75%
Medicare, on the doctors’ lines
For each MBS item when you are admitted as a private patient, Medicare pays 75% of the MBS fee and your hospital cover pays the other 25%, if your policy covers it.
Buy Health InsuranceIndependent guide · not a health fund
Every health bill, read line by line
Choosing a private health policy, and changing one, explained the way the bills arrive: what you pay, what your fund pays and what Medicare pays. Each guide is built from the official pages and links to them.
Example only · invented figures
An overnight operation as a private patient. The policy covers the treatment, the hospital has an agreement with the fund, and the policy has a $500 excess.
- Surgeon’s fee$1,500.00
- Medicare: 75% of a $1,000 MBS fee−$750.00
- Your fund: the other 25%−$250.00
- You pay (the gap)$500.00
- Anaesthetist’s fee$700.00
- Medicare: 75% of a $400 MBS fee−$300.00
- Your fund: the other 25%−$100.00
- You pay (the gap)$300.00
- Hospital: bed, theatre, dressings$6,000.00
- Medicare: no benefit for hospital charges$0.00
- Your fund (an agreement hospital)−$5,500.00
- You pay (your policy’s excess)$500.00
- Total charged$8,200.00
- Paid by Medicare and your fund−$6,900.00
- Out of your pocket$1,300.00
Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee for doctors’ services in hospital and your fund pays at least the other 25%, but doctors may charge more than the MBS fee, and Medicare pays nothing towards the hospital’s own charges.
How to read the receipts
- Charged
- What the doctor or hospital bills. Doctors set their own fees.
- Medicare
- The government’s share, worked out from the MBS fee, not from the doctor’s fee.
- Your fund
- What your policy pays, which depends on your cover and the agreements your fund has with the hospital and doctors.
- You pay
- Whatever is left: the gap, an excess or a co-payment.
Three payers, one bill
Who pays which line
As a private patient, your total out-of-pocket cost is the sum of the hospital’s charges, the doctors’ fees and other providers’ fees, minus whatever Medicare and your insurer pay. Three rules decide most of the lines.
No cap
On what a doctor can charge
Doctors are free to charge more than the MBS fee, and many do. The difference can land on you unless your doctor bills under a gap arrangement with your fund.
$0
From Medicare, on the hospital’s lines
Accommodation, theatre fees and other hospital charges get no Medicare benefit. What your fund pays depends on your policy and whether it has an agreement with that hospital.
The guide
Six receipts for choosing and changing a policy
How cover works in general (hospital and extras, the tiers, waiting periods and the government surcharges) is explained on privatehealth.gov.au. These six pages pick up where that leaves off: the money once you hold a policy.
Switching health funds
What carries over, what starts again, and the certificate that proves it.
Gap payments, explained
Why a covered operation can still leave a bill, and the no-gap and known-gap deals.
Extras limits and annual caps
Per-visit benefits, combined limits, sub-limits and the year they reset.
Comparing policies on privatehealth.gov.au
Reading a Private Health Information Statement, line by line.
Premium changes each April
Who approves the increase, when, and what your fund must tell you.
Complaints about a health fund
Your insurer first, then the Private Health Insurance Ombudsman.
Printed on the back
Eight questions to ask before you are admitted
The Private Health Insurance Ombudsman suggests asking your doctor or the doctor’s office these questions when they arrange your admission as a private patient, and confirming the answers with your insurer.
- What are the MBS item numbers for the services, and what will each one cost?
- Do you take part in my insurer’s gap cover scheme, and will you treat me under it?
- Will I have any out-of-pocket costs, and how much?
- Who are the other doctors treating me, such as an anaesthetist or assistant surgeon, and how can I get an estimate of their fees?
- Will you give me a written estimate of what I will pay?
- How will you bill me?
- Which hospital will I be admitted to, and does it have an agreement with my insurer?
- When will I have to pay?
Getting an estimate of the cost before you agree to treatment is called informed financial consent, and the Department of Health calls it your right. It might not be possible in an emergency. More on informed financial consent.
Where to check
The official places behind every receipt
- privatehealth.gov.auAn Australian Government site managed by the Private Health Insurance Ombudsman. It holds a Private Health Information Statement for every policy from every registered insurer.
- Compare PoliciesThe search on privatehealth.gov.au: who is covered, where you live and the type of cover you want.
- Department of Health, Disability and AgeingThe rules insurers work under, out-of-pocket costs, and the yearly premium round.
- Medical Costs FinderA government tool showing the typical costs of common specialist procedures, and what people have paid out of pocket.
- Commonwealth OmbudsmanWhere the Private Health Insurance Ombudsman takes complaints, through its online form. How a complaint works.