Health Insurance FAQs

Answers when you need them

Have a question about your Medicare Levy Surcharge, Lifetime Health Cover loading, or perhaps you're just looking to take better care of your teeth with an extras policy? No matter the query, Sergei has the solution for your Health Insurance needs.

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Health insurance resources

Lifetime Health Cover Loading calculator

LHC applies to anyone over 31 (following their 31st birthday) who isn’t covered by private hospital cover.

Calculate your LHC loading now

Medicare Levy Surcharge calculator

This surcharge affects high income earners ($90,000+ per annum for singles, $180,000+ for couples/families).

Calculate your MLS now

Should I consider health insurance?

If you’re not sure about health insurance, this quick quiz will help you figure out what’s in it for you

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Health insurance Frequently Asked Questions

About Compare the Market

Why don’t you have all the health funds on your website?

Quite simply, not every insurer chooses to display their products through us. We have a selection of health funds available and will continue to expand the range to ensure we always have suitable policies available to meet your needs – as well as to provide an unbiased comparison.

Ambulance

Do I need ambulance cover?

Yes, everyone should have cover for emergency transportation in Australia. Whether that cover is paid for by your state or territory government, accessed through a subscription or a health insurance policy, or provided to you through a concession card; no one should be without this crucial protection.

To find out if you need ambulance cover in your state or territory, see if you are covered for emergency transportation in your state.

Am I covered for an ambulance ride in my state?

Medicare does not pay any benefits towards the cost of ambulance transport or services.

The table below outlines how ambulance cover works in each state.

State/territoryAmbulance Cover entitlements
All states and territoriesDepartment of Veterans Affairs Gold Card holders are covered for state and territory ambulance services across Australia.
Australian Capital Territory Health Care Concession Card and Pensioner Concession Card holders have access to free emergency ambulance services. ACT residents who do not qualify for a concession can take out cover through a private health fund.
New South Wales Health Care Concession Card, Pensioner Concession Card, and Commonwealth Seniors Health Card holders have access to free ambulance transport services. NSW residents who do not qualify for a concession can take out cover through a private health fund.
Northern Territory Pensioner Concession Card and Commonwealth Seniors Health Card holders have access to free ambulance transport services. NT residents who do not qualify for a concession can take out cover through a private health fund, or a subsciption with St John Ambulance Australia (NT).
Queensland

Ambulance fees for Queenslanders are covered by the state government Australia wide.
South Australia

If you seek ambulance cover you can take out insurance from a private health fund, or a subscription with the SA Ambulance Service.
Tasmania

Ambulance fees for Tasmanians are covered by the state government within Tasmania, Queensland and South Australia. To be covered while travelling in all other states and territories you can take out Domestic Travel Insurance.
Victoria

Pensioner Concession Card and Healthcare Card holders have access to free ambulance transport services. Victorian residents who do not qualify for a concession can take out cover through a private health fund, or a subscription with Ambulance Victoria.
Western Australia Western Australian Aged Pensioners are entitled to free primary ambulance services. WA residents who do not qualify for a concession can take out cover through a private health fund, or a subscription with St John Ambulance.

Source: PrivateHealth.gov.au, Health Insurance, What is Covered, Ambulance, Information current as of April 2018.

Does Medicare cover ambulance?

Medicare does not cover Ambulance transport or services. However, depending on what state you live in, you may be entitled to government-funded ambulance services if you hold certain concession cards. Otherwise will need to take out an ambulance subscription, or a health insurance policy that includes emergency transportation cover, to ensure you are not faced with unexpected costs during an emergency.

Need more information? Find out, ‘what is ambulance cover and is it for you?

How much does an ambulance trip cost?

A ride in an ambulance can cost anywhere from hundreds of dollars to thousands. For example, if you are a Victorian resident, you can expect to pay up to $1,776 for emergency ambulance road transport as of July 2017. In NSW, your call out fee is $372 for an emergency, then you’re charged $3.35 per km, with a maximum charge of $6,095 as of July 2017!

For this reason, it’s important to make sure you have the right cover. Find out the cost of emergency transportation.

Source:  New South Wales Government, Health, Ambulance Service of NSW, Fees and Charges, Charges for NSW Residents.
Department of Health & Human Services, State Government of Victoria, Australia, Ambulance Victoria Fee Schedule 2017-18.

Claiming

Is cosmetic surgery covered by private health insurance?

Coverage for cosmetic surgery all depends on whether it is elective surgery to improve your appearance (e.g.  non-medically required breast enhancements or reduction, tummy tucks or liposuction, facelifts, or nose jobs) or medically necessary surgery to treat, repair, or reconstruct deformities (congenital or other), injuries, burns, scars, and more.

Elective cosmetic surgery to improve appearance, or any surgery not listed on the Medicare Benefits Schedule, is not covered by private health insurance. Reconstructive plastic surgery that is medically necessary (i.e. to improve or maintain health or repair injuries or damage) and is listed on the Medicare Benefits Schedule - is generally covered by private health insurance in Australia. However, there may be waiting periods, out of pocket expenses, and terms and conditions found in your policy’s product disclosure brochure.

Can you claim ultrasound procedures on private health insurance?

Outpatient services such as ultrasounds are usually not covered by health insurance, as the service usually takes place outside of a hospital and attracts a Medicare benefit.

Is Botox covered by insurance?

Botox injections (and any cosmetic surgery) will only be covered by health insurance in Australia if the surgery or treatment is deemed medically or clinically necessary and holds a Medicare item number. For example, Botox injections are covered by insurance if they are used to combat chronic migraines (subsidised on the Pharmaceutical Benefits Scheme – PBS) or to treat repetitive strain injury (RSI) - mostly in hands.

Medicare also pays a benefit towards Botox treatment for medical purposes. However, if the Botox treatment is purely to improve appearance (without any medical purpose), then it will not be covered by health insurance or Medicare.

Is acupuncture covered by private health insurance?

Acupuncture consultations can be covered by private health insurance if it is included as part of your natural or alternative therapies extras cover. It is seen as an effective procedure to treat pain (chronic, dental, joint, muscle) and medical conditions (like nausea from chemotherapy or pregnancy).

However, you will only be covered if the treatment and consultation is performed by a qualified practitioner recognised by your fund, and based on Australian guidelines and regulations, or performed by someone who is registered with an approved association. Claiming acupuncture benefits through an extras policy will also have an annual dollar amount limit (or sub-limit for natural or alternative therapies) and a waiting period (usually two months, but 12 months if you suffer from a pre-existing medical condition).

Are massages covered by health insurance?

Health insurance does not cover general massages. However, remedial massages performed by an accredited registered practitioner are covered by most health insurance policies via extras cover under alternative therapies or natural therapies & remedies.

Your health insurance fund may provide a benefit towards some or all of the costs of your remedial massage up to a limit. There is often a waiting period to be covered and a sub-limit that may cap your massage cover at a dollar amount for the year.

Is STD testing covered by health insurance?

STD or STI testing is usually covered by Medicare if you have a Medicare card. Consultation and screening can be performed by most GPs or doctors (who can choose to bulk bill or charge regular doctors’ fees). As the services are outside of the hospital and come under Medicare, this isn’t something that private health insurance in Australia pays a benefit towards.

Is LASIK surgery covered by insurance?

There is a limited number of health funds that offer a rebate towards LASIK surgery, or laser eye surgery, and sometimes only if you hold the right level of health insurance and have served a waiting period of up to three years, among other terms and conditions.

Laser surgery does not have a Medicare item number. It is best to talk to a health insurance expert to determine which fund or policy includes LASIK eye surgery under optical cover, and to establish if you are entitled to some form of a rebate.

Can I claim sunglasses on private health insurance?

Non-prescription sunglasses are generally not covered by health insurance extras. In some instances, funds will contribute to the cost of cancer council products for sun protection, but terms do apply, so look into this before you purchase.

However, prescription sunglasses are covered by private health insurance funds if you have optical cover in your extras, where you can receive a full or partial rebate (depending on your level of cover, optical sub-limits, and the cost of your prescription glasses).

Dental cover

Is Invisalign covered by private health insurance?

Invisalign – unobtrusive, ‘clear aligner’ braces – is usually categorised and priced similarly to conventional braces. If you have cover for orthodontic major dental work included in your health insurance, then you may be covered for Invisalign - although dental extras coverage in Australia differs between health funds & policies, so it is best to check with your insurance provider or PDS.

In Australia, Invisalign treatment can cost between $6,000 and $9,000. Health policies may have both an annual and lifetime benefit limit on the amount you can claim for orthodontic or major dental treatment, including Invisalign. It is important to check with your insurer whether you are covered for Invisalign treatment and whether treatment coverage is capped.

Does Medicare cover dental treatment?

In the majority of cases, Medicare does not offer cover towards dental procedures. This means you will be required to pay for your routine and major dental care out of your pocket. Private health insurance, however, can help towards the cost of dental services under extras policies.

Are braces covered by health insurance?

Orthodontic treatment, such as braces, can be a high-cost, major dental procedure (with costs ranging from $2,000 up to almost $10,000). Health insurance can contribute to the cost, but only if you have an extras policy that includes major dental and orthodontic cover.

With dental cover in Australia, your policy will determine your waiting period and the amount you can claim through annual and lifetime limits. For example, lifetime limits for orthodontics (through top-level extras) commonly range from $2,400-$3,000, while yearly sub-limits may vary.

Is teeth whitening covered by health insurance?

Many health funds do contribute to the cost of teeth whitening via their extras policies under routine dental. However, there may be limits to the amount of cover you can receive, and cover is only provided where teeth whitening carries a dental item number and is performed by a registered dentist. In understanding dental cover in Australia, because teeth whitening is usually not medically necessary, it is therefore not covered by Medicare.

Glossary

What are non-PBS pharmaceuticals?

The Australian government’s Pharmaceutical Benefits Scheme (PBS) subsidises the cost of a specific list of drugs, which are then available to the public at a lower cost. Non-PBS pharmaceuticals are those that do not appear on this list, and which therefore will cost considerably more.  Where your fund specifies that it covers non-PBS pharmaceuticals within a particular policy, you should still check whether there are additional limitations and how much they will pay towards the prescriptions.

What is a clearance certificate?

This is a document that contains important information on your previous policy, such as what benefits you were covered for, what your annual limits were, what you have already claimed, and how long you have been with the health fund. Under the Private Health Insurance Act, there are “portability” rules, which ensure that your new fund recognises any waiting periods that you have already served. Your clearance certificate is used to verify this, along with ensuring Lifetime Health Cover loading is applied at the appropriate rate. In most cases, your new fund will take care of the transfer certificate procedure on your behalf, so long as you have clearly requested it in the application process.

What is an agreement hospital?

An agreement hospital is a private hospital or day surgery that holds a contract with your insurer to provide inpatient services with low or no out-of-pocket expense for your accommodation and theatre fees.

Each fund will have different arrangements with different hospitals it’s important to check that the hospital you would prefer to go to, has an agreement with your health fund. You can do this by speaking to your fund.

What are out-of-pocket expenses in health insurance?

Out-of-pocket, or ‘gap' payments, are what you’re charged for medical treatment if the total cost falls outside of what is covered by Medicare and private health insurance. For treatment as a hospital patient, Medicare covers 75% of the Medicare Benefits Schedule (MBS) fee. Private health insurance will cover 25% of the remaining MBS fee, meaning 100% of the MBS is covered.

However, if your specialist or doctor charges more than the MBS, this remaining amount is for you to pay. This is called your ‘gap’ or out-of-pocket expense.

Most health funds will offer gap cover arrangements in your private hospital coverage, but ultimately it is up to your doctor/specialist/anaesthetist to choose to participate in this arrangement on a case-by-case basis. If they do, it can reduce or eliminate your ‘gap’ or out-of-pocket expense.

What are restrictions?

Restricted services on your policy will only be covered to a limited extent, most of the time this means that you will be covered up to the amount that is charged as a private patient in a public hospital. Restricted coverage does not allow you to avoid the public waiting list for surgeries, to ensure that any services you feel you may need are fully included in your policy.

Always check your policy brochure for details of any restrictions that may apply to your coverage.

What are exclusions?

Exclusions are conditions and/or services that are excluded from your policy, meaning that your health fund won’t pay any benefits towards treatment for these services. Different policies will have various exclusions, and your level of cover is determined by what services are included or excluded.

So, if you require treatment for a service that is excluded from your policy, it is essential that you explore your options with a doctor - as no benefit will be available through your private health insurance.

What is a co-payment?

A co-payment is similar to excess. The difference between the two is that, generally speaking, you pay an amount for each day of your stay, up to a certain number of days. Always check with your insurer before you organise any treatment that may attract a co-payment.

If you elect to pay a co-payment when signing up for cover, it could reduce your monthly premiums. Find out how your co-payment amount can affect your premium.

What is an excess?

An excess is a lump sum payment you owe if and when you have to go into hospital. The rules on when you are required to pay this excess will vary from policy to policy – some insurers will only charge the excess amount once per year, while others may apply it for each admission.

If you elect to pay a higher excess, it could reduce your monthly premiums. Always check the fund’s policy brochure for details of any excesses that may apply to your policy. Find out how your excess amount can affect your premium.

What is an inpatient?

An inpatient is someone who is admitted to hospital. This could be for day surgery, an overnight stay, or an unspecified time period.

What is a benefit limitation period?

A benefit limitation period (BLP) is where a health fund restricts the benefits available for a particular condition or treatment, for a set period of time. This period will be in addition to the normal waiting periods, and the restrictions will be removed once the BLP is served.

You should check the policy details to ensure that you fully understand how, or if, benefit limitation periods apply to your health cover.

What is a restricted fund?

Restricted funds can be joined exclusively by members of a specific industry, employer, or group. For example, Doctors, Nurses, Banks, Railway and Transport services and the Defence Force - among others. In some cases, family members and extended family are also eligible to join.

Government Levies, Loadings, and Rebates

Can an overseas visitor claim on the private health insurance rebate?

Yes, provided the overseas visitor has a compliant health insurance policy from an Australian fund and are eligible for Medicare. However, if the overseas visitor has an overseas policy or isn’t eligible for Medicare, they will be unable to claim a rebate.

Learn more about the private health insurance rebate and how to claim it.

Does my age affect my rebate?

Yes, your age does affect the amount that you can claim for the Australian Government Rebate for private health insurance. The government has established different tiers for the rebate, which are determined by your income bracket and age.

Australian Government Rebate for private health insurance
Singles
Families
≤$90,000
≤$180,000
$90,001-105,000
$180,001-210,000
$105,001-140,000
$210,001-280,000
≥$140,001
≥$280,001
< age 6525.415%16.943%8.471%0%
Age 65-6929.651%21.180%12.707%0%
Age 70+33.887%25.415%16.943%0%

 

What is the private health insurance rebate?

The private health insurance Australian Government Rebate is an Australian Government initiative to assist Australians in paying their premiums. Depending on your age and how much you earn, you can receive a rebate of anywhere between 8.47% and 33.89% back from your premium (as of April 2018).

You can claim this rebate through a reduced premium or during your tax return. Learn more about the Australian Government private health insurance rebate and how to claim it.

What’s the difference between the Medicare Levy and the Medicare Levy Surcharge?

You’re not alone in asking this question, and it’s a common point of confusion when it comes to health insurance.

The Medicare Levy is 2% of your taxable income and is charged to tax paying Australians earning over $26,120. There’s no way to avoid this Levy; it’s in place to provide funds to the Medicare System, enabling you to seek treatment in a public hospital at no cost to you when you need it.

The Medicare Levy Surcharge (MLS) is an amount you have to pay on top of your 2% Medicare Levy if you earn over a certain threshold and don’t have private hospital cover. You are exempt from paying this additional Medicare Levy Surcharge for the number of days in any tax year you hold private hospital cover.

See Medicare Levy Surcharge for more information.

Who pays the Medicare Levy Surcharge (MLS)?

The Medicare Levy Surcharge (MLS) is payable by Australian taxpayers who earn over $90,000 as a single or $180,000 as a couple or family and don't hold private hospital cover. For families with children, the threshold increases by $1,500 for every child you have after the first. However, if you are exempt from the Medicare Levy, you may also be exempt from the MLS.

This is between 1% and 1.5% depending on what income bracket you fall into. Having private hospital cover will make you exempt from paying the MLS. Learn more about the Medicare Levy Surcharge.

Do I have to pay the Medicare Levy Surcharge (MLS) if I have private health insurance?

If you have a hospital policy from a compliant Australian provider that has an excess of $750 or less ($1,500 or less for couples and families), you can avoid paying the Medicare Levy Surcharge. This is an additional surcharge that is payable by Australian taxpayers who do not hold private hospital cover, and earn over $90,000 as a single and $180,000 as a couple or family (with the threshold increasing by $1,500 for each child after the first) unless they fall into one of the exemption categories or hold private hospital cover.

It’s important to note that holding extras cover will not make you exempt from paying the MLS.

I’ve just become a permanent resident, and I’m over 30 years old. Do I have to pay Lifetime Health Cover loading?

Once you become eligible for Medicare, you have one year to take out private hospital insurance cover without incurring any LHC loading. If you sign up after this period, LHC loading will be applied.

If you believe your health fund has applied the loading to your premium by mistake, you need to provide them with a copy of your Medicare Letter of Eligibility in order for them to remove the loading from your cover. You can obtain one of these letters from your nearest Medicare office.

I’ve just turned 30; do I have to purchase private cover?

Private cover is not compulsory. However, the Government created an initiative on the 1st of July 2000 called Lifetime Health Cover (LHC) Loading, to encourage people to take out health insurance at an earlier age and maintain their cover; in order to reduce the strain on the public system. If you don’t take out health insurance before the first of July following your 31st Birthday, but you do take it out later in life, you will be charged a loading of 2% for each year you are past 30 on top of the cost of your hospital policy premiums.

Once you have a hospital insurance policy, the loading does not increase further, and once held for ten years continuously the loading will no longer be charged. See Lifetime Health Cover for full details.

What is the Lifetime Health Cover (LHC) loading?

Back in July 2000, the Australian Government introduced Lifetime Health Cover (LHC) loading as an incentive for people to take out a form of hospital insurance earlier in life - to relieve pressure on the public system. If you take out hospital cover with a health fund before the 1st of July following your 31st birthday, you will establish your “Certified Age at Entry” as 30. You will be required to pay no loading on top of your hospital insurance premiums unless you have a gap in your hospital insurance of more than 1,094 days over the remainder of your lifetime.

However, if you decide to take out hospital cover at a later stage, you will be required to pay a 2% loading on top of your premium for every year you are over 31, up to a maximum loading of 70%. So if you take out a policy for the first time at age 40, you can expect to pay an LHC loading of 20% on your premium. Learn more about Lifetime Health Cover loading.

How does private health insurance affect my tax?

Whether or not you hold health insurance can affect your tax in a number of ways. The first of these being the Medicare Levy Surcharge (MLS). This is an additional levy that is charged to taxpayers who earn over $90,000 a year as a single or $180,000 a year as a couple or family who do not hold private hospital cover. The table below gives an example of the MLS you may have to pay depending on your income threshold.

 Base tierTier 1Tier 2Tier 3
Income threshold
Single$90,000 or less$90,001 – $105,000$105,001 –$140,000$140,001 or more
Family$180,000 or less$180,001 – $210,000$210,001 – $280,000$280,001 or more
Medicare Levy Surcharge (MLS)
 0%1%1.25%1.5%
Total MLS Paid
Single$0$900 - $1,050$1,312.50 - $1,750$2,100 or more
Family$0$1,800 - $2,100$2,625.01 - $3,500$4,200 or more

Note: For every dependent child after your first born, the family income threshold increases by $1,500. For example, a family with two children within the tier one would have an income threshold of 91,501 – 106,500.

Taking out private hospital cover can save you money at tax time by making you exempt from this Medicare Levy Surcharge. For example, if you are a family earning $220,000 a year and you took out a basic hospital policy that only cost you $1800 a year, you’d be saving $950 per year by paying for your health insurance premiums instead of paying $2750 in the Medicare Levy Surcharges Taxes.

However, it’s important also to consider your health needs when purchasing a policy, as the cheapest option might not always be the best for your needs.

The other way that having health insurance may affect your tax return is through the Australian Government Rebate for Private Health Insurance. This rebate is based on your income and can be claimed as a discount to your premium throughout the year, or as a lump sum when doing your tax return. For more information see our guide to the Private Health Insurance Rebate.

Please note that health insurance premiums are not tax deductible.

How it works

Can I choose to be treated as a public patient in a public hospital if I have private hospital cover?

Yes. Being treated as a public patient in a public hospital will always be available to you at no cost, provided you hold a Medicare card. Keep in mind that being a public patient means you won’t get to choose your doctor and you’ll be subject to the public waiting lists for any emergency treatment, which means you don’t get a choice of when you’re admitted to hospital.

Is my employer required to provide private health insurance?

Australian employers are not required to provide their employees with private health insurance, unlike companies/organisations in other parts of the world. It is entirely up to you if you wish to seek private health cover.

What is my health insurance gap?

The difference between what your health fund pays and what your specialist charges while in hospital is known as the “gap”.

When you’re admitted to hospital, there are item numbers that are billed for each different procedure and service. These are all approved by Medicare and are listed on the Medicare Benefits Schedule (MBS). The MBS outlines what the government believes providers “should” charge for these services.

When you have private health insurance and are treated as a private patient, Medicare covers 75% of the Schedule Fee, and your private health insurance pays the remaining 25%. If your specialist chooses to charge above the MBS, you are required to pay this gap out-of-pocket.

There are ways to reduce out-of-pocket expenses. While you’re admitted to hospital, it’s important to ask your specialist for an Informed Financial Consent Form. This will outline how much your doctor will charge and which Medicare Item Numbers you are receiving treatment for. You can then discuss the details on this form with your health fund and have them confirm exactly how much they will pay out, what your gap will be (if any), and whether or not you are eligible for any gap reduction. These discussions are worthwhile as they can save you hundreds of dollars.

Most health funds will offer gap cover arrangements, which can reduce or eliminate your out-of-pocket expenses. Ultimately, it’s up to your doctor/specialist/anaesthetist to choose to participate in this arrangement on a case-by-case basis.

Does the cost of policies increase each year?

Each year, funds must apply to the Minister for Health and Ageing to approve any premium changes at least 60 days before the proposed change is planned to take effect. The overall cost of health care tends to increase every year, and the providers need to keep pace with this in order to provide you with adequate cover.

Therefore most policies will increase on the first of April each year.

To find out how you can get the most out of your cover to counteract premium increases, be sure to review your cover regularly and compare health insurance policies.

Can I choose to be treated as a public patient in a public hospital if I have private hospital cover?

Yes. Being treated as a public patient in a public hospital will always be available to you at no cost, provided you hold a Medicare card. Keep in mind that being a public patient means you won’t get to choose your doctor and you’ll be subject to the public waiting lists for any emergency treatment, which means you don’t get a choice of when you’re admitted to hospital.

Do I have to get private cover?

It’s certainly not mandatory to take out health insurance, although it can be a smart idea - depending on your situation. Taking out a policy does not affect your Medicare entitlements; it just means you also have access to the extra benefits of the private healthcare system.

Having access to treatment as a private patient means, if you do need medical treatment, you have greater options available to you. On top of this, you may also be able to avoid the Medicare Levy Surcharge (MLS), which is a tax charged to those earning above a certain amount each year and don’t have private hospital coverage Private hospital cover also helps you avoid or reduce any applicable Lifetime Health Cover (LHC) loading.

Who is PHIO?

The Private Health Insurance Ombudsman (or PHIO) takes care of enquiries and complaints about all aspects of private health insurance. They are an Australian Government agency but act independently of both the government and the providers when it comes to handling complaints and disputes.

The PHIO manages the privatehealth.gov.au website and provides advice to the general public as well as the health insurance industry and government. They also publish regular bulletins on the performance of providers, with an emphasis on the nature of the complaints they receive and how those are resolved.

To contact the PHIO, call 1300 737 299 or email phio.info@ombudsman.gov.au.

Can I be denied health insurance in Australia?

Health insurance in Australia is community rated, meaning health funds are not allowed to deny an application (or charge higher premiums) to an Australian based on their health status, age, or claims history. Health funds can, however, impose waiting periods for pre-existing conditions, and you must have either a blue or green Medicare card to qualify for private health insurance.

If you believe you’re being treated unfairly or being denied cover by your private health fund, you can contact the Private Health Insurance Ombudsman to raise your concerns.

Why should I have private health insurance?

Weighing up whether or not you should take out private health cover is a decision you’ll have to make according to your own circumstances. As you make your choice, be sure to keep the following in mind:

  • Peace of mind. There’s no denying the importance of your health. That’s why health insurance can be so beneficial during times of illness, injury, and through life’s many stages. An appropriate level of health cover offers you (and your family) peace of mind that you have access to treatment when you need it – whether it’s for a broken leg, fillings in your teeth, or for something more severe.
  • Choose benefits tailored to you. Private health insurance offers a variety of services, within basic, mid, or comprehensive level covers. Depending on your individual needs, you can choose from hospital only, extras only, or a combined hospital and extras policy. Additionally, there are health insurance policies tailored to specific life stages which accommodate singles, families, seniors, and more.
  • Avoid public waiting lists. If you ever need to undergo medically-necessary elective surgery, private hospital cover can be an invaluable purchase. With around 748,000 Aussies admitted for medically necessary elective surgery waiting lists in 2016-17, private cover helps you avoid public waiting lists for procedures, and instead utilise the (much faster) private
  • Avoid the Medicare Levy Surcharge (MLS). The Medicare Levy Surcharge (MLS) is designed to encourage Aussies to take out health cover to decrease the demand on the public Medicare system. Anyone who doesn’t have private hospital insurance and earns above the specified income threshold will be subject to the surcharge unless they qualify for one of the (few) exemption categories. You can learn more about the MLS here, or use our handy MLS calculator to determine whether or not you’re affected.
  • Avoid the Lifetime Health Cover (LHC). The Lifetime Health Cover (LHC) loading is a government initiative designed to encourage Aussies to take out private hospital cover earlier in life. If they don’t take out cover before the 1st of July following their 31st birthdays, they’ll begin to incur the loading. LHC loading starts at 2% of your base hospital insurance premium and increases by 2% each year until you take out cover. You’ll cease paying the loading after 10 years of continuous hospital cover.
  • Claim on the Australian Government Private Health Insurance Rebate. If you take out private health insurance, you can claim on the Australian Government Private Health Insurance Rebate – an initiative that helps you pay for your health insurance premiums (hospital, extras, or combined policies). The rebate levels fluctuate, depending on how much your household earns.

If you require further information, call our experts on 13 32 32. It costs nothing to review your options through us, and our health insurance experts can handle all the confusing paperwork, so you don’t have to waste time browsing multiple sites looking for a better deal.

How can I be sure my health fund will be able to pay if I make a claim?

