“Out of pocket” expenses refer to the difference between what your doctor charges you for treatment and what your Medicare or health fund covers. This difference has to be paid by you since it is not covered by the health insurance policy.
Out of pocket expenses can occur due to a number of reasons including:
a) You are claiming for items that are not covered by your policy.
b) You have to undergo a procedure that is not recognised by Medicare and hence benefits are not payable.
c) You want treatment at a hospital that is not contracted by your health insurance company.
d) There is no suitable health cover for your treatment at the hospital.
e) You are still within the “waiting periods” after just joining a health fund or upgrading your level of cover.
How to avoid out of pocket expenses
As you prepare to go to hospital and are organising your hospital stay, ask the doctor for a cost estimate for your procedure. If other medical specialists will be involved, for example, anesthetists and assisting surgeons, have them included in the estimates.
With the estimates at hand, contact your private health insurance company. They will check whether your procedure is covered, whether you have served the mandatory waiting period and whether the hospital you want to get treatment at is contracted to them. Opting for a hospital not contracted with your health fund will cost you more.
Inform your health fund manager of the total cost estimates for both doctors and specialists that will be involved. The estimate should also include MBS items. The manager will check how much is covered by your policy. You will know whether you are covered 100 percent or if not, what out of pocket expenses you will have to cater for.
Some private health insurance companies have agreements with doctors to cover the out of pocket expenses you are likely to incur. With these agreements, the doctors agree to charge you less than what they have quoted. The agreements are known as “Medical Gap Scheme”.
One way of eliminating out of pocket expenses is to inquire from the doctors and specialists who will be carrying out your procedure whether they will participate in your health insurance’s Medical Gap Scheme. However, it is not mandatory for them to participate. Each doctor and/or specialist involved can choose whether or not they wish to participate.
In case the doctors and/or specialists do not wish to participate in your health insurance’s Medical Gap Scheme, you can look for another doctor who is willing to do so. Alternatively, opt to have the procedure done at a public hospital. While Gaps are not pleasant, they keep the cost of health insurance down and make it affordable.
With private health insurance, you can choose the doctor and hospital you want and avoid the waiting list in public hospitals. This gives you peace of mind.
{ 0 comments }