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.

That's right; we're not just a great place to compare

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.


Do I need ambulance cover?

Yes, everyone should have cover for emergency transportation in Australia, whether that cover is paid for by your state government or accessed through a subscription, health insurance policy or concession card.

Am I covered for ambulance services 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 ambulance services across Australia.
ACTHealth Care, Concession Card and Pensioner Concession Card holders have access to free emergency ambulance services. ACT residents who don’t qualify for a concession can take out cover through a private health fund.
New South WalesHealth Care, Concession Card, Pensioner Concession Card, and Commonwealth Seniors Health Card holders have access to some free ambulance transport services. NSW residents who don’t qualify for a concession can take out cover through a private health fund. The state government also subsidises 49% of the bill for ambulance treatment or transport services.
Northern TerritoryPensioner Concession Card and Commonwealth Seniors Health Card holders have access to free ambulance transport services. NT residents who don’t qualify for a concession can take out cover through a private health fund, or a subscription with the Territory ambulance service.
QueenslandEmergency pre-hospital ambulance treatment and transport fees for Queenslanders are covered by the state government.
South AustraliaYou can take out ambulance cover from a private health fund, or through a subscription with the SA Ambulance Service.
TasmaniaAmbulance fees for Tasmanians are covered by the state government.
VictoriaPensioner Concession Card and Healthcare Card holders have access to free ambulance transport services. Victorian residents who don’t qualify for a concession can take out cover through a private health fund, or a subscription with Victoria’s ambulance service.
Western AustraliaWestern Australian pensioners over 65 are entitled to free, medically necessary, emergency and urgent ambulance services. If you don’t qualify for a concession card, you can take out cover through a private health fund or a subscription with the state ambulance service

Source: – Ambulance. Accessed August 2022.

To see how you’re covered for ambulance services while travelling interstate, check with your state ambulance service, concession card provider or health insurer.

Does Medicare cover ambulances?

Medicare does not cover ambulance transport or services. However, depending on your state of residence and personal circumstances, you may be entitled to government-funded ambulance services.

Need more information? Read more about ambulance cover.

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 $1,927 for regional and $1,306 for metropolitan emergency road transport as of July 2022. For NSW residents, your call out fee is $415 for emergency road transport, then you’re charged $3.75 per km, with a maximum charge of $6,797 as of July 2022.

For this reason, it’s important to make sure you have the right cover if you’re not entitled to government funded ambulance transportation. Learn more about the cost of emergency transportation.

1. NSW Ambulance – Accounts & Fees. Accessed August 2022
2.Victoria State Government: Department of Health – Ambulance fees. Accessed August 2022


Is cosmetic surgery covered by private health insurance?

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

Elective cosmetic surgery to improve appearance, or any surgery not listed on the Medicare Benefits Schedule (MBS), is not covered by private health insurance. Reconstructive plastic surgery that is medically necessary (e.g. to improve/maintain health or repair injuries) and is listed on the MBS 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 brochure.

Can you claim ultrasound procedures on private health insurance?

Outpatient services such as ultrasounds are not covered by health insurance, as the service usually takes place outside of a hospital and attracts a Medicare benefit. However, health insurance can cover diagnostic tests such as X-rays, MRIs and ultrasounds when they’re conducted as a part of your inpatient hospital treatment.

Is Botox covered by health 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 may be covered by insurance if they’re used to treat chronic migraines (subsidised on the Pharmaceutical Benefits Scheme [PBS]) or repetitive strain injuries.

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), it won’t be covered by health insurance or Medicare. You should review your policy brochure and contact your fund if you are not sure whether your Botox treatment will be covered by your insurance.

Is acupuncture covered by private health insurance?

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

However, you’ll only be covered if the treatment and consultation is performed by a qualified practitioner recognised by your fund or by someone who is registered with an approved association. Your extras policy’s acupuncture benefits will usually have an annual limit (or sub-limit for natural or alternative therapies) and a waiting period (usually 2 months).

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 natural therapies and remedies.

Your health 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 you’ll need to serve 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 pays a benefit towards.

Is LASIK surgery covered by health insurance?

There is a limited number of health funds that offer a rebate towards LASIK or laser eye surgery, as this service doesn’t have a Medicare item number. You’ll likely only be covered 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.

It’s best to talk to a health insurance expert to determine which fund or policy includes LASIK eye surgery under extras optical cover, and to check if you’re entitled to 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 and conditions 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 for the cost of your glasses (depending on your level of cover and optical sub-limits).

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 dental work included in your health insurance, you may be covered for Invisalign, although dental extras coverage in Australia differs between health funds and policies, so it’s best to check with your health fund.

Health policies may have both an annual and lifetime benefit limit on the amount you can claim for orthodontic treatment, including Invisalign. It’s important to check with your insurer whether you’re covered for Invisalign treatment and if treatment benefits are capped.

Does Medicare cover dental treatment?

In the majority of cases, Medicare does not offer cover towards dental procedures. This means you’ll 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 dental procedure. Health insurance can contribute to the cost, but only if you have an extras policy that includes orthodontic cover.

With dental cover, your policy will determine your waiting period and the amount you can claim through annual and lifetime limits.

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. Because teeth whitening is usually not medically necessary, it’s therefore not covered by Medicare.


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 will therefore cost considerably more. When 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 used when switching between health funds that contains important information on your previous policy, such as what benefits you were covered for, what your annual limits were, what you’ve already claimed and how long you’ve 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’ve 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 expenses for your accommodation and theatre fees.

Each fund will have different arrangements with different hospitals, so 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 is above what’s covered by Medicare and private health insurance. For treatment as a private hospital patient, Medicare covers 75% of the Medicare Benefits Schedule (MBS) fee; private health insurance will cover 25% of the remaining MBS fee.

However, if your specialist or doctor charges more than the MBS fee, you’ll need to pay the remaining amount. 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’s up to your treating health professional to opt in to 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 you’ll be covered up to the amount that’s charged as a private patient in a public hospital. Restricted coverage does not allow you to avoid the public waiting list for surgeries.

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

What are exclusions?

Exclusions are conditions and services that are excluded from your policy, meaning that your health fund won’t pay any benefits towards treatment for these services. Your level of cover is determined by what services are included and excluded, which differ between policies.

So, if you require treatment for a service that’s excluded from your policy, it’s 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 an excess. The difference between the two is that you generally make a co-payment for each day of your stay in hospital. This is often limited to a maximum amount per admission or year. 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 you’re admitted to hospital. The rules on when you’re required to pay this excess will vary from policy to policy. In many cases, insurers will only charge the excess amount once per year, regardless of how many times you are admitted to hospital.

If you elect to pay a higher excess, it could reduce your monthly premiums. Always check your fund’s policy brochure for details on any excesses that may apply to your policy.

Learn more about 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 your 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, like doctors, nurses, banks, railway and transport services and the Defence Force. In some cases, family members and extended family of these employees are also eligible to join the fund.

Government levies, loadings, and rebates

What is the private health insurance rebate?

The Australian Government’s private health insurance rebate is an 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 8.202% and 32.812% back from your premium (as of April 2021).

You can claim this rebate through a reduced premium or during your tax return. Learn more about how to claim the rebate.

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 is eligible for Medicare. However, if the overseas visitor has an overseas policy or isn’t eligible for Medicare, they won’t be able to claim a rebate.

Learn more about how to claim the rebate.

Does my age affect my rebate?

Yes, your age does affect the Australian Government rebate you can claim back on your 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
< age 6524.608%16.405%8.202%0%
Age 65-6928.710%20.507%12.303%0%
Age 70+32.812%24.608%16.405%0%

For families with children, the thresholds are increased by $1,500 for each child after the first.

Source: - Australian Government Private Health Insurance Rebate. Current from 1 July 2023

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

The Medicare levy is 2% of your taxable income and is charged to almost all tax-paying Australians earning over $26,120. There’s no way to avoid this levy; it’s in place to provide funding 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 charge for the number of days in any tax year you hold private hospital cover.

Who pays the Medicare Levy Surcharge (MLS)?

The Medicare Levy Surcharge (MLS) is payable by Australian taxpayers who earn over $93,000 as a single or $186,000 as a couple or family and don't hold private hospital cover (From 1 July 2023). For families with children, the threshold increases by $1,500 for every child you have after the first. However, if you’re exempt from the Medicare levy, you may also be exempt from the MLS.

The MLS is 1-1.5% depending on what income bracket you fall into. Having private hospital cover will make you exempt from paying the MLS.

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 health fund that has an excess of $750 or less ($1,500 or less for couples and families), you can avoid paying the Medicare Levy Surcharge (MLS). It’s important to note that holding extras cover will not make you exempt from paying the MLS.

