Private hospital cover of Bronze or above allows you to get treatment for cancer, choose your own doctor and stay in your own private room.
This guide will tell you how Medicare and private health insurance can work together to get you the help you need and also how to minimise your out-of-pocket expenses.
Your costs can vary based on the type of cancer you have. A study published by the Medical Journal of Australia in 2018 uncovered the average out-of-pocket costs for five major cancers: breast, prostate, lung, colorectal and melanoma.
They found that breast cancer patients have the highest out-of-pocket costs, ranging from $1,165 to $7,495 with a median of $4,192.Lung cancer patients have the lowest, ranging from $367 to $3,196 with a median of $1,078.
Of course every patient is different and so is every cancer. A rare bone marrow cancer could potentially cost more than those cancers studied.
Another 2018 report from the Consumers Health Forum of Australia (CHFA) shows that nearly half of Australian cancer patients paid more than $5,000 in out-of-pocket expenses for their treatment over a two-year span and a quarter spent more than $10,000.
Needless to say, you will experience some out-of-pocket expenses whether you go public or private, but luckily there are ways to reduce them.
How does private health insurance cover cancer treatment in Australia?
Private health insurance can work alongside Medicare, giving you the benefit of having more control over your treatment and where it occurs. It covers you in four major ways:
In-hospital cancer treatments. Private health insurance will contribute to your in-hospital treatments at a private clinic, including doctor's fees, accommodation, prescriptions and the treatment itself.
In-hospital psychology. The only level of cover where you'll get this for sure is a Gold level policy, although some policies as low as Bronze Plus will offer it. The good news is, you can upgrade your policy to one that covers psychiatry and skip the waiting period if you find you need this cover at the last minute.
Prescriptions. Some extras policies cover medication that is not on the Pharmaceutical Benefits Schedule (PBS). Some rare forms of cancer require obscure medications meaning there's a chance you could be prescribed an expensive drug that Medicare doesn't cover.
Rehab. Some extras policies will cover a host of treatments that help you recover, like physio, exercise physiology, speech therapy and even acupuncture.
Ambulance. Many policies offer emergency ambulance cover. You can find this on both hospital and extras policies. This is unnecessary in states like QLD and TAS, which provide ambulance cover for residents.
You'll experience more out-of-pocket expenses with private health insurance, but the trade-off is that you get treated sooner by your choice of doctor. .
Plus you will still be able to claim Medicare benefits.
Compare Private Health Insurance for Cancer Treatment
Quotes are based on a single individual with less than $90,000 income, $500 excess and living in Sydney.
What is the best health insurance for cancer patients?
If you're looking for the best insurance policy, here's a few things to consider::
Get a Bronze policy or higher. All Bronze policies and above are required to offer treatment for cancer and you're unlikely to find private cover at levels below that.
Consider your transportation costs. If you have to travel more than a certain distance for your treatment (around 200-250km), some private policies will cover some of your transportation and accommodation costs. This can be a great way to save on some of those costs that often fly under the radar but still add up.
Don't forget your extras. An extras policy can offer a host of important treatments that can help you cope and recover like physical therapy, speech therapy and psychological counselling. It can even cover medications that Medicare doesn't.
Look for a large network of agreement hospitals. Most private insurers have a network of private doctors and hospitals that have agreed to lower their out of pocket costs for their customers. Look for an insurer that has a wide network with lots of providers near you.
Think about other services you might need. You might want to consider a policy with in-hospital psychiatry since cancer can take a toll on you mental health. Or you may have a family history of cancer and want to have children before any possible diagnosis. In that case you may want to consider a policy that covers pregnancy.
Are there any waiting periods for cancer treatment?
Here are the typical waiting periods you can expect as a cancer patient:
Hospital treatments
If you already have cancer. 12 months since it's a pre-existing condition. It could still worth considering cover since you may have to wait for public treatment.
If you don't have cancer. 2 months. If you haven't been diagnosed and haven't developed any symptoms, you can get treatment sooner.
Is cancer treatment covered by Medicare in Australia?
Yes. Whether or not you use private health insurance, you'll still rely on Medicare for a large portion of the costs. According to the Sydney Morning Herald, Medicare will cover an average of 63% of the total costs, which ranges from 51% for prostate cancer to 89% for lung cancer.
Medicare provides rebates for some outpatient services, many of which aren't covered by private health insurance. These outpatient services include:
GP visits
Specialist visits
Blood tests
CT scans
MRIs
Biopsies
Medicare can also pay for all of your in-hospital treatments if you choose to be treated as a public patient.
Cancer treatment in Australia and your out-of-pocket costs
Why do out-of-pocket expenses vary so much from patient to patient?
