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Is your teen eligible?

The Medicare Dental Plan covers eligible teenagers aged 12-17. He or she must be eligible for Medicare. Certain benefits also need to be received by the teenager themselves or their family, guardian or carer. These conditions only need to be met for a single day in the calendar year in some cases. A letter will be sent to you to if you are eligible – there is no need to apply.

What is covered?

The Medicare Teen Dental Plan is designed to make preventative check-ups less costly. The voucher covers an oral examination, but may also include x-rays, a scale and clean, a fluoride treatment and fissure sealing if needed. If the check-up indicates that any other dental work should be carried out, it will not be covered by this voucher.

How it works

Once the voucher has been received, there are several steps that you need to take.

1. Making an appointment. Firstly, you need to book an appointment for the check-up. Be sure to confirm that the dentist will cover the check-up under the Medicare Dental Plan, as not all will necessarily accept the voucher. Ask about the costs too – some dentists will charge more than the $163.05 claimable from Medicare, which would leave you with out-of-pocket costs to cover.
2. Attending the appointment. Take your Medicare card along with the voucher.
3. Claiming the Medicare benefit.
• Your dentist may bulk bill Medicare directly. This does not require you to do anything other than sign an Assignment of Benefit form.
• However, your dentist may ask you to pay upfront, and you can then claim the cost back from Medicare.
• In some cases, you may need to take an unpaid account to Medicare. You will then receive a cheque to give to your dentist. If your dentist charges above the Medicare benefit, you will need to pay the difference.

Beyond the Medicare Teen Dental Plan

The Medicare Teen Dental Plan is designed to cover check-ups. If your teen is lucky, this may be sufficient, but you cannot count on this to be the case. If your teen needs dental work or is not eligible for help from Medicare, a private health fund may help with your dental costs.

Private health insurance is not always as expensive as you might think. Compare health insurance policies to find a plan that fits the needs of the whole family. Look into the details of extras cover like dental plans during your health insurance comparison, as there can be variations in the items covered and the amount you can claim.

What does hospital cover include?

As the name suggests, you are covered for in-hospital services. For out-of-hospital services, you can arrange additional extras cover. Extras cover is often combined with hospital cover. This may be a set package of extras, or you may be able to choose which extras you want. Having hospital cover alone will help to keep health care costs down. However, you may also want cover for many non-hospital services that you may need.

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Why you might need ancillary cover?

Ancillary cover will help with out-of-hospital costs. Just a few of the options include dental, optical, podiatry and pharmacy. Many of these are not covered through Medicare. Here are a few examples of ancillary options for which Medicare only provides basic cover, or none at all.

• Dental. Basic dental treatment is covered for teens through the Medicare Teen Dental Program. The chronically ill can get some dental care through the Chronic Disease Management Program. For the latter, the health condition must be likely to affect oral health.
• Optical. Eye tests performed by optometrists are covered by Medicare. If you need glasses or contact lenses, these are not covered by Medicare.
• Complementary therapies. These are not usually covered. For example, acupuncture is only covered if it forms part of a doctor’s consultation.
• Physiotherapy/podiatry/chiropractic. None of these are covered by Medicare unless you qualify for the Chronic Disease Management program.
• Ambulance services. These are not covered by Medicare. Queensland and Tasmania have free ambulance services, but in other states you may need ambulance cover.
• Pharmacy. Many medicines are subsidised through the Pharmaceutical Benefits Scheme (PBS).  However, not all medicines are. This extra insurance covers non-PBS medicines.

Waiting periods

Many extras carry waiting periods that must be served before you can claim. How long you have to wait depends on the extra in question. Extras such as general dental, physiotherapy, palliative care and psychology carry two month waiting periods. Major dental cover has a longer wait time of twelve months. The lesser waiting periods may sometimes be waived by health funds as a sign up bonus.

Cover levels

Depending on your policy, you may not be covered for everything. For example, having dental cover does not mean that you are covered for all dental work. Having basic cover means that there will be limits. This makes it crucial to compare health funds to look at your options. Expect out-of-pocket expenses if you need treatment that is not covered by your policy.

Ancillary cover will provide benefits for out-of-hospital services. Exactly what you are covered for depends on your policy level. Basic cover is cheaper, but not very broad. Be sure to compare health insurance policies as not all are the same.

