Private health insurance cover is generally divided into hospital cover, general treatment cover (also known as ancillary or extras cover) and ambulance cover.
Private hospital policies give you a choice of doctor and cover to be a private patient in a public or private hospital. General treatment policies cover treatments outside of hospital such as dental, optical, physiotherapy or pharmacy. Not all policies cover all services - check with your insurer to find out what is included on your policy and what you may need to pay for yourself.
You can purchase these policies separately, or as a 'combined' policy.more
Private health insurance cover is generally divided into hospital cover, general treatment cover (also known as ancillary or extras cover) and ambulance cover. Ambulance cover may be available separately, combined with other policies, or in some cases is covered by your state government.
In Australia, private health insurance is 'community-rated', rather than 'risk-rated' like most forms of insurance. Private health insurers cannot refuse to insure any person, and must charge everyone the same premium for the same level of cover, despite their risk profile and likelihood of using health services.
There are different types of cover that offer different benefits. Check with your health insurer to be sure of exactly what you are covered for.
With hospital cover you have the right to choose your own doctor, and decide whether you will be treated at a public or a private hospital that your doctor attends. If you are a private patient at a private hospital, you may also have more choice as to when you are admitted to hospital. If you are a private patient in a public hospital, public hospital waiting lists still apply.
When you are admitted to hospital, you have the following treatment options:
|Choice of hospital
|Choice of doctor
|Public patient, public hospital
|Private patient, public hospital
|Private patient, private hospital
Generally, any medical services which Medicare covers and are listed under the Medicare Benefits Schedule (MBS) can also be covered to some extent by private hospital insurance. Services which are not listed on the MBS, such as elective cosmetic surgery or laser eye surgery, are only covered by private hospital insurance to a limited extent or may not be covered at all, depending on the policy.
Every health insurer offers policies with different levels of cover. Generally, the more expensive policies cover a wider range of services, while the lower cost policies will limit what services will be covered in a private hospital.
Four new tiers of hospital cover began rolling out from 1 April 2019 and became mandatory from 1 April 2020. All hospital insurance policies are classified as Gold, Silver, Bronze or Basic. For more information about the new tiers, see Product tiers & Clinical categories.
As with any other insurance policy, you can manage your cover by choosing comprehensive cover with higher premiums, or pay lower premiums for reduced cover. You can also reduce your premiums by opting to pay some of the costs through an excess or co-payment.
For more information about hospital cover, see Private Health Insurance Basics.
The health insurance policy you buy will have some limitations on hospital treatment, which might include:
General treatment cover (also called ancillary cover or extras cover) provides insurance against some or all costs of treatment by ancillary health service providers. The extent of your cover depends on the type of policy you select and may include services such as:
Nearly all services covered under general treatment are only covered to a limited extent. There are various limits that may apply, for example a limit per service, per year, or lifetime limits. Some services may not be covered at all.
You should check the Private Health Information Statement about any policy you are interested in, and seek information from your insurer for details of these limitations.
Medicare does not cover the cost of emergency or other ambulance services. You can organise cover for this service as part of your hospital or general treatment cover, or as a stand-alone cover.
The options for ambulance cover vary depending on what state or territory you live in. For further information please see the Ambulance section of the website.
Private health insurers can cover a wide variety of clinically appropriate alternatives to hospital treatment. This can include treatment provided in your own home or in community healthcare clinics (known as hospital substitute treatment), as well as programs to manage or prevent chronic disease.
It is not mandatory for health insurers to offer cover for these services. Participation in these programs may be subject to your level of cover and eligibility criteria, so check with your insurer for more information.
Common examples of hospital substitute treatment include:
Common examples of chronic disease management include: