What is the difference between hospital and extras cover?

Private hospital cover is designed to pay a benefit towards treatment as a private inpatient in a private or public hospital (e.g. surgery and giving birth). To be considered an inpatient, you need to be formally admitted to hospital by a healthcare professional; specialist consultations inside a hospital don’t count as inpatient services.

When you’re treated as a private patient, Medicare will pay 75% of the Medicare Benefits Schedule (MBS) fee, which is the cost the government has deemed reasonable for that treatment. Your private health insurance will then pay the remaining 25%, plus other expenses like theatre fees, accommodation and more.

Keep in mind that your doctors and hospital can choose to charge more than the MBS fee, in which case you may still have some out-of-pocket expenses. These out-of-pocket costs can be reduced or removed entirely if your hospital or treating doctors participate in your health fund’s gap cover scheme.

There are several benefits to hospital cover that you’ll want to consider when deciding if it’s the right product for you. With hospital insurance, you can choose your available treating doctor, recover in a private room (subject to availability) and, perhaps most importantly, avoid lengthy public waiting lists for elective surgeries by going to a private hospital.

Hospital cover is standardised across all health funds by the Australian Government. All Australian health funds must divide their policies into tiers based on the clinical categories covered. These tiers are Basic, Bronze, Silver and Gold – with each category including a broader range of services than the one below it.

Gold policies are the most comprehensive, while Basic hospital cover has the most exclusions. On all tiers except Gold, health funds can offer cover for additional clinical categories from the higher tiers. If they do, the policy can be given a ‘plus’ or ‘+’ to denote its additional cover.

For example, if a Silver policy offers cover for having a baby as a private patient (usually only covered by Gold), the policy will be classified as Silver Plus.

Yes, but you will have to serve a 12-month waiting period before you can claim on your hospital insurance policy for treatments relating to your condition (excluding rehabilitation, psychiatric and palliative care). These waiting periods exist to prevent people from signing up for health insurance when they fall ill and immediately cancelling their cover once treated.

Also known as general treatment or ancillary cover, extras cover contributes towards the costs for health services outside of hospital that Medicare doesn’t pay a benefit towards. Depending on your extras policy, you may be able to claim a benefit for dental check-ups, physiotherapy, chiropractic, hearing aids and more.

As extras cover isn’t regulated in the same way as hospital cover, health funds typically offer a variety of different levels of cover. However, some funds will still categorise their policies as ‘basic’ or ‘comprehensive’. A ‘basic’ policy may offer cover for less expensive services (e.g. scale and cleans for your teeth) or have lower claim limits. Meanwhile, ‘comprehensive’ policies will usually cover more services (e.g. root canals, crowns and bridges) with higher annual limits in exchange for paying a higher premium.

That’s completely up to you. Some people only take out hospital cover because they want more choice if they need surgery. While other people just want extras cover for out-of-hospital treatments like dental, optical and physio. It’s all up to you if you would like to get hospital cover, extras cover or both.

Having a pre-existing condition won’t affect your eligibility for extras cover. Any waiting periods are also unaffected by having a pre-existing condition.

Medicare is Australia’s public health system that helps to cover the cost of a range of medical, hospital and pharmaceutical treatments. For treatment as a private inpatient, Medicare must deem the procedure medically necessary for your private health insurance to be able to pay a benefit.

Private health insurance also allows you to choose your own doctor (based on availability), stay in a private room in a private hospital (provided one is available) and avoid the public system waiting lists for treatment by attending a private hospital.

Any person with a Medicare card is entitled to public treatment, whereas only those who have an eligible hospital insurance policy will receive a benefit from their health fund towards their treatment if they choose to be admitted as a private inpatient.

Outside of the hospital, your private health insurance policy may pay a benefit towards treatments that Medicare doesn’t cover. These treatments can include things like dentistry, physiotherapy and podiatry.

Ambulance services aren’t covered by Medicare. Ambulance cover can be included on both hospital and extras products; however, the level of cover can vary. In some cases, an eligible hospital policy may provide a higher level of ambulance cover than an extras product.

Depending on where you live, your state government may cover the costs of emergency ambulance transportation. Alternatively, you may be able to purchase an ambulance subscription from your state ambulance service.

For more information about how to get covered for ambulance services, refer to our guide to ambulance cover or contact your local ambulance service.