation fees
  • Operating theatre fees
  • Prostheses costs, such as plates, screws, or artificial joints
  • Medicines and dressings
  • Costs for physiotherapy and other therapies provided within the hospital

The amount covered by your private hospital insurance for these charges depends on several factors, including your policy and whether your insurer has an agreement with the hospital where you're being treated.

Policy Coverage: Different policies offer varying levels of coverage for hospital charges. Some policies may only cover the minimum amount mandated by the government, which could result in higher out-of-pocket costs for you.

Hospital Agreements: If your insurer has an agreement with the hospital, it can have a significant impact on your out-of-pocket costs. In some cases, you may have no out-of-pocket costs for hospital charges, while in others, you may be required to pay an agreed amount based on your policy.

Agreed Amounts: The agreed amount can be structured in different ways, such as a total agreed amount or excess, or an agreed amount per day of hospital stay up to a certain cap, known as a co-payment.

Out-of-Agreement Hospitals: If the hospital where you're seeking treatment does not have an agreement with your insurer, it may result in higher out-of-pocket costs for you.

Figuring Out Your Hospital Admission Costs

To determine your total out-of-pocket costs as a private patient, you need to consider hospital charges, doctors' fees, and fees from other providers, while taking into account Medicare and private health insurance payments.

Here’s an example:

Suppose you have private hospital insurance for an operation at a private hospital. Your insurance policy has a $750 excess and does not include a co-payment requirement.

Your surgeon charges $1,800 for the procedure, and unfortunately, they do not have a gap cover arrangement with your insurer.

The Medicare Benefits Schedule (MBS) fee for the surgeon's services is $1,000. Medicare pays $750, while your health insurer covers $250. This leaves you with an $800 gap that you are responsible for.

In addition to the surgeon, you also required the services of an anaesthetist, assistant surgeon, and underwent radiology and pathology tests. You can calculate your out-of-pocket costs for these providers in the same manner as you did for the surgeon. Let's assume their combined fees amount to $3,500, and you are required to pay $600 out of pocket.

Moving on to the hospital charges, the total is $8,500. While your insurer covers most of this cost, there is no Medicare benefit applicable. However, you must pay an excess of $750 as per your insurance policy.

Considering all the components, the total cost of your treatment amounts to $13,800. Out of this, you are responsible for paying $2,450, which is broken down as follows:

  • $800 for the surgeon and $600 for other providers
  • $750 excess for hospital charges

Understanding Gap Arrangements for Hospital Treatment

When it comes to hospital treatment, it's important to understand gap arrangements and how they can impact your expenses.

Doctors who provide private medical services have the freedom to set their own fees, which can sometimes be higher than the fees recommended by the government (known as the Medicare Benefits Schedule or MBS fee). This difference between the doctor's fee and the MBS fee is called the gap.

In most cases, you are responsible for paying the gap, unless there is a gap cover arrangement in place with your private health insurer. Gap cover arrangements are agreements between doctors and insurers that aim to reduce or eliminate the out-of-pocket costs for patients.

It's worth noting that there can be variations in fees for the same level and quality of care, depending on the doctor and their location. It's a good idea to consider whether the fees charged by your doctor offer good value in relation to the care provided.

Private health insurers often have gap cover arrangements with specific doctors. These arrangements can help lower your out-of-pocket expenses. There are two types of gap cover arrangements:

  • No Gap: Under this arrangement, if your doctor charges within the agreed limit set by your insurer, you won't have any additional costs to pay.
  • Known Gap: If your doctor charges more than the agreed limit but falls within another limit set by your insurer, known as the known gap limit, you will only need to cover the difference between the doctor's fee and the insurer's payment.

However, if the treatment costs exceed the known gap limit, you will be responsible for paying the remaining gap out of your own pocket, while the insurer will contribute a portion based on the recommended fee.

FAQs

What is the Pharmaceutical Benefits Scheme (PBS)?

The PBS subsidises the cost of medicines for Australians, reducing the amount you pay.

What is informed financial consent?

Informed financial consent refers to the right to receive an estimate of costs from your doctor or hospital before agreeing to undergo treatment. This helps you understand potential out-of-pocket expenses and make informed decisions.

How can I find typical costs for medical services?

You can use the Medical Costs Finder tool, which provides information on the typical costs of various medical specialist hospital procedures. It helps you estimate potential expenses and make more informed choices.

What is a rebate?

A rebate refers to the amount of money you receive back from Medicare or your private health insurer after paying for a medical service. The rebate helps reduce your out-of-pocket costs and is based on the applicable fee schedule or policy coverage.

Is Health Insurance Still Worth It?

You might be wondering if health insurance is still worth it considering the out-of-pocket costs.

The answer? Most definitely.

Even though you may have to pay some expenses on your own, having health insurance can actually save you a ton of money in the grand scheme of things.

Health insurance provides you with financial protection, access to a network of healthcare providers, and peace of mind during unexpected health situations.

With insurance, you don't have to worry about the hefty bills that can come with treatments, hospital stays, or visits to specialists.

So, despite the out-of-pocket costs, having health insurance is like having a safety net that ensures you can receive quality healthcare without breaking the bank.

It's definitely a wise investment that can bring you long-term savings and valuable support when you need it most.

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