A Health Savings Account

The health savings account can be a powerful tool. Even if you already have private health insurance, there are benefits to keeping money saved up to help cover excesses, co-payments and other expenses related to your health care.  Such an account may work well if you want a high-excess policy with low premiums, giving you peace of mind that you will be able to afford your share of your health treatment costs.

Consider this kind of option, especially if you’re looking to save money on your regular health insurance premium.  A savings account can help you with the out-of-pocket expenses that you’ll meet, whether for a minor ailment or for a more serious health issue.

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Marriage and Health Insurance

If you have a spouse who is employed rather than self-employed, you may be able to get some health insurance cover by being named on your spouse’s policy.  This is likely to work out cheaper than obtaining a separate policy for each of you. Employee health insurance may cost less than private health insurance as an individual, and sharing a policy with your spouse is typically cheaper too.

Look at the enrolment period that may be required in order to sign you up on your spouse’s policy; there may be other enrolment conditions to be met, too.  Contact the administrator of your spouse’s health insurance plan to find out more.

Holding On to an Employee Policy

If you were recently employed by another company, you might be able to keep your current health insurance plan. This means you would have to take on the full responsibility of paying the premium, as well as any out-of-pocket costs. The amount you pay for your ex-employee health insurance will vary, and it may be more expensive than standard health insurance. However, you may find it useful as a temporary option if you only intend to be self-employed for a short time or if you haven’t had time to compare health insurance and choose another policy.

Overview

Whatever you do, make sure you have adequate funds or adequate insurance coverage for your health needs.  You don’t want to be without cover and then unexpectedly have to pay a high healthcare bill for a treatment for which Medicare doesn’t give benefits.

There are some insurers offering health insurance specifically deisgned for the self-employed, so this is worth researching before you compare private health funds. Take a look at some standard and alternative options for your health insurance needs.  Maybe your old employee policy or spouse’s policy could come into play in your decision, or you could use a savings account to reap the advantages.  Whatever the case may be, take your time and evaluate what might be best for you.

If you already have private health insurance, you may worry about how to afford to maintain enough cover for your needs. If you don’t already have health insurance, Lifetime Health Cover loading fees may make you feel that you cannot afford to compare health insurance. Even if you can afford to continue being a health fund member, you may worry about meeting the out-of-pocket costs that are not covered by this. This may seem like a scary prospect, but there is hope.

Thankfully, there are various concession cards that can help you out. One of these is the Commonwealth Seniors Health Card (CSHC). This can lower your costs for PBS medicines. It can also help with the costs of other health services.

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Commonwealth Seniors Health Card Eligibility

Could you be eligible for the CSHC? You must satisfy the following eligibility criteria.

• You are an Australian resident
• You are not serving a waiting period as a new Australian resident
• You are of Age Pension age, but are not eligible for the Age Pension
• You are not receiving Social Security or DVA benefits
• You must provide Centrelink with the Tax File Number for you and your partner (or be exempted from doing this)
• You must meet the adjusted taxable income criteria. This is currently $50,000 (singles) and $80,000 (couples). For dependent children, the threshold goes up by $639.60 per child. Not sure what counts as taxable income? Check with Centrelink to confirm. Super payments for over 60s are usually tax-free, but this is not always the case.

How It Works

The CSHC entitles you to discounts on PBS medicines. You may also benefit from being eligible for the Medicare Safety Net, which would reduce your out-of-hospital costs on medical services assuming that you meet the threshold. Another major benefit is bulk-billing rates for doctor appointments. GPs are encouraged to adopt bulk-billing, but they are not obliged to do so.

The CSHC does not cover your dependents. If you want them to be able to benefit too, there is an alternative concession card. The Low Income Health Care Card offers the same benefits as the CSHC but also covers dependents.

Getting the Card

You can register your claim online via an Intent to Claim. In effect, this informs Centrelink of your intention to apply for a concession card. You will need to make your claim within 14 days of your Intent to Claim. You can also claim by paper form, by telephone or in person at a Centrelink centre.