All registered private health insurers in Australia are monitored by the government agency Australian Prudential Regulation Authority (APRA). A crucial part of APRA’s role is to ensure that each insurer is financially sound.

Each year, APRA publishes a complete list of all funds, detailing their revenues, expenses, and the prudential reserves that are available to ensure claims can be paid.

How does the health system work in Australia?

The Australian healthcare system is comprised of public (Medicare) and private healthcare.

Under the public system, residents enrolled in Medicare have access to a range of medical services at no (or at a lower) cost, including:

  • treatment at a public hospital as a public patient;
  • doctors, optometrists, and other allied health professionals; and
  • cheaper prescriptions, wherever listed on the Pharmaceuticals Benefits Scheme (PBS).

As a private patient in a public or private hospital, Medicare will cover 75% of the Medicare Benefits Schedule (MBS) fee. Private health insurance will then contribute the remaining 25% of the MBS, providing your policy offers coverage towards the service.

Other benefits of health insurance may mean you can opt for your choice of doctor, have a private room where available, and you may also avoid long waiting periods.

On top of this, private health insurance is community-rated. This means insurers will not deny your health cover claim based on your age, gender, medical history, or how likely you may be to claim on benefits. The only eligibility requirement is that you must hold a Medicare card and have served the applicable waiting periods for your services before admission and claiming.

Your health insurance may also pay benefits towards other services where Medicare does not pay a benefit, including, but not limited to, dental, optical, and physiotherapy.

To learn more, please read our guide on private vs. public health insurance.

Do pensioners need private health insurance?

Private health insurance is not a legal requirement for pensioners, nor is it included in, or subsidised by, the Age Pension. As you get older, you may need specific medical services or treatment.

Life is filled with the unexpected, and your health is no exception as you age. Despite the perks of the Age Pension, pensioners may be left with out-of-pocket expenses that are not covered under the Age Pension or Medicare. Health insurance may help you get back on your feet sooner, particularly when it comes to public hospital waiting lists for surgeries that impact your quality of life, such as hip or knee joint replacements.

Depending on your policy type, private hospital insurance may allow you to choose your own doctor and provide coverage as a private patient in a private hospital. You’ll even be able to stay in a private room, should one be available. Extras policies, on the other hand, assist towards the cost of out-of-hospital care, such as dental, optical, physiotherapy, health aids (glucose monitors, crutches, blood pressure monitors), or hearing aids.

Despite these benefits, health insurance might be difficult to afford for Australians on a pension; especially if they require top-level hospital cover, or if they’ve accumulated the full LHC loading. If you’re weighing up your options, be sure to read about acquiring private health insurance as a senior.

Is private health insurance compulsory in Australia?

Purchasing private health insurance in Australia is not compulsory. Fortunately for us, Australia has a universal health scheme called Medicare, which provides cover for medically-necessary services and treatments. You decide whether or not private health insurance is a suitable option for you or your family.

While health insurance is not compulsory, there are a few reasons why Aussies opt for private cover. Some of these reasons include:

  • Coverage toward the cost of private hospital admissions
  • Allowing choice of doctor and hospital
  • The chance to avoid public waiting lists for procedures.

Private hospital cover also helps you avoid the Medicare Levy Surcharge (MLS) and Lifetime Health Cover (LHC) loading. Furthermore, extras cover can help you claim benefits for services outside of hospital that Medicare does not pay towards, such as dental, eyeglasses, physiotherapy, and, in some cases, even gym memberships.

It’s important to reflect on what your priorities are when it comes to your health; many would say that being able to access the services you need when you need them is crucial.

If you need help deciding on which policy may be best for you, speak to one of our experts on 13 32 32.

Are health insurance premiums affected by my lifestyle?

In Australia, health funds are not allowed to charge you more for your policy based on health status, age or claims history. Why? Private health insurance is community rated.

The Australian Government developed the principle of community rating to give everyone equal access to private health insurance. Regardless of whether or not you’re a smoker, are facing an ongoing illness, have a family history of cancer, or are completely healthy; you’ll still be charged the same base premium.

For example, both a single, healthy 20-year-old and a single, unwell 60-year-old will pay the same premium for the same cover. However, the cost of premiums for similar cover may vary between health insurers.

What doesn’t private health insurance cover?

Private health insurance encompasses two broad areas of care: hospital and extras.

  1. Hospital policies cover private patients who are treated in a private or public hospital.
  2. Extras policies cover some out-of-hospital services/treatments that are not covered by Medicare.

Private health insurance does not cover out-of-hospital medical services which are covered by Medicare. This includes GP visits, consultations with specialists (in their rooms), diagnostic imaging, and tests.

Also, it is possible that your health fund may not cover the total cost of the doctor’s services provided to you in hospital if your doctor is charging above the Medicare Benefits Schedule of Fees (MBS). It is also possible that the hospital you are treated in/your specialist does not have an agreement with your health fund. This could leave you with an out-of-pocket expense called a ‘gap’.

It is crucial that you speak to both your doctor and your health fund before being admitted to the hospital, to find out exactly how much treatment will cost and what your out-of-pocket expenses will total.

Who’s covered by my policy?

Who is covered by your policy depends on what specific “family type” you choose when you make your purchase.  The different family types are:

  • Single – Covering the primary policyholder only
  • Couple – Covering the primary policyholder and their partner
  • Family – Covering the primary policyholder, their partner, and any number of their children under a specific age (determined by the health fund)
  • Single parent family – Covering the primary policyholder, and any number of their children under a specific age (determined by the health fund)
  • Extended family – Some health funds offer extended family policies designed to cover adult dependents up to the age of 25.

How do I know if I need private health insurance?

There are some fundamental steps you can take to determine whether or not private health insurance is suitable to you. Start by talking to your GP, to clearly identify what your health needs will be for the next few years, as well as what’s in your family history. You’ll then have a better idea as to (a) what you need to plan for in the future, and (b) what you need to look for when searching for the right private health insurance to ensure you get the most value from your policy.

Furthermore, you can discuss with family members and friends to see what triggered them to take out private health cover. Their reasoning behind obtaining health insurance may (or may not) be relevant to your situation. Other reasons you may want to consider health insurance are to avoid the Medicare Levy Surcharge if you earn over a certain threshold, or to avoid paying Lifetime Health Cover loading – a loading payable on top of your private hospital cover which increases for each year following your 31st birthday that you didn’t hold hospital cover (only applicable once you take out hospital cover).

If you’re still unsure about private health insurance, take our take our quiz and we’ll explain what’s in it for you.

Joining or switching funds

Does health insurance have lock-in contracts?

No, private health insurance in Australia has no lock-in contracts, and you are free to cancel or switch your cover at any time. This could mean switching between policies within the same fund, or even switching funds entirely! You’re not discouraged from changing your cover, and this is proven by the fact that there are no exit or cancellation fees.

