Comparing private health insurance and Medicare when it comes to mental health
Mental health support has progressed significantly in recent decades, with a greater focus placed on access, community-based care and community mental health literacy. Because of this, subsidised outpatient mental health services are available in both our public and private health care systems.
The shared goal across all is to ensure that every person - regardless of their location, level of income or profession - has accessible and affordable mental health care.
Growing support from the Australian Government
Given the need, changes were made to the Medicare Benefits Schedule to allow for greater access to mental health care provided in a community setting. Before this, most government subsidised care could only be provided in hospital. The Better Access initiative helps to cover the cost of outpatient mental health services through treatment plans prescribed and managed by general practitioners.
Benefits provided with private health insurance
Private health insurance is another way to access subsidised outpatient mental health services. Many extras (or general treatment) policies provide benefits towards psychology and counselling services, that can be used at the discretion of the policy holder. Waiting periods, limits, benefits and recognised providers vary across all health funds.
So what happens when you have access to Medicare and Private Health Insurance benefits?
The way to claim for mental health services is dependent on how your provider has billed for the service they have delivered. For example, if your GP has prescribed you a mental health care plan and your therapist delivers a service under this plan, you can expect your invoice to contain a Medicare item number for you to claim benefits through Medicare.
In general, private health insurance is unable to pay a benefit towards any ‘gap’ arising from these Medicare subsidised services.
But once you have claimed your maximum sessions through Medicare, you can then claim any additional psychology or counselling visits under your private health extras policy (subject to your health fund’s recognised providers and your available benefits and limits). This allows you to have access to more subsidised services if you need. In these instances, your service is billed as a private consultation.
It is important to have a conversation with your GP and therapist as to how you should be claiming your mental health benefits.
If you decide not to obtain a mental health care plan from your GP, you are still able to claim benefits through extras cover.
So how do the benefits differ?
Below is an example of how benefits can differ between Medicare and private health insurance.
Please note, this is not representative of all private health insurance policies and is only related to the products available with Doctors’ Health Fund. Contact your health fund for more information on the mental health benefits available to you.
Medicare and Extras mental health benefits
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| Medicare benefits with a mental health care plan | Extras benefits with Doctors’ Health Fund | |
|---|---|---|
| Benefits cover services provided by: | Psychiatrists, psychologists, counsellors, social workers and occupational therapists (when recommended by your GP). | Psychologists and counsellors. |
| Can I choose my practitioner? | Your GP may have certain practitioners to refer you to. | Yes. With no preferred provider networks, you can choose the best provider for you and still receive benefits. |
| How are benefits accessed? | Benefits can be accessed once a plan is prescribed by your GP. | Any member who has extras cover and has served the two month waiting period can access mental health benefits. This is regardless of your health status or whether you’ve visited a GP first. |
| How many sessions are covered? | A plan can cover up to 20 sessions, however the number of sessions you attend is guided by your GP. Your treatment will be aligned to the goals you and your GP set prior to treatment and will be monitored throughout. | You can claim up to 9 sessions on Total Extras, up to 7 on Essential Extras and up to 6 on Starter Extras each year*. It is up to you when you use these benefits, until your annual limit has been reached. |
| Do they pay benefits towards telehealth services? | Yes | Yes |
| Can a benefit be claimed in conjunction with another benefit on the same service? | No | No |
| How are benefits claimed? | To be eligible for benefits, the invoice must contain a Medicare item number and be sent to Medicare for processing. | To be eligible for benefits, the service must be billed as a private consultation (not to contain a Medicare item number) and submitted via our app, email, post or fax. |
*A fixed benefit of $100 is paid per service, up to the annual limits allocated to each level of cover. These annual limits are renewed on 1 January each year. Essential and Starter Extras benefits are part of a combined annual limit with other therapies. Please refer to your policy for more information.
Established by the AMA in 1977, Doctors’ Health Fund provides health cover to members of the medical community and their families. Visit our website to find out more about the benefits and services Doctors’ Health Fund provides or to contact our expert team.
Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy.