Outpatient Cover for Citizens and PRs?

bigbadboogieman on 26/07/2019 - 11:18
Last edited 26/07/2019 - 11:26

Hi Guys,

I am one of those people who don't understand how private cover works. Did a few online searches and even got Medibank to callback and spoke with the Rep but still a bit of confusion. A shy friend who is a new Permanent Migrant needed help so was trying to help out. I would appreciate any help and comments from the OZB community.

Q1) Outpatient cover: Cover for visit to a Specialist in their private practice that may be run from a private or public practice. For e.g. visit to a Hand Surgeon's appointment for initial consultation for extreme wrist pain or treatments at such places for ailments not requiring hospitalization.

Our confused findings so far: I couldn't find any private insurers that covered such outpatient treatments. The Medibank Sales Rep said only Medicare covers Outpatient. I know for a fact that Medicare would cover only $67 on a $240 visit while the balance is out of pocket, i.e. gap. I have personally completed such visits (paid out of pocket) but never thought twice. Tried to get my GP to refer to a public hospital specialist office and GP did call Westmead hospital but they said Specialist visits won't be covered fully but the nerve conduction test, etc would be covered if referred by the specialist.

The Rep even went ahead and said that none of the Insurers in Australia will cover Outpatient visits if you're a PR or Citizen which was surprising as even I didn't know this fact (if it's true). My new friend says they had cover for Outpatient in their country of citizenship through an insurer without any dramas.

Q2) Government Rebates: Online quotes show a rebate between 25% to 0% depending on your annual income. The premium shows net of this rebate which is all good. I read somewhere there is a rebate for holding medical insurance that you get from ATO at the time of filing tax returns. What's that all about? I am assuming that's the same rebate so if the insurer takes it and then the insured party takes it at year-end as well wouldn't that be double dipping?

Thanks in advance for your comments and helping us out.

Health & Beauty

Comments

  • HighAndDry on 26/07/2019 - 11:28
    +1

    Q1) I think the rep means that if something is covered by medicare, it's not covered by private health insurance. Which is why the "citizen or PR" part is relevant. Afaik, this is accurate. PHI is supposed to cover only things not covered by medicare.

    Q2) There are two separate things - one is a rebate paid by the govt towards your PHI, details here. The second is NOT having to pay the Medicare levy surcharge, payable if you meet some conditions and don't hold PHI, details here.

    • bigbadboogieman on 26/07/2019 - 15:04

      Thanks. I do understand MLS which is in addition to the normal medical levy. On the rebates I was confused because I have seen people claim Tax off-set for a normal health insurance rebate. I supposed its either you claim in your return or as a reduction through your premium. You cannot have both.

      https://www.ato.gov.au/individuals/medicare-levy/private-hea…

      Claiming your rebate
      If you meet the eligibility requirements for a private health insurance rebate, you can claim your rebate as either:

      • a premium reduction which lowers the policy price charged by your insurer
      • a refundable tax offset when you lodge your tax return.

      You will need to lodge a tax return if you think you are eligible to claim the private health insurance rebate and you have not claimed any or all the rebate from your insurer as a premium reduction.

      • HighAndDry on 26/07/2019 - 15:05

        Oh yeah - private health insurers like to quote their premiums after accounting for the rebate, so that it looks cheaper.

      • Findmebargain on 27/07/2019 - 00:29
        +1

        OP, this is in relation to your question Q2.

        Premium reduction is estimated based on your income in the current financial year and the insurers usually default to the lowest tier fir income up to $90k so you get the max reduction, unless you tell them that you expect to earn more than $90k.

        People who claim their rebate at tax time would have paid their premiums in gross terms (without claiming rebates reduction) so they get their rebate in full at whichever rate they were eligible for at tax time.

        People who claim the reduction along the year but if it turns out at tax time that there is a gap between their actual income and the income based on which the rebates were claimed, then there would be an adjustment in the tax return.

        Your health fund would provide the ATO your annual PHI statement showing how much rebates have been claimed during the year so that should just flow into your tax return working out the rebates or adjustments automatically for you if your are doing it via MyGov.

        • bigbadboogieman on 27/07/2019 - 00:57

          Cool good to know. That reconciles things I suppose because I was wondering that people could just disclose incorrect income to Insurers and claim the full rebate.

  • Amaris on 26/07/2019 - 11:39
    1. The rep was right. By legislation, health funds are not allowed to cover the gap for outpatient medical specialist or GP visits.
      There are some policies available to overseas visitors and working visa holders that do cover outpatient visits over the medicare rate (upto AMA published rates). However, Australian citizens or permanent residents are unable to sign-up to these policies.

    Visits public hospital clinics are free AFAIK.

    • bigbadboogieman on 26/07/2019 - 15:08

      So far personal experience my GP wasn't able to refer to a Specialist at the local public hospital (Westmead Hospital). He did call them to see if he could refer. May be its this specific hospital and not in general. The only people I have seen to reach to those specialists are through a referral after being treated through the hospital's emergency.

      • Amaris on 27/07/2019 - 11:05

        Most big public hospitals have clinics in most specialities. However, since the clinics are limited it is quite hard to get into see a doctor. What usually happens is that the GP faxes a referral to the clinic where a doctor would go through the details and 'triage'. So patients deemed to require quick access will get an early date.

    • bigbadboogieman on 26/07/2019 - 15:13

      Are there any links to this legislation which bars insurers to cover the gap for outpatient medical specialists..? Its understandable that its deliberately done to prevent doctors from overcharging patients if the insurer was to cover which would result in excessive hardship for people not having a private cover. This way no one is covered and everyone pays out of pockets so the pricing has to be set carefully.

  • brad1-8tsi on 26/07/2019 - 12:37

    Unfortunately, sometimes you just have to pay the gap

  • [Deactivated] on 26/07/2019 - 17:48

    Outpatient with Medicare is free in the hospital grounds but if they have an office down the road you will pay full fare but get a rebate off Medicare, you will still be out of pocket. Make sure the consultation is in the hospital as an outpatient but you will have to wait for a booking and it always seems to be a Tuesday etc only per week and no choice of days only times if your lucky. That may suit you if not expect to pay for convenience.

Login or Join to leave a comment
Login Join