Also, any waiting periods that you have already served will transfer with you to the same or lower level of cover with your new policy. You’ll only ever have to serve waiting periods for the new benefits you are adding on to new cover.

Can you cancel your health insurance at any time?

There are no contracts in health insurance, so cancelling your health cover is a simple process that only requires notification of your intentions to your health fund via telephone or email.

If you decide to cancel your health policy, any contributions paid in advance will be reimbursed by your insurer. You will also receive a Clearance Certificate, which shows the details of your old policy; including the waiting periods you served and the details of your current Lifetime Health Cover (LHC) loading. If you are cancelling to switch to a new fund, it is important to provide your Clearance Certificate to the new fund to ensure a smooth carry-over of waiting periods served.

What should I do if I don’t hear from the health fund I’ve joined?

It could take up to ten working days for the documentation to reach you from the health fund you’ve joined; but if you are concerned you can contact your health fund, or, if you have compared/purchased health insurance through our service, you can call us on 1800 777 712, and we will investigate.

Do I have to wait until my policy expires before I can switch?

No, you can switch health insurance at any time, and your present insurer will refund you the balance of any premiums you have paid in advance. To ensure that you can take advantage of any waiting periods you have served, you need to make sure that your premium payments are up to date when switching to your new policy.

Do I have a cooling off period?

Absolutely. Whenever you take out a new health insurance policy, you will have a minimum 30 day cooling off period in which to change your mind. As long as you have not claimed on that policy, you should expect to receive a full refund of any premiums that you have already paid. Please note though, that if you have already cancelled a previous policy in order to take out the new one, your previous policy will not be reinstated automatically.

Can I change my level of cover?

Yes, you can change your level of cover, health insurance policy, and even your provider, at any time. So, if your health needs change and you need more comprehensive cover, you can elect to upgrade your policy at any time. Conversely, you can also downgrade your cover, but it is important to make sure you’re not losing any benefits that you may require.

Please bear in mind that if you upgrade your cover, you will have to serve the relevant waiting periods before you will be covered for the upgraded/increased benefits. This applies if you move to a policy that has lower excess payments or co-payments.

It is also important to ensure there is no gap in coverage when moving from fund to fund, as some health funds allow a short gap of 1 or 2 months between transfers, but this is not guaranteed. Rules vary between funds, so make sure you ask before switching health insurance if you’re unsure.

Kids

Who is classed as a dependent child?

A dependent child is an unmarried person under an age that is specified by the health fund. Most of the time this specified age is 21 regardless of whether or not they are studying, and 25 only if they are studying full time.

Some funds have a higher or lower age limit, so it’s important to ask about this particular age rule if you have teenage or adult children. If your child is over 21 and not studying, some funds have special rules allowing them to stay on your policy a little longer provided they meet certain criteria.

The one thing that doesn’t change with most funds though is that once your child turns 25, they have to take out their own cover.

My kids are growing up, how long can they stay on our health insurance policy?

Some health insurance providers have a maximum age of 18 years for a young dependent single, while others allow young singles to remain under their parent’s family policy, in some instances until they’re 21 or even 25 years old if they’re a full-time student. Others may allow someone to be classed as an adult dependent if they’re not studying full-time, but are still living at home and remain financially dependent on their parents. However, this can carry an additional cost to premiums, depending on the fund.

Just because the kids are growing up doesn’t mean they don’t need looking after. Once they’re old enough though, point them towards paying for their own policy.

Life stage

I’m turning 60 soon. How can I get the most value out of my health insurance policy?

It could be time to consider ensuring you’re covered on a more comprehensive policy. Whilst 30 seems like yesterday, you may be feeling the impact of a few extra years on your eye sight, and it may take a little longer to roll out of bed.

A top hospital cover that pays benefits towards a wider range of services will give you the peace of mind knowing that you can choose your doctor of choice, avoid public waiting lists and go to a private hospital for services ranging from cataract removal, heart related surgeries, cancer treatments, joint replacements, and in hospital rehabilitation after surgeries.

In the interests of value, consider if you are seeking to be covered for procedures like pregnancy related services and obesity surgeries and if not - remove from your policy to reduce premiums.

On the extras side of your cover consider whether you may need hearing aids, dentures or partial plates, podiatry or orthotics, prescription glasses, even gym membership’s to maintain an active lifestyle. Waiting periods can vary between two months in most cases to three years for some services, so best to plan ahead.

If price is a major barrier, ensuring where possible you remove unnecessary services from your cover is essential, there are also options in regards to the amount of excess you pay when you are admitted to hospital that can help to reduce your monthly premium. Learn more about the private health insurance rebate, or review your health insurance to ensure it continues to fit your lifestyle and budget.

I’m turning 40 soon. How can I get the most value out of my health insurance policy?

As you know 40’s are the new 30’s. With a few decades of experience, you’re more knowledgeable about what you may need to consider when it comes to your health. To ensure you’re getting value out of your health insurance, you should consider if your policy has an appropriate level of claimable benefits covering common items that can arise in your 40’s.

Extra benefits to cover for dental check-ups, prescription glasses, physiotherapy, even gym memberships can help you maintain your health and wellbeing.

Perhaps you no longer need cover for obstetrics and maybe you’re not quite at the stage of joint replacements and cataract surgery - removing these types of benefits from your policy may save you money (depending on what other services you need).

However preventative tests for family history are common, including colonoscopies for bowel cancer, gastroscopies for IBS, mammograms - breast cancer screens etc. it’s worth reading through the benefits in your policy brochure as some funds cover medical services like heart checks, at-home bowel screenings, skin cancer checkups, and more.

Review your health insurance to find a policy that works best for you.

I’m turning 30 soon. How can I get the most value out of my health insurance policy?

Possibly the best years of your life! There are a few ways to get value out of your health insurance before you turn 30. Taking out private hospital cover before the 1st of July following your 31st birthday will ensure you are not charged the Lifetime Health Cover (LHC) loading – a 2% surcharge accrued for each year you are over the age of 30 that you didn’t hold hospital cover. For clarity, if you decide to take out private hospital cover for the first time at age 35, you’ll pay 10% more for your hospital cover than if you’d joined five years earlier.

Even a basic level of hospital cover can give you the peace of mind knowing that you’re covered for treatments as a result of an accident, as well as saving you from LHC if applicable.

If you’ve decided that children are on the cards, then having an appropriate level of private health cover for pregnancy-related services can aid towards expenses including private accommodation for the delivery, allow choice of obstetrician and on the extras side you may be able to claim on maternity options such as birthing classes.

Make sure you’re covered for the things you might actually use while you’re young, such as extras benefits like dental, optical, remedial massage, or chiropractic treatment, don’t pay for cover you may not need until you’re older. Seek out more value in your health insurance by comparing a range of policies today.

I’m turning 50 soon. How can I get the most value out of my health insurance policy?

Half a century – what a milestone! Finding value in private health insurance when you’re 50 heavily depends on your circumstances; are you a young vibrant 50 or are you feeling every year of it in your aches and pains?