What is the Lifetime Health Cover (LHC) loading?

In 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 don’t take out hospital cover with a health fund before 1 July following your 31st birthday, you’ll be required to pay a 2% loading on top of your premium for every year you’re over 30, 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.

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 without incurring any Lifetime Health Cover (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 health insurance?

Private health insurance is not compulsory. However, Lifetime Health Cover (LHC) loading was created as a way to encourage people to take out health insurance at an earlier age and maintain their cover to reduce the strain on the public system. If you don’t take out health insurance before 1 July following your 31st birthday, you’ll be charged a loading of 2% for each year you’re over the age of 30 on top of your standard premiums if you do take out cover later in life.

Once you have a hospital insurance policy, the loading does not increase further, and once held for ten continuous years, the loading will no longer be charged.

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 $93,000 a year as a single or $186,000 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 (From 1 July 2023).

 Base tierTier 1Tier 2Tier 3
Income threshold
Single$93,000 or less$93,001 – $108,000$108,001 –$144,000$144,001 or more
Family$186,000 or less$186,001 – $216,000$216,001 – $288,000$288,001 or more
Medicare Levy Surcharge (MLS)
Total MLS Paid
Single$0$930 - $1,080$1,350 - $1,800$2,160 or more
Family$0$1,860 - $2,160$2,700 - $3,600$4,320 or more

Note: For every dependent child after your firstborn, the family income threshold increases by $1,500. For example, a family with two children within Tier 1 would have an income threshold of $94,501 – $109,500.

Taking out private hospital cover can save you money at tax time by making you exempt from the MLS. For example, if you’re a family earning $220,000 a year and you took out a basic hospital policy that only cost you $1,800 a year, you’d be saving $950 per year by paying for your health insurance premiums instead of paying $2,750 in MLS charges.

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’s private health insurance rebate. This rebate is based on your income and can be claimed as a discount on your premium throughout the year, or as a lump sum when doing your tax return.

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 current Medicare card and the treatment is deemed clinically necessary. 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 elective 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 and organisations in other parts of the world. It’s entirely up to you if you wish to take out private health cover.

What is my health insurance gap?

The difference between what your health fund pays and what your specialist charges for your treatment is known as the gap.

When you’re admitted to hospital, item numbers 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.

However, 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’re 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 you’re 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 treating health professional 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 Department of Health 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.

Traditionally, most policies will increase on 1 April each year; however, recently many health funds have deferred their rate rises to return Covid-19 savings to members

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.

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 that 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 insurance.

What is the Age-Based Discount?

To encourage younger people to take out private health insurance the Australian Government introduced the age-based discount in 2019. This lets health funds give their members a discount on their premiums when they sign up earlier in life. It’s up to the health fund if they offer this discount, so it’s something worth looking for when you’re comparing your options.

The age-based discount is as follows:

Source: Private Health Insurance Ombudsman – Age-based Discount, 2022


This means that if you take out a policy with an age-based discount between 18-25, you’ll get 10% off your premiums on that policy until the age of 41 provided you maintain a policy that allows you to retain your aged based discount.  After you turn 41, it will decrease by 2% per year until it reaches zero.

What is the PHIO?

The Private Health Insurance Ombudsman (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 health funds when it comes to handling complaints and disputes.

The PHIO manages the 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 health funds, with an emphasis on the nature of the complaints they receive and how those are resolved.

To contact the PHIO, call 1300 362 072 or email [email protected].

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 base 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?

Whether or not you should take out private health cover is a decision you’ll have to make based on your own circumstances. When making 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 and 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 serious.
  • Choose benefits tailored to you. Private health insurance offers a variety of services, within all levels of cover. 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 a medically necessary elective surgery, private hospital cover can be an invaluable purchase. Private cover helps you avoid public waiting lists for procedures, and instead utilise the (much faster) private health system.
  • Avoid the Medicare Levy Surcharge (MLS). The MLS is designed to encourage Australians to take out hospital 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 exemption categories. You can learn more about the MLS here .
  • Avoid the Lifetime Health Cover (LHC). LHC loading is a government initiative designed to encourage Australians to take out private hospital cover earlier in life. If you don’t take out cover before 1 July following their 31st birthday, you’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’s private health insurance rebate, an initiative that helps you pay for your health insurance premiums (hospital, extras or combined policies). The rebate levels vary depending on how much your household earns.
  • Age based discount. If you’re between the ages of 18-29, you may be able to take advantage of the Age-Based Discount when you take out an insurance policy. This discount is offered by some insurers to encourage people to take out cover earlier in life and could save you up to 10% on the cost of your premiums.