Need help with your health care costs as you get older? This is a big concern for many seniors. Don’t forget to compare health cover – it may not cost as much as you think. Beyond this, concession cards can make things a bit easier. For example, the CSHC can help with buying PBS medicines and can also reduce medical costs. This can be a big help for many seniors but not everyone will be eligible.

Alcohol is a depressant drug that can cause a host of physical problems. It can bring about disability and death. Too much can lead to physical illness as well as violent behaviour and accidents. Frequent alcohol drinking can result in addiction too. This could then lead to serious mental health problems later on.

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There are solutions for people facing alcohol addiction. For one thing, relevant medical and psychological help can be readily accessed through health insurance.

Private Health Insurance and Alcohol Abuse Treatment

Being treated as a private patient in a private health facility such as a rehab centre is one of the benefits you may find in a private health insurance policy. Those with private health funds may access treatments according to their policy inclusions:

• Accommodation at an alcohol treatment facility may be covered in full under hospital cover. Coverage may be for a short one-day stay or for an extended period, as determined by the doctor overseeing your treatment.
• Hospital cover may pay a percentage of the doctor’s fees for alcohol addiction treatment.
• Access to 24/7 ambulance services may be made available through ambulance cover.
• Fees for out-of-hospital consultations may be partly paid by general treatment cover.

Private health funds are not created equal. Some will provide coverage for alcohol treatment, while some will not. Carrying out a comprehensive private health insurance comparison is crucial. You want to make sure this particular health issue will be addressed if it is likely to affect you.

Fortunately, doing a thorough insurance comparison no longer requires tedious legwork. There are reputable health insurance comparison sites which makes this task easier. They can accurately gather and present quotes from various insurers. It can all be done with just a few clicks of your mouse and some basic information entered on-screen.

Make sure to review all the exclusions and restrictions before buying a health insurance policy. Read the product disclosure statement to ensure you fully understand all the terms of the policy you will be buying.

Help from Medicare for Alcoholics

Alcoholics can now count on Medicare health support thanks to the Australian government’s new program called Better Access to Healthcare. One can now seek assistance for alcohol treatment from a psychologist who is registered with Medicare.

These conditions have to be met:

• You must get a recommendation from your primary healthcare provider before seeing a psychologist. It can be from your general practitioner or your psychiatrist, or from your paediatrician if you’re a minor.
• Your primary healthcare provider can refer you to a particular psychologist. However, you can always choose to work with another. If you take the latter option, make sure that the one you’ll be enlisting has a Medicare Provider Number.
• A maximum of ten individual sessions and ten group therapy sessions per year can be received through Medicare.

It is important to remember that not all Medicare-listed psychologists follow the suggested schedule fees. Expect to pay for the difference between the schedule fee and the practitioner’s rate if this is the case with your psychologist. If a bulk billing system is used, then you won’t have to worry about paying out of pocket for professional fees at all. Familiarise yourself with these essential details. This will help you prepare financially before starting your treatment for alcohol addiction.

Disability Benefits under Private Health Insurance

No disability coverage is as varied as the ones extended by private health insurance providers. It is crucial to read through every insurance product disclosure statement when in the medical insurance comparison phase.

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Insurers have different names for different types of disability covers. These are the most common ones:

• Trauma Cover – This insurance gives coverage for those who have been injured. It also applies for illness such as stroke or cancer. The cover may provide assistance for previous and ongoing medical costs not covered by health insurance. The costs for needed lifestyle and housing changes which make the patient’s life more manageable may be included too.
• Income Protection Cover – This insurance provides for a person who is unable to work because of injury or illness. Income replacement may be provided for a set period of time. It can also continue for the rest of the afflicted person’s life depending on the terms of the policy.
• Total and Permanent Disability Cover – This insurance provides steady financial assistance when the policy holder is deemed fully and permanently disabled. Every insurer has its own criteria for determining this medical state. Commonly, total and permanent disability means being unable to work in the former job. It also pertains to being completely unable to work again in any kind of occupation.

Doing a private health insurance comparison does not only entail checking the rates offered by insurers. One should also examine these important points:

• Coverage level – Debilitating injury or illness has a huge impact on one’s life. Think about how much income you and your family will need if you’ll be unable to work. This will help you decide how much disability cover to get. Other kinds of life insurance should be taken into account. For instance, if you have a superannuation fund going and it includes total and permanent disability cover, then there is no point in obtaining similar insurance.
• Waiting periods – Waiting periods basically prevent immediate claims after policy purchase. This tends to increase the costs for all members of the health fund. Providers have varying waiting periods but they normally range from 60 to 90 days.
• Life insurance – If you already have life insurance cover, this may include some coverage for disability such as trauma cover or income protection.

Disability Benefits from the Government

Welfare payments as well as services for the disabled can be obtained from the following. This is based on the National Disability Insurance Scheme and National Injury Insurance Scheme.

Centrelink

Centrelink is in-charge of distributing welfare payments such as:

• Carer Allowance. This may be extended to people who take care of injured, disabled, ill, or aged members of the family who require additional round-the-clock care.
• Carer Payment. This may be provided to people who are unable to work because they provide full-time care to a disabled, ill, or aged member of the family.
• Mobility Allowance. This may be extended to injured, ill, or disabled persons so that they can attend in approved activities. The allowance is meant to cover transportation costs because they can not use public transport without the assistance of a carer.
• Sickness Allowance. This may be extended short-term to wage earners who are unable to go to work because of a medical condition.
• Disability Support Pension. This may be provided to Australians who have a severe physical, mental, or intellectual impairment, and who receive government employment and wage support.

CRS Australia

CRS Australia assists the disabled or injured acquire and keep suitable and gainful jobs. This agency works closely with employers to ensure workplace safety. The focus is of course on the disabled.

Australian Hearing

Australian Hearing provides support to hearing-impaired Australians. Assistance is in the form of medical services. They also help the hearing-impaired access cheaper products that are crucial to improving their quality of life.

Who Is the Private Health Insurance Ombudsman?

The Private Health Insurance Ombudsman is the name for an Australian Government agency that deals with consumer concerns about their private health funds. However, the Ombudsman acts independently of the Government.

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What Does the Ombudsman Do?

The stated purpose of the Private Health Insurance Ombudsman is to “protect the interests of people who are covered by private health insurance.”

The Private Health Insurance Ombudsman office handles consumer inquiries and complaints regarding all aspects of private health insurance, but the Ombudsman also works with the government and the private health insurance industry, offering advice to them, and publishing independent reports about the performance of the health insurance industry.

Publications that inform consumers about private health insurance funds, making complex aspects of the industry clearer to the general public, and helping the public to understand their responsibility as members of private health funds, are available from the Ombudsman.

How Can the Ombudsman Help Me?

When you encounter problems with your private health fund that cannot be resolved by contacting the health fund directly, the Ombudsman can take your complaint and assist you in reaching a resolution.

If your complaint stems from a misunderstanding of your benefits, the Ombudsman’s staff will help you to understand how your benefits work and what you can do to use them effectively in the future. However, if your complaint is not due to a misunderstanding, the Ombudsman will initiate contact with your health fund or third parties with whom you have experienced difficulty using your health fund, and obtain more information and suggestions for resolving the problem.

In cases of complaints that are complex,  the Ombudsman will seek additional information about the problem from the health fund or other organization, and in some cases, recommend a certain course of action to resolve the problem.

How Do I Make a Complaint to the Ombudsman?

You can make a complaint to the Ombudsman by contacting them through the following channels:

Mail: Suite 2, Level 22, 580 George St, Sydney NSW 2000
Complaints Hotline: 1800 640 695 (free from anywhere in Australia, though mobile phone charges may apply)
Telephone: (02) 8235 8777
Fax:   (02) 8235 8778
Email: info@phio.org.au

While your complaint is being investigated, Ombudsman staff will keep you regularly informed about the status of your complaint, usually by telephoning you.

If your tiredness symptoms need further investigation, you’ll want to know if you’re covered for tests and appointments with specialists. Here is a guide to what can be covered through Medicare and what you will need private health insurance for if you want to minimise your out-of-pocket expenses.

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What does Medicare cover?

GP consultations. Medicare will reimburse 100% of the Medicare Benefits Schedule fee for visiting a doctor outside of hospital. There is no fee for you to pay if his or her fee is the same as the MBS fee. It may not work out like this, though, as GPs can choose to charge above the MBS fee. This difference between the GP’s fee and what Medicare will cover mean that there may be out-of-pocket costs that you have to pay.