Regardless of what kind of lifestyle you live, ensure that your policy fits your needs, whether it is claiming benefits like prescription glasses, gym memberships and podiatry to maintain your healthy lifestyle, or cover for physiotherapy and joint replacements to fix those rickety knees.

To ensure you find value, assess what you believe you’ll need in the next 10 years. Although you may not need them now, think about hearing aids, health aids and appliances, such as blood pressure monitors and CPAP machines, even if you’re fit and healthy. Ensuring your policy offers cover for the unexpected such as heart related procedures, cancer treatments and removing such things as pregnancy related services, will ensure you’re not amongst the many Australians paying for things they don’t need on their policies.

It’s important that you shop around to make sure the policy you choose comes at a price you’re comfortable paying. Look after yourself and get the most value out of your cover by comparing health insurance now.

Medicare & MLS

Is pathology covered by Medicare?

Medicare covers most pathology costs. In fact, around 85% of all pathology services are bulk billed. The Pathology Services Table (PST) lists tests that have benefits available through Medicare. Only tests listed on the Medicare Benefits Schedule (MBS) are subsidised by the Australian Government if they meet these criteria:

  • the treating medical professional requesting the pathology test is registered with Medicare;
  • the pathology test is for a medical reason;
  • the pathology sample is sent to a Medicare-approved laboratory; and
  • the pathology test is supervised, and quality assured as per Medicare accreditation rules.

Some specialists do not bulk bill and can charge fees greater than the Medicare rebate, which means you may face some out-of-pocket expenses. It is therefore important you ask your general practitioner and specialist if there will be any out-of-pocket expenses before going ahead with any tests.

Which blood tests are covered by Medicare?

The majority of blood tests are covered by Medicare, with bulk billing options available depending on which doctor refers the blood test. The covered tests are fully outlined in the Medicare Benefits Schedule (MBS), with some of these including:

  • glycosylated haemoglobin (used to monitor diabetes);
  • iron level studies;
  • nutritional and toxicity metals testing; and
  • thyroid function testing.

Only tests listed on the MBS are covered, provided they meet certain conditions, such as the following:

  • the treating practitioner is registered with Medicare requests the pathology test
  • there is a medical reason for the pathology test
  • the pathology sample is sent to a Medicare-approved pathology lab
  • the pathology test is supervised and quality-assured as per Medicare accreditation rules.

Medicare does not cover any blood tests associated with elective cosmetic surgery, genetic testing, and insurance testing.

Is dialysis covered by Medicare?

Dialysis treatment is included in the Medicare Benefits Schedule (MBS). This means you will receive a 75% rebate of the schedule fee as a private patient, as well as an extra 25% rebate if you hold an appropriate level of health insurance as well.

Covered services may include (for chronic renal failure):

  • haemodialysis;
  • haemoperfusion;
  • haemofiltration; and
  • peritoneal dialysis.

What does Medicare pay for?

Medicare is the core of Australia’s public healthcare system and covers a range of costs under hospital, medical, and pharmaceutical industries. You can choose to have your healthcare subsidised by either Medicare-only cover or both Medicare and private health insurance.

Medicare in hospital

When it comes to using Medicare to cover hospital costs, you can elect to be treated as a public patient, even if you have private health insurance. However, Medicare doesn’t cover:

  • costs that are not clinically necessary, or surgery costs for cosmetic reasons
  • private patient hospital expenses, like accommodation and theatre costs
  • hospital and medical costs incurred overseas
  • ambulance services, depending on your state

You will also be unable to choose your own doctor or specialist, or stay in a private room.

Medicare and medical costs

Visits to a general practitioner outside of hospital can attract a 100% reimbursement of the Medicare Benefits Schedule (MBS) fee or 85% of the MBS fee for specialists. You won’t need to pay anything for bulk-billing doctors.

Medicare doesn’t cover the following:

  • life insurance and superannuation examinations
  • ambulance services, depending on your state
  • most dental examinations and treatment
  • most specialist services, like physiotherapy, occupational therapy, eye therapy, speech therapy, podiatry, chiropractic, or psychology services
  • glasses and contact lenses
  • hearing aids
  • home nursing
  • acupuncture, unless it forms part of your doctor’s consultation.

Do I need health insurance if I have Medicare?

Medicare is a vital aspect of our public healthcare system in Australia, as it provides cover for 75% of qualifying medical costs, which are listed under the Medicare Benefits Schedule (MBS). However, Medicare does not provide cover for all services outside of the hospital, like most dental examinations, physiotherapy sessions, and psychology services.

Furthermore, the waiting list for some elective surgeries in the public system can be more than twice as long as the waiting periods experienced by some private patients. You can also be charged the Medicare Levy Surcharge (MLS) if you don’t hold hospital cover, or hit with the Lifetime Health Cover (LHC) if you don’t take out cover before the 31st of July after you turn 31.

I found out I’m paying the Medicare Levy Surcharge. Can health insurance help me avoid it?

Yes, it can. Anyone who earns over $90,000 as a single or $180,000 as a couple or family is subject to the Medicare Levy Surcharge (MLS). For families with children, this threshold is increased by $1,500 for every child after the first. The way to avoid this additional surcharge is to hold a hospital policy from a compliant Australian health insurance provider that has an excess of $750 or less ($1,500 or less for couples and families).

However, it’s important to note that holding extras only cover will not make you exempt from paying the MLS. In addition, the Medicare Levy Surcharge applies for every day in the financial year you aren’t covered. So, if you take out private hospital cover midway through the financial year, you’ll still have to pay the MLS for the other half of the year that you weren’t privately insured.

Learn more about the Medicare Levy Surcharge, and find out if you have to pay by using our MLS calculator.

Pre-existing conditions

I have a pre-existing condition. Can I still get private health insurance?

Yes, you can. The only thing you need to remember is that there is a 12 month waiting period for pre-existing conditions. As long as you take out or switch to a suitable policy, you will receive the full benefit for the treatment as soon as you have served the waiting period.

What is a pre-existing condition?

A pre-existing condition is any condition or illness that you had signs or symptoms of in the six month period before you took out a policy or upgraded to a higher level of cover. This condition may or may not have been diagnosed. There is a twelve-month waiting period on treatment for pre-existing conditions, with the exception of rehabilitation, psychiatric or palliative care, where the waiting period is two months (or less, depending on the circumstances).

Will my pre-existing condition mean I am unable to take out private health insurance?

No, you may still take out private health insurance. This product is ‘community rated’, which means that the price for base premiums remain the same for everyone - whether you have a few health issues or you’re a fit and healthy.

The only thing you need to remember is that there is a 12 month waiting period before you can claim on any treatments for your pre-existing condition. As long as you take out (or switch to) a policy from a registered Australian health fund, you will receive the benefit available for the treatment as soon as you have served the waiting period.