If you want further information, you can 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 Australian Prudential Regulation Authority (APRA), a government agency. 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 lower) cost, including:

  • Treatment at a public hospital as a public patient
  • Doctors, optometrists and other allied health professionals
  • Cheaper prescriptions, when 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 for your treatment. Private health insurance will then contribute the remaining 25% of the MBS, providing your policy offers coverage towards the service.

Another benefit of health insurance is that you may be able to have your choice of doctor and recover in a private room where available. You may also avoid long public hospital waiting lists.

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, read our guide on private versus 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. Although, as you get older, you may need specific medical services or treatment that could prove costly without the right support.

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 aren’t covered under the 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, can assist towards the cost of out-of-hospital care, such as dental, optical, physiotherapy, health aids (e.g. glucose monitors, crutches, blood pressure monitors) and 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 Lifetime Health Cover (LHC) loading. If you’re weighing up your options, be sure to read about private health insurance for 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 then get to decide whether private health insurance is a suitable option for you or your family.

While health insurance is not compulsory, there are a few reasons why Australians opt for private cover:

  • 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, prescription glasses, 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 base premium because of health status, age or claims history, since private health insurance is community rated.

The Australian Government instituted community rating for health insurance to give everyone equal access to private healthcare. Regardless of whether 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 base 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 doesn’t 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’s 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 (MBS) fees. It’s also possible that the hospital you’re treated in or your specialist doesn’t have an agreement with your health fund, which could leave you with an out-of-pocket expense called a ‘gap’.

It’s crucial that you speak to both your doctor and your health fund before being admitted to hospital to find out exactly how much your 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 purchase your policy. 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 31

How do I know if I need private health insurance?

There are some fundamental steps you can take to determine whether 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 your family’s medical history. You’ll then have a better idea as to what you need to plan for in the future, and 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 motivated them to take out private health cover; their reasoning behind taking out health insurance might be relevant to your situation, particularly if it relates to family medical histories. 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 premiums which increases for each year following your 31st birthday that you didn’t hold hospital cover.

Joining or switching funds

Does health insurance have lock-in contracts?

No, private health insurance in Australia doesn’t have lock-in contracts. 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.

Also, any waiting periods that you’ve already served will transfer with you to the same or lower level of cover with your new policy. You’ll only have to serve waiting periods for the new benefits you’re adding 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 you to notify your health fund of your intentions via phone or email.

If you decide to cancel your health insurance 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 applicable). If you’re cancelling to switch to a new fund, it’s 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 10 working days for the documentation to reach you from the health fund you’ve joined. However, if you’re concerned, you can contact your health fund; if you 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 take advantage of any waiting periods you’ve 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. If you haven’t claimed on that policy within that timeframe, you can expect to receive a full refund of any premiums that you have already paid. Please note though, that if you cancelled a previous policy 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 health fund 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’s 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’ll be covered for the upgraded benefits. This also applies if you move to a policy that has a lower excess or co-payments.

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


Who is classed as a dependent child?

A dependent child is an unmarried person under an age that is specified by the health fund. Generally, this specified age is 21 regardless of whether they’re studying, and up to 31 only if they’re studying full time.

Some funds have different age limits, so it’s important to ask about your fund’s 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 until 31 provided they meet certain criteria.

The one thing that doesn’t change with most funds, though, is that once your child turns 31, they’ll need to take out their own cover.

How long can my kids stay on my health insurance policy?

Many health funds will allow young singles to remain under their parent’s family policy until they’re 21 or even 31 years old in some instances. Dependents over the age of 21 may be classed as an adult dependent if they’re not studying full-time. For some funds, this can come with a premium increase. Dependent rules vary between funds, so it’s a good idea to speak to your health fund or one of our experts to discuss the best options for your family.

Just because your kids are growing up doesn’t mean they don’t need looking after. Once they’re old enough, encourage them to take out their own policy.

Life stage

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

There are a few ways to get value out of your health insurance before you turn 30. Taking out private hospital cover before 1 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’re 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 peace of mind by saving you from LHC (if applicable). In some cases, basic hospital over may include cover for accidents provided the fund rules are met.

If you’ve decided that children are on the cards, having an appropriate level of private health cover for pregnancy-related services can help pay towards expenses including private accommodation for the delivery and your choice of obstetrician; on the extras side, you may be able to claim on maternity benefits such as birthing classes or post-birth physiotherapy.

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.

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

With a few decades of experience behind you now, 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 ask yourself if your policy has an appropriate level of claimable benefits that can cover common issues that can arise in your 40s.

For example, perhaps you no longer need cover for obstetrics, and you might not quite be at the stage of life for 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 common health issues are important to include in your policy, like colonoscopies for bowel cancer, gastroscopies for IBS and mammograms. It’s worth reading through the benefits in your policy brochure, as some funds also cover medical services like heart checks, at-home bowel screenings, skin cancer check-ups and more.

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

Finding value in private health insurance when you’re 50 heavily depends on your circumstances. Are you a young and 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’s 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, take some time to assess what you believe you’ll need in the next 10 years.

For example, 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. Having a policy that covers the unexpected such as heart surgeries and cancer treatments, and removing things like pregnancy related services, can ensure you’re not among the many Australians paying for things they don’t need on their health policies.

It’s important that you shop around to find a policy that 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.

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

It could be time to consider switching to a more comprehensive policy.

High-level hospital cover that pays benefits towards a wider range of services can give you the peace of mind knowing that you can choose your doctor and get a private room when available. You can also avoid public waiting lists for services ranging from cataract removal, heart surgeries, cancer treatments, joint replacements and in-hospital rehabilitation after surgeries.

To get the best value for money, go through your policy and check whether you’re paying for procedures you no longer need, like pregnancy services and obesity surgeries. If you have cover for services you don’t use, you may want to consider a more suitable policy that better meets your needs.

With extras cover, consider whether you may need services and benefits like hearing aids, dentures or partial plates, podiatry or orthotics, prescription glasses or even gym memberships to maintain an active lifestyle. Waiting periods can vary between two months in most cases to three years for some services, so it’s best to plan ahead.

If price is a major barrier, it’s essential to remove unnecessary services from your cover. There is also the option to increase the amount of excess you pay when you’re admitted to hospital, which can help to reduce your monthly premium. You may also want to learn more about the private health insurance rebate or review your health insurance to ensure it continues to fit your lifestyle and budget.

Medicare & MLS

Is pathology covered by Medicare?

Medicare covers most pathology costs; in fact, around 85% of all pathology services are bulk billed. Only the tests listed on the Medicare Benefits Schedule (MBS) are subsidised by the Australian Government, and only 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
  • The pathology test is supervised and quality assured as per Medicare accreditation rules.

However, you might find that some specialists don’t bulk bill and can charge fees greater than the Medicare rebate, which means you may face some out-of-pocket expenses. Therefore, it’s important that 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 you for the blood test. The covered tests are fully outlined in the Medicare Benefits Schedule (MBS) and are subject to certain conditions, but some tests that are covered include:

  • Glycosylated haemoglobin (used to monitor diabetes)
  • Iron level studies
  • Nutritional and toxicity metals testing
  • Thyroid function testing.

Keep in mind that 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’ll 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:

  • Haemodialysis
  • Haemoperfusion
  • Haemofiltration
  • 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 or both Medicare and private health insurance.

Medicare in hospital

When it comes to using Medicare to cover hospital costs, you can choose 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 also won’t be able to choose your own doctor/specialist or stay in a private room while you recover.

Medicare and medical costs

Visits to a general practitioner outside of hospital can attract a 100% reimbursement of the Medicare Benefits Schedule (MBS) fee, while specialists appointments are covered for 85% of the MBS fee. 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 and 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 all qualifying medical costs, which are listed under the Medicare Benefits Schedule (MBS). However, Medicare doesn’t provide cover for those treatments you receive outside of the hospital, like most dental examinations, physiotherapy sessions and prescription eyewear.

Furthermore, the waiting list for some elective surgeries in the public system can be much longer than the waiting times experienced by some private patients. You can also be charged the Medicare Levy Surcharge (MLS) if you don’t hold hospital cover, or be hit with the Lifetime Health Cover (LHC) loading if you don’t take out cover before 1 July after you turn 31.

Pre-existing conditions

What is a pre-existing condition?