Specialist consultations. Medicare will reimburse 85% of the MBS fee. Even if the consultant’s fee is in line with the MBS fee, there is still the remaining 15% to cover. Specialists, like GPs,  may charge more than the MBS fee, so check the fees before you see a specialist for your fatigue issues.

Diagnostic tests. If your doctor advises that tests are necessary to discover the reasons why you’re feeling so tired, Medicare may cover the costs. Many tests and examinations come under this cover, including x-rays.

If your doctor bulk bills, you pay nothing as they bill directly to Medicare. If they do not bulk bill, you need to pay the difference between their fee and what Medicare will cover. This may involve paying your doctor in full, sending your receipt to Medicare and being reimbursed for the MBS fee amount. Or it may involve being given a cheque to give to your doctor along with any balance that you still owe.

What does the Medicare Safety Net cover?

The costs can soon mount up if you find that you need regular consultations with a doctor who charges above the MBS fee. The Medicare Safety Net is in place to help with these out-of-pocket costs. If your out-of-pocket costs reach the Safety Net threshold, 100% of the MBS fee for eligible services will be reimbursed through Medicare. There may still be out-of-pocket costs to meet though. The Original threshold for all Medicare cardholders is $413.50 in March 2012 . For concession cardholders and families eligible for FTB(A), the threshold is $598.80.

If your out-of-pocket costs reach a certain amount, the Extended Medicare Safety Net can help. For out-of-hospital services, up to 80% of your out-of-pocket costs can be covered. Some services are capped so you will not get this level of help on those. Getting to the bottom of your symptoms should be covered as consultations with GPs and specialists are included in the safety nets. Many diagnostic tests are also covered. The Extended threshold is $1198 in March 2012. This is for all Medicare cardholders.

Will private health insurance help?

The main intention of private health insurance is to cover services that would otherwise be unavailable or unaffordable. Services that are available through Medicare are not covered. More specifically to this scenario, medical services provided out-of-hospital, such as GP visits and consultations with specialists, are not covered by private health funds. The gap between the MBS fee and the fee charged may be covered by Medical Gap insurance.

However, you may choose to compare health insurance for private hospital cover, which may give you greater choice about where, when and from whom you receive treatment. This may be reassuring if you feel that your condition warrants swift attention, for example if tiredness is affecting your ability to work. You may also want to look into extras cover for specific treatments such as chiropractic or optical care, in case you need to access these services in the future.

Summing things up

Are you worried about arranging a consultation with your GP in case the costs start to grow beyond your budget? Remember that Medicare will cover 100% of the MBS fee for GP visits. It also covers 85% of the MBS fee for consultations with specialists. There may still be some out-of-pocket fees if your doctor charges above the MBS fee but Medicare should cover the bulk of the costs. Health insurance will not help with the costs of out-of-hospital medical services, but you may be able to use gap insurance to minimise your out-of-pocket costs.

Can I get help through Medicare?

There is good reason why dental is such a popular health insurance extra. Medicare provides only limited dental care. Getting help with dental costs through Medicare is not possible for many people. However, you may be able to receive dental care through Medicare through the following programs if you qualify.

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Medicare Teen Dental Plan

This program is designed to make dental check-ups more affordable for families with teenage children. Is your teen eligible for this? Firstly, he or she must be aged between 12 and 17. He or she must also be eligible for Medicare. Beyond this, certain benefits need to be received. You can see more details about eligibility on the Medicare Teen Dental Plan website.

Chronic Disease Management program

You must meet the criteria and be referred to a dentist by your GP to be eligible. You must have a chronic condition requiring complex care. This must have been present for six months or more. Your oral health must be deemed to be affecting your general health or have the potential to do so. If eligible, it covers things like assessments, preventative treatment, fillings, extractions, restorative work and dentures. Speak to your GP if you think that you may qualify.

Why do I need dental insurance?

When money is tight, many people think twice about having dental insurance. Far from being an unnecessary expense, it can actually save you money in the long run. Making the effort to maintain good dental health can help to protect against bigger expenses further down the line. Regular check-ups can catch problems before they become more serious – and more expensive.