Cancer treatment is not as straightforward as something like fixing a broken nose, where the diagnosis is straightforward and you book into see a single surgeon who fixes you up and sends you on your way.
Here are some of the things that make cancer treatment different:
Every cancer is different. A rare form of blood cancer will probably require more testing and more specialist visits than a malignant mole clearly visible on the skin.
Diagnosis can take a while. Depending on what type of cancer is suspected, you could be running around from your GPs to the testing clinics, back to the GP, over to a specialist who sends you for some more tests, then back to the specialist and so on.
Treatment can vary widely from case to case. If you need treatment, you might need anything from surgery to remove a tumor to chemotherapy to hormone therapy to rehab to all of the above.
You won't always be checked into a hospital. Sometimes you'll be a patient in a hospital other times you'll be treated as an outpatient.
You can't always choose where you have certain procedures. Sometimes you'll have no choice but to visit a private clinic for procedures like an MRI or radiation therapy. Other times you'll be able to locate a public clinic that will do certain things cheaper..
How can I work out my out-of-pocket costs for cancer treatment?
Look at all of the various treatments, procedures or consultations that you could encounter as a cancer patient.
Your ability to get public and/or private assistance is slightly different in each case. By looking at the options you have and the financial roadblocks you can encounter in each case, you can develop strategies that will help you minimise your out-of-pocket expenses as a whole.
How is it covered by Medicare? It's free if the GP bulk bills Medicare but if they don't they'll probably charge an amount above the Medicare rebate. You will be responsible for that portion, known as your gap.
How is it covered by private health insurance? It's not. Private health insurance doesn't apply to GP visits.
Implication: You could end up having dozens of GP visits, but it's relatively easy to avoid large out-of-pocket costs by finding a GP that bulk bills Medicare.
How can you reduce your costs? There are plenty of GPs all around Australia who bulk bill. Locate a couple in your area and stick with one you feel comfortable with.
Can you use private health insurance? Only if it's part of your in-hospital treatment.
How is it covered by Medicare? For outpatient tests, certain tests and scans are 100% covered by Medicare if done in a public facility. However, more and more facilities are being privatised meaning you'll get a Medicare rebate and likely pay an out-of-pocket fee. In addition, some scans aren't covered at all, especially those looking for rarer forms of cancer.
How is it covered by private health insurance? Outpatient tests and scans aren't covered by private health insurance and you'll have to rely on the Medicare rebate.
If you're a private patient in a hospital, you will receive a Medicare rebate on tests as long as they are on the Medicare Benefits Schedule (MBS), which is Medicare's list of covered treatments. You will be responsible for any difference in cost and for the full costs of tests and scans that aren't on the MBS.
Implication: These costs can be difficult to predict for a number of reasons:
Diagnosis isn't always straightforward
Not all scans are covered
Private facilities can be hard to avoid
How can you reduce your costs? Keep open communication with your GP about wanting to minimise your out-of-pocket expenses. Research all the public testing facilities in your area and request that your GP refer you to them if possible. If your doctor or someone on the facility tells you something isn't covered, ask them for the item number and search the MBS just to be sure. Make sure you have your bank account information updated in the Medicare system so you can get your refund in a timely fashion.
How is it covered by Medicare? It's free if it meets all of the following conditions:
A GP refers you
The specialist bulk bills
It's a service listed on the Medicare Benefits Schedule (MBS).
If the specialist doesn't bulk bill, you will receive a rebate (and probably pay some out of pocket costs) as long as the consultation is on the MBS.
How is it covered by private health insurance? It is not. Private health insurance doesn't apply to specialist visits.
Implication: Finding a specialist near you who bulk bills can be challenging since they aren't as common as GPs. However, it shouldn't take much legwork to do the research.
How can you reduce your costs? Ask your GP to refer you to a specialist who bulk bills. If they don't know any, do your own research and suggest some names. If you can't find a specialist that bulk bills, email a few others and ask them for a schedule of fees so you can compare prices.
How is it covered by Medicare? This is free if it's done as a public patient in a public hospital, but you will be on a waiting list if the treatment isn't urgent. Your accommodation and anesthesia will also be covered free of charge.
How is it covered by private health insurance? If you have a private hospital policy that covers cancer, you can choose to be treated privately instead. Medicare and private insurance will cover the MBS fee for the surgery and the anesthesia. You will pay your insurance excess and any gap the doctor an anesthetist charge above the MBS fee. You may also have some out-of-pocket costs for your accommodation. This is called your co-pay.
Implication: There are usually more out-of-pocket expenses related to surgery in a public hospital. However, the benefits are that you get to choose who treats you, you can avoid the long wait times associated with the public system and you're pretty much guaranteed a private room.
