What is an MRI scan and does health insurance cover it?
Magnetic resonance imaging (MRI) scans are a sophisticated type of diagnostic technology. MRI machines will emit a strong magnetic field around the body part being scanned, which can be used to see inside the body and identify certain issues and abnormalities.
While X-rays are good at scanning bones, MRIs are good at scanning liquids and fats, which are found throughout your body in muscles and organs. This makes it a unique way of picking up on issues that might otherwise go undetected, or finding the physiological cause of seemingly unexplainable symptoms. For example, if someone is suffering from recurring headaches, an MRI scan is a good way of scanning the brain itself for abnormalities or problems, while X-rays might only show the skull.
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How private health insurance covers MRI scans
Your private health insurance may cover MRI scans. Depending on the purpose of the scan, there are several different components of your policy that may cover your MRI such as:
- Joint investigations. This is the investigation and analysis of a limb joint for the purpose of diagnosis or in preparation for surgery. An MRI may be recommended for this, in which case you will be able to claim it against joint investigations if applicable.
- Gastroscopy. This refers to the inspection and diagnosis of the digestive system, including the bowels and oesophagus. An MRI may be recommended by your doctor for diagnosing health issues affecting these. If referred for this purpose, you may be able to claim an MRI against the gastroscopies component of your health insurance policy, if present.
- Diagnostic imaging. This is the general term for procedures like X-rays, CT scans, MRIs and other imaging techniques. This is one of the most likely categories on which you can claim MRIs. As always, it is only claimable if done for a valid medical purpose, which can be proven with a registered doctor’s referral.
- Health screenings. Usually included as an extra, health screenings refer to any preventative measures undertaken to identify potential health issues. MRIs are an effective form of health screening, but because they are not strictly medically necessary you cannot claim them on Medicare. Some policies may let you claim an MRI health screening within the limits and restrictions of that policy.
Private health funds are most often used to cover the gap when having an MRI done at a private hospital, or to pay for MRI scans that are not strictly medically necessary, such as for the purposes of a health screening or if it has otherwise not been recommended by a doctor.
Terms and conditions to look for in health insurance policies
When comparing health insurance policies to cover MRI scans, there are some terms, conditions and phrasings to look out for.
- Sections you can claim your MRI with. Look for joint investigation, gastroscopy, diagnostic imaging, health screenings and similar terms. Depending on your particular health issues, you might be able to claim the MRI costs against these features.
- Limits. The limit is the highest amount that can be claimed for a certain procedure. For private health insurance, these are typically annual limits, which are the maximum amount of benefits that can be claimed per year. These might be per-person, or per-family if there are multiple people covered by your policy.
- Exclusions. This refers to circumstances and conditions under which your health fund will not pay out. Some common exclusions include treatments being done overseas (you will typically require travel health insurance for this), scans performed without a distinct medical purpose or doctor’s referral and treatment of pre-existing conditions. This can be a particular concern for seniors, as such conditions may accumulate over the years, slowly limiting your options. You may wish to look at special health insurance policies for baby boomers if you are over 65.
How to claim MRIs on Medicare
Medicare is Australia’s public health insurance, automatically available to all permanent residents. It will almost always cover an MRI scan, as long as it has been ordered by a GP or a recognised medical specialist. Physiotherapists might recommend MRIs, but because they are not actual medical doctors you will be unable to claim these on Medicare.
- Medicare will cover 75-85% of the cost of an MRI scan, which can range from about $150 to $500 depending on the body part being scanned and the conditions being looked for.
- To claim an MRI on Medicare you must have been referred by a GP or a medical specialist.
The process for claiming and the amount covered by Medicare both depend on whether you are a public or a private patient, and whether you are visiting a public or a private hospital.
- Public hospitals will accept the 75-85% as the entire fee if you are a public patient, meaning you will not need to pay any of the cost yourself. If you are a private patient who has chosen to use that public hospital then you will still need to pay the gap, either out of pocket or with private health insurance.
- Depending on your location and the hospital, private hospitals will either not be eligible for Medicare, or will require you to pay “the gap” (the remaining 15-25%) yourself or through private health insurance. You cannot be admitted to a private hospital as a public patient.