The only exceptions to 12 month waiting periods for pre-existing conditions are for benefits for in-hospital rehabilitation, in-hospital psychiatric treatment, or palliative care, where the waiting period is only two months (or less, depending on the circumstances).

Learn more about pre-existing health conditions and how they may affect you.

Pregnancy cover

What does private health insurance cover for pregnancy?

Considering an appropriate level of health cover when planning your pregnancy is important, as health insurers have a 12-month waiting period that you must observe before you'll be covered for birth-related services in hospital.

The benefits of private hospital cover that include Pregnancy and Obstetrics benefits are:

  • Being able to choose your own obstetrician (depending on availability) to look after you not only at the time of the delivery, but also throughout your pregnancy. However, it's important to keep in mind that your health fund will only pay benefits towards your obstetrician fees for any treatment or services while in hospital, not for your outpatient appointments or check-ups;
  • Being covered up to the Medicare Schedule of Fees for any doctors or obstetrician fees while admitted in hospital;
  • Cover for hospital accommodation and labour ward costs at a hospital that has an agreement with your insurer;
  • Some funds cover Boarder Accommodation, which means your partner may be able to stay with you in hospital over-night. This depends on your fund's rules, policy inclusions, and hospital availability.

Also, depending on your health insurance provider, if you have private extras cover you may be able to claim benefits towards: pre-natal care (pre-birth education and advice); post-natal classes (birthing classes, breastfeeding classes, midwife visits, sleep consultations); Pilates; physiotherapy (to help ease back pain and pelvic pain); and psychology consultations (for guidance, and to help mothers with postnatal depression).

These pregnancy and birth related services can be of value during this time, however there are some out-of-pocket expenses that should still be expected, such as ultrasounds, testing, and your appointments and check-ups (Medicare can pay a benefit toward these).

Want to learn more? We’ll help you understand pregnancy in health insurance.

Is there a benefit to getting private health insurance while pregnant?

Private health insurance does offer benefits for expectant mothers, however, it’s important to note that there is a 12 month waiting period for claiming in-hospital birth-related services under private health insurance. This means that taking out this type of insurance will not benefit you while you are already pregnant - you will need to take out cover before getting pregnant to claim benefits.

If you're already covered for pregnancy by your private hospital policy and have served the 12 month waiting period – or for any future pregnancies – the benefit of having health insurance is that it will help pay towards the costs of giving birth to your child as a private patient, with an obstetrician of your choice, in a private room (if one’s available).

However, if you're already pregnant and are not insured, there are some extras policies that may also allow you to claim on benefits that can assist you during your pregnancy, outside of hospital with shorter waiting periods, such as pre-natal classes, Pilates, physio, and lactation consultants. These waiting periods vary between funds, so it's important to read your policy brochure to ensure you understand when you can start claiming.

If you are planning on having more children in the future, it’s important that you understand pregnancy in health insurance, and consider pregnancy cover well ahead of falling pregnant – to ensure you have the benefit of health insurance at the right time.

We’re planning on starting a family soon. When do I need to get pregnancy cover if I want to give birth in a private hospital?

There is a 12 month waiting period before you are covered for in-hospital birth-related services under private health insurance. Before you try to conceive, get a suitable level of cover. This is the first thing you should do if you plan on starting a family, and needs to occur more than a year before you hope to have any children.

When the time comes, provided you have served those waiting periods, the benefit of having private health insurance is that it will give you the choice to choose your obstetrician and will pay towards the costs of giving birth to your child in a private hospital.

Discover everything you need to know about pregnancy cover here.

Tax time

Do I pay GST on premiums?

Private Health Insurance premiums are free of GST. The only exceptions to this are Visitors Health Insurance and Overseas Student Health cover, which are classified as General Insurance, and attract GST.

Can you salary sacrifice health insurance?

Technically, no. While you can salary package your health insurance, this is not seen as a salary sacrifice. Contributions made to your premium are generally made with money that has already been subject to tax, while income that is sacrificed is deducted before tax.

Waiting periods

If I go overseas, how can I avoid waiting periods?

Many funds are prepared to suspend your health cover while you are overseas for an extended period (i.e. months/years), and allow you to resume when you return.  There are specific rules and processes in place when suspending your cover that are different with each fund, so it’s important to discuss this with them as soon as soon as you start planning your trip.

In most cases, by suspending your cover, you will not have to pay premiums while you are overseas. Upon your return, you will be able to resume your private cover without having to re-serve any waiting periods. If you are part-way through serving a waiting period, you will have to serve the remainder of your waiting period when your return.

Your Lifetime Health Cover loading amount won’t be affected either, so long as you re-establish your cover within the agreed timeframe on your return. While your cover is suspended during your time overseas, you will still be a member with your fund.

Why are there waiting periods and how long are they?

Waiting periods are there to protect health fund members. If they weren’t in place, someone could sign up one day, claim on expensive treatment the next, and cancel before paying any premiums.  This type of behaviour disadvantages members, as it results in increased premiums for all fund members.

Standard waiting periods for hospital cover are as follows.

  • 12 months for pre-existing conditions, except where these are related to psychiatric care, rehabilitation or palliative care, where the waiting period is only two months
  • 12 months for obstetrics (pregnancy/IVF)
  • 2 months in all other circumstances (disregarding pre-existing conditions).

Individual funds set the waiting periods for extras cover. Make sure you are fully aware of all the waiting periods you may have to serve.

What are health insurance waiting periods?

Waiting periods refer to the amount of time you have to wait before you can claim for a particular treatment on your new policy / new level of cover. A waiting period is an essential surety that denies members of a fund the ability to lodge a large claim shortly after joining, only to cancel their membership afterwards.

The government sets the maximum waiting periods that funds can impose for hospital treatment:

  • 2 months for psychiatric care, rehabilitation or palliative care, even with a pre-existing condition; and
  • 2 months in all other circumstances.

Individual health funds set the waiting periods for extras (i.e. ancillary or general treatment) cover and vary from insurer to insurer. They can range from anywhere between two months and two years. To learn more, read about waiting periods for private health insurance.

When I switch health insurance, will I have to resit my waiting periods?

When you switch health insurance policies, your new health fund will honour any waiting periods for services you’ve already completed waits for with your previous fund, if you move to the same or lower level of cover. For example, if you’ve already served the waiting periods for heart surgery, you won’t have to do so again with your new health insurance policy. The only time you may be required to serve the waiting periods are:

  • If you haven’t completed your original waiting period. For instance, if you’ve served six months for a benefit requiring a 12-month wait, you’ll need to complete the remaining six months with your new health insurance provider before you’ll be covered for that service or benefit.
  • For new or higher benefits. For example, if your new policy includes a benefit you weren’t previously covered for (e.g. orthodontics), you’ll need to complete the waiting period before being covered for those benefits.

Learn more about waiting periods for private health insurance. Or, if you’re ready to switch, compare a range of policies side-by-side with us.

So, what are you waiting for?

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