How can you reduce your costs? There are ways to reduce your out-of-pocket costs if you decide to go the private route. Your private health insurer may have special arrangements in place with certain private hospitals, known as agreement hospitals, that have agreed to reduce your out-of-pocket expenses.
You can also ask your private doctor to treat you in a public hospital, where you can save on some of the associated fees like accommodation.
How is it covered by Medicare? Intravenous chemo and radiotherapy is free in a public hospital. However more and more radiotherapy services are run by private clinics so depending on where you live, you may have no choice but to use their services. If that's the case, you'll get a rebate from Medicare but most likely also pay some out-of-pocket fees.
For chemo and hormone medication taken out of the hospital, Medicare will pay for most of it as long as it's part of the Pharmaceutical Benefits Scheme.
If your medication is not on the PBS (eg, it's for a rare form of cancer or it's a new cutting edge drug), you could end up shouldering the entire cost.
How is it covered by private health insurance? If it's done in-hospital, private insurance will cover your intravenous chemo and radiotherapy, but you may have to pay a gap fee. If it's done as an outpatient, private insurance won't cover you. However, you'll still be eligible for a Medicare rebate.
Private health insurance doesn't cover an oral chemo treatment or hormone therapy taken out-of-hospital, so you'll have to rely on the PBS as mentioned above. Some private extras policies will help out with the cost of non-PBS medications.
Implication: You can expect some out-of-pocket costs for chemo, radiotherapy and hormone treatments since much of this involves pharmaceuticals you'll be taking as an outpatient.
How can you reduce your costs? For all outpatient service, research public clinics in your area and ask your GP to refer you to one of them. If there are only private clinics, call them and ask. them for a schedule of fees so you can compare costs. In regard to outpatient medication, the only thing you can really do is take out a private extras policy that covers non-PBS medications in case you happen to be prescribed one.
How is it covered by Medicare? In-hospital medication that's on the PBS will be fully covered in a public hospital. For prescription medications you take as an outpatient, you'll be covered for most of the cost as long as the medications are on the PBS.
How is it covered by private health insurance? Whether you're an inpatient or an outpatient, you'll be covered for most of the cost as long as the prescription is on the PBS. You'll have some out-of-pocket costs.
If it's not on the PBS, you'll be responsible for the entire cost although some private extras policies will help toward some non-PBS pharmaceuticals.
Implication: You'll most likely have some out-of-pocket costs for prescriptions no matter where you are treated. Since many of these aren't directly related to your treatment, there's a good chance you can find most of them on the PBS.
How can you reduce your costs? If you're prescribed supplementary medication like pain medication or anti-nausea medication, ask the prescribing doctor to make sure it's on the PBS. You can also take out a private extras policy to help out with non-PBS medications if you're prescribed one. Just keep in mind there is usually a waiting period of around two months. Shop around at various chemists for the best price and choose generic versions of the medication if possible.
How is it covered by Medicare? In-hospital psychology and rehab (like physio and exercise physiology) will be fully covered in the public system. Some public hospitals with a lot of resources may offer some of these services like speech therapy and exercise physiology.
You can get a Medicare rebate for out-of-hospital rehab, psychiatry and psychology but this probably won't cover the full cost and you will be responsible for the rest.
How is it covered by private health insurance? Your private health insurance will also cover in-hospital rehab but it may or may not cover in-hospital psychology depending on your policy.
A private extras policy may also contribute to some of these services as an outpatient, but these will not cover the full cost and you'll have to come up with the rest.
Private surgeons may offer certain free classes like classes like nutrition, group counselling or yoga.
Implication: Most people will experience out-of-pocket costs related to allied health services unless they are lucky enough to live near a major public hospital that provide all of these services.
How can you reduce your costs? Take out a private extras policy that covers a range of services like physiotherapy, speech therapy and psychology.
Maximise your Medicare rebates by asking your GP to enroll you in the Chronic Disease Management plan, which can help patients with chronic or terminal diseases become eligible for additional rebates for services like physiotherapy and speech therapy.
You can also ask your GP to enroll you in a Mental Health Treatment plan, which will make you eligible for rebates on psychological counselling.
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Richard Laycock is Finder's insurance editor, and has spent the last five years wrangling insurance product disclosure statements. His musings about insurance have appeared on Money Mag, Yahoo Finance, and Travel Weekly. When he’s not helping people make sense of insurance fine print, he is testing the quality of cocktails in his newfound home of New York. Richard studied Media at Macquarie University and The Missouri School of Journalism and has a Tier 1 Certification in General Advice for Life Insurance.
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