What dental cover can I get?

Some health funds have ‘no gap’ schemes. This means that preventative and diagnostic services do not have ‘gap’ payments and you will not be out-of-pocket. Other services are at generally at lower cost too.

Some health funds will have agreements with providers so that you are charged less for dental treatment. How much you will get out of this largely depends on your coverage level. Always compare health funds – some may have unlimited benefits, but other may have annual maximums.

Bear in mind that there may be little scope to use your existing dentist under the cover of your new health fund. Want to keep your own dentist? When you compare health insurance, make sure that you look at whether your current dentist is a part of their coverage network. Some health funds will let you choose your dentist, so if you are keen to keep the same dentist, you may prefer to look for health funds that don’t limit cover to their selection of preferred or participating dentists.

If you have got dental cover, your health fund will cover some of your dental care costs. It is important to have an adequate level of coverage for your needs, as you may find very limited cover offers less value for your premium.

What is the Medicare Benefits Schedule?

The Medicare Benefits Schedule lists the services that are available as Medicare benefits. It is published by the Department for Health and Ageing (DoHA) and updated regularly on their MBS website. Every item on the MBS has its own Schedule fee, which is set by the Australian government.

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Medicare will not necessarily cover the full Schedule fee. For GP fees, 100% of the MBS fee is reimbursed by Medicare. This means that you will have nothing to pay if your GP’s fees are in line with the MBS fee. For specialists fees, 85% of the MBS fee is reimbursed. This means that if your specialist’s fees are the same as the MBS fee, you will still have 15% to pay. This “gap” may be covered by private health insurance.

However, doctors can choose to charge more than the Schedule fee. In this situation, you will need to pay the difference between the MBS fee and what the doctor or specialist charges, plus the “gap” if applicable. The difference is known as an “out-of-pocket” amount. Private health insurance may cover the difference in part or in full.

The Medicare Safety Net

Australian residents and some overseas visitors can get free or affordable treatment as a public patient in a public hospital. However, Medicare does not cover everything. For example, out-of-hospital costs can easily leave you out of pocket. This type of out-of-pocket expense can quickly add up if you need more than a few appointments.

This is where the Medicare Safety Net can come into play. This is designed to reduce your out-of-pocket expenses so that your medical costs come down. Could you be eligible for this? If you or your family’s “gap” payments exceed the threshold in a calendar year, 100% of the MBS fee will be reimbursed through Medicare. Bear in mind that this only applies to out-of-hospital services. This may not always mean that you will not have anything to pay though. There may still be “out-of-pocket” expenses to meet if the MBS fee does not cover the full cost of the service.

The Extended Medicare Safety Net

Your out-of-pocket costs may still add up, even if you qualify for the Medicare Safety Net. If they reach a certain amount in a calendar year, the Extended Medicare Safety Net can help. Through this, 80% of your out-of-pocket costs will be met as long as they are for out-of-hospital services. This applies to the rest of the calendar year.

Some Medicare services are capped under the Medicare Safety Net. This means that you will only be able to receive a certain amount back regardless of the treatment costs. This can include obstetrics, assisted reproductive technology and some varicose vein and cataract treatments. This is known as an Extended Medicare Safety Net (EMSN) benefit cap. For these services, you may receive the EMSN benefit cap amount if it is lower than 80% of your out-of-pocket costs.

Tests and doctor visits are covered by the Medicare Safety Nets. This includes GP consultations, specialist consultations, blood tests, CT scans, x-rays, pap tests and ultrasounds. In-hospital services are excluded, as are medical services not covered by Medicare.

Medicare Safety Net thresholds

For 2012, the thresholds are:

• Original threshold = $413.50 for all Australians
• Extended General threshold = $1198 for all Australians
•  Extended Concessional threshold = $598

MBS Summary

Not previously been aware of the Medicare Benefits Scheme? Every item on it has a Schedule fee, which affects how much you pay for Medicare services. If your treatment costs more than the Schedule fee, you can find yourself with a “gap” amount and “out-of-pocket” costs. The Medicare Safety Net can help with this but it will not cover everything. For non-Medicare services, you may want to compare health insurance to cover them. As always, be sure to compare health funds for the most affordable and relevant cover for your needs.