Managing your policy

From time to time, you should review your insurance to make sure it still meets your healthcare needs.

Lowering your premiums

If the cost of your insurance has become a concern, there are many ways you can manage your policy to allow you to have lower premiums. Some health funds provide discounts depending on your situation, rate protection if you pay in advance and if need be you may be able to suspend your membership for a time rather than fall behind in payments.

Some health insurance policies will give you full cover for the costs of hospital accommodation and in-hospital medical charges. Other policies require you to meet some of the costs, in exchange for lower premiums. You can agree to:

  • not be covered for certain services (exclusions), or
  • only receive limited benefits for a certain service (restricted benefits), or
  • pay a set amount towards the cost of your hospital treatment (excess or co-payment).

Exclusions

If your policy has an exclusion for a particular condition, you are not covered for treatment as a private patient in a public or private hospital for that condition.

For example, if your policy excludes obstetric services, hip replacements and knee replacements, and you go into hospital as a private patient for one of these conditions, your health insurer will not pay any benefits towards your hospital and medical costs.

If you need treatment for an excluded service, your options would be to seek treatment as a public patient or to cover the full cost of the treatment yourself.

Restricted Benefits

If your policy has restricted benefits for some conditions, you will be covered for treatment for those conditions but only to a limited extent. You will face considerable out-of-pocket costs if you have this treatment as a private patient.

If you need treatment for an restricted service, your options would be to seek treatment as a public patient, or as a private patient in a public hospital or to cover some or most of the cost of the treatment yourself.

Excess

An excess is an amount of money you agree to pay for a hospital stay, before health insurer benefits are payable. This is sometimes referred to as a front-end deductible.

For example, if your policy has an excess of $200, you will be required to pay the first $200 of your hospital costs should you go to hospital as a private patient. An excess may apply every time you go to hospital in a year, or may be capped at a total amount that you will have to pay in a year.

Co-payment

With a co-payment, you agree to pay a set amount each day you are in hospital. This can also be referred to as an overnight excess, daily excess or patient moiety.

For example, a policy may have a co-payment clause that requires you to pay the first $50 for each day of hospital accommodation. If your policy has such a co-payment and you were in hospital for five days, you would have to pay $250 ($50 x 5). The total amount of co-payment you pay per hospital stay is often limited to a set maximum amount.

Exclusions, restrictions, excess and co-payments are listed on the Standard Information Statements.

Discounts

Health funds may offer discounts on premiums for people who:

  • pay their premiums at least three months in advance,
  • pay by payroll deduction,
  • pay by pre-arranged automatic transfer from an account,
  • have agreed to communicate with the private health insurer, and make claims under the policy, by electronic means,
  • belong to a contribution group under the rules of the fund, eg your health insurance product is organised through your workplace or an organisation you belong to, and
  • where the insurer is not required to pay a state or territory levy (e.g. if you are a pensioner or a low income earner in New South Wales or the Australian Capital Territory, your premium may be reduced because you are entitled to free ambulance cover).

Check with your health fund to see if you are eligible for any of these discounts.

Rate protection

If you can pay your premiums 12 months in advance, some funds will offer a rate protection policy.

With a rate protection policy, if the rates are increased within the 12 months you have already paid you will not have to pay the increased rate until your 12 months of cover ends.

If you do not have a 'rate protection' policy, the fund will ask you to pay the balance owing on the new rates, or reduce the length of time your payment covers.

Failure to pay

If you fall more than two months behind in paying your contributions, your private insurance will lapse and you will not be insured.

Some funds may not accept payment of arrears in excess of two months. When you resume your payment, the insurer may impose further waiting periods before you can claim benefits again.

Suspending your membership

Health funds may grant suspensions for an agreed period of time, at their own discretion, for circumstances such as working or studying overseas, financial hardship or temporary unemployment.

During the suspension you will not be able to claim and if you are over the income threshold you will be required to pay the Medicare Levy Surcharge for that period. Suspension rules differ between funds so you should check to see if you will need to serve any waiting periods again.

Suspending your membership with the agreement of your health fund will not affect your Lifetime Health Cover entitlements.