Finding your way in the health system

Public healthcare

Australia’s public health system helps you to have affordable care. Some services are free in the public system, but you will probably still need to pay some costs yourself. You can choose to be treated in the public system even if you have private health insurance. It’s your decision. You can also have some care in the public system and some in the private system.

Public hospitals

Public hospitals and some community-based services provide free or low-cost care for people with a Medicare card. If you’re being treated as a public patient in a public hospital, you can’t choose your doctor or other members of your healthcare team. Treatment is based on your needs, so you may have to wait longer for care than a private patient, but this isn’t always the case.

Medicare

The Australian Government fully or partly covers the cost of a range of many medical services including cancer care.

Medicare may cover some or all the cost of:

• visits to GPs and specialists outside the hospital
• certain tests and scans used in cancer diagnosis 
• some medical services provided in private hospitals.

Medicare Safety Net

Once your gap payments for health care outside the hospital add up to a certain amount, Medicare will pay a higher benefit for the rest of that calendar year. For details, call Medicare on 132 011 or visit Services Australia's Find the threshold amounts for Medicare Safety Nets.

What if you don’t have a Medicare card?

If you’re not a permanent Australian resident and don’t have a Medicare card, you may need to pay the full healthcare costs. Some people can still get public healthcare, including refugees and eligible asylum seekers, as well as people from countries with reciprocal healthcare agreements (where 2 countries agree to provide visitors with health care).

Bulk-billing 

Some GPs and specialists accept the Medicare benefit as full payment for a service. This is called bulk-billing, and it means you don’t need to pay anything. To find GPs and specialists who bulk-bill, visit Healthdirect's Service Finder. Not all doctors bulk-bill, so you’ll need to pay the difference between the Medicare fee and the doctor’s fee. This is called a gap payment.

Pharmaceutical Benefits Scheme (PBS)

Many cancer medicines are expensive. The PBS covers all or part of the cost of many prescription medicines for people with a current Medicare card.

If you’re treated as a public patient in a public hospital, the PBS pays for most medicines. This means these drugs are free. You might need to pay a small amount (dispensing fee) for some medicines you take home. If you're a private patient, you may have to pay part of the cost of PBS medicines, but the overall cost will be capped under the PBS Safety Net.

Some new cancer drugs are not funded by the PBS, but you still may be able to have them.

PBS Safety Net

The PBS Safety Net further reduces the cost of PBS medicines once you or your family have spent over a certain amount on medicines each year (the threshold). For details, call 1800 020 613 or visit Services Australia's PBS Safety Net thresholds.

If you want to have radiation therapy in the public system after private surgery, tell your surgeon at the time of surgery and you’ll go on the waiting list. By the time you’re ready for radiation therapy after surgery, you should have a place.

Oncology nurse

Private health care

Some people prefer to be treated as a private patient so they can choose their own doctor and avoid potentially longer waiting times for treatment. Most people who use private health care have private health insurance.

Private hospitals and health services

Private doctors, hospitals and other providers set their own fees. Private health insurance may pay part of the bill. For some treatments, Medicare may also cover part of the cost.

You’ll probably still need to pay some money yourself. This is known as a gap payment. You may also be charged for things such as your hospital room, operating theatre fees and medicines.

Before treatment starts, your cancer care team will explain what costs you need to pay. This is called informed financial consent.

Check with your private health insurer about what your policy covers.

Private health insurance

Ask what your policy covers. If you’ve joined recently, there may be a waiting period. Private health insurance does not pay for out-of-hospital services that Medicare covers (e.g. GP visits). It doesn’t usually cover radiation therapy, which is mostly given as outpatient treatment.

Thinking about the costs

Before being treated as a private patient, it’s good to ask:

• your doctor for a written estimate of their fees, who else will care for you (e.g. an anaesthetist) and how you find out what their fees will be
• your private health insurer what costs they’ll cover
• the hospital if there are any extra treatment and medicine costs.

Your private health insurer may have arrangements with certain doctors and hospitals (medical gap scheme). Using these services can cut costs.

Drugs not on the PBS

Doctors may recommend a drug that’s not on the PBS. This is called a private prescription. These drugs are often very expensive, and you may need to pay the full price for them. This cost will not count towards the PBS Safety Net.

Some private health insurance policies may cover part of the cost of a private prescription. Check with your fund.

You also may be able to access non-PBS drugs by joining a clinical trial or through a compassionate access scheme. This is when a drug company is willing to provide a drug to a patient for free or at reduced cost.

Gap payments

Some doctors don’t bulk-bill, so you’ll have to pay the difference between the Medicare benefit and the consultation fee.

It's often up to the doctor to set their fee, and different doctors set different fees. When you make an appointment with your doctor, ask if there’ll be a gap payment and what it will be. Keep in mind that a doctor with a larger gap payment is not necessarily any better than another doctor with a lower gap payment.

Informed consent

To help you make a decision that’s based on your values, your doctor must give you information about:

• what the proposed treatment involves and how it may help
• other treatment options
• possible side effects and risks
• any likely out-of-pocket costs (called informed financial consent).

Information is usually given in English. If you need an interpreter, tell your doctor or call the free interpreter service TIS National on 131 450.

When you understand this information and agree to treatment, this is called informed consent. You’ll usually be asked to sign a document to show that you understand the information you are given and agree to treatment. If you’re confused or need more information, talk to your doctor or someone in your cancer care team.