A pre-existing condition is any condition or illness that, in the opinion of a medical practitioner appointed by your insurer, 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 12-month waiting period on treatment for pre-existing conditions, except for rehabilitation, psychiatric or palliative care, where the waiting period is two months (or less, depending on the circumstances).

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

Yes, you can. If you are not already covered for services and treatments relating to that condition, the only thing you need to remember is that there is a 12-month waiting period for pre-existing conditions. Provided that you take out or switch to a suitable policy, you’ll receive the full benefit for the treatment as soon as you have served the waiting period.

Health insurance is community rated, which means that the price for base premiums remains the same for everyone regardless your age, gender, whether you have health issues or if you’re fit and healthy.

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 serve before you'll be covered for birth-related services in hospital.

The benefits of having pregnancy and obstetrics cover in your hospital insurance can include:

  • Being able to choose your own obstetrician (depending on availability) to look after you 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 Benefits Schedule 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.
  • Potentially being covered for boarder accommodation, which means your partner may be able to stay with you in hospital overnight. This depends on your fund's rules and policy inclusions, as well as hospital availability.

If you have private extras cover in addition to your hospital policy, you may be able to claim benefits towards outpatient services like pre-natal care (such as pre-birth education and advice), post-natal services (like birthing classes and breastfeeding classes), midwife visits, sleep consultations, physiotherapy (to help ease back pain and pelvic pain) and psychology consultations for postpartum depression and general mental health care.

These pregnancy and birth related services can be of great value during this time; however, you should still expect some out-of-pocket expenses  like those for services such as ultrasounds, testing and your appointments and checkups (Medicare can pay a benefit toward these).

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

Private health insurance does offer benefits for expecting mothers, such as extras cover for outpatient services like physiotherapy, classes and checkups. However, there is a 12-month waiting period for in-hospital pregnancy and birth services. This means that taking out hospital cover when pregnant won’t cover you for your birth in a private hospital.

However, depending on your health fund, you may still want to take out a hospital policy while pregnant, as it will allow your newborn to be covered from birth with no or fewer waiting periods. Conditions for coverage from birth vary between funds, so make sure you understand how your baby is covered before taking out cover.

If you're already covered for pregnancy by your private hospital policy and have served the 12-month waiting period, health insurance can help pay towards the costs of giving birth to your child as a private patient with an obstetrician of your choice and in a private room (if available).

If you plan 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.

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 can be covered for in-hospital birth-related services by your health insurance. Before you try to conceive, make sure you have a suitable level of cover.

When the time comes, provided you have served the relevant waiting periods, you may have the option of choosing your obstetrician, and your policy can 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 GST-free. The only exceptions to this are Overseas Visitors Health Insurance and Overseas Student Health Cover, which are classified as general insurance and therefore attract GST.

Can I 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

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 or new level of cover. Waiting periods are necessary to prevent new members from claiming on high value benefits only to immediately cancel their membership, which would increase premiums for other members.

The government sets the maximum length of waiting periods that funds can impose for hospital treatment, which are:

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

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

Why do waiting periods apply?

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.

If I move overseas, how can I avoid waiting periods when I come back?

Many funds can suspend your health cover while you’re overseas for an extended period, 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 you start planning your trip.

In most cases, you won’t have to pay premiums while you’re overseas since you’ve suspended your cover. When you return, you’ll be able to resume your private cover without having to re-serve any waiting periods. If you’re part-way through serving a waiting period, you’ll have to serve the remainder of your waiting period when you come back.

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’ll still be a member with your fund.

When I switch health insurance, will I have to re-serve my waiting periods?

When you switch health insurance policies, your new health fund will honour any waiting periods you’ve already completed 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 6 months for a benefit requiring a 12-month wait, you’ll need to complete the remaining 6 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 that you weren’t previously covered for (e.g. orthodontics), you’ll need to complete the waiting period for that benefits before being covered. If you previously had a $500 limit on dental services and upgrade to an $800 limit, you will need to serve a waiting period before you can access the additional $300.
  • Increased excess. If you switch from a $750 excess to a $500 excess, you will need to serve a waiting period before the lower excess applies. If you’re admitted to hospital before you complete this waiting period, you’ll have to pay the higher excess.

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.

single alexksander portrait in bottom global block

So, what are you waiting for?

Compare health insurance
Or call us on 1800 304 709
single sergei portrait in bottom global block