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Private hospital cover helps pay for your treatment as a private patient in an Australian hospital. With private hospital cover, you can have your choice of doctor and stay in a private room (both depending on availability), as well as avoid long public waiting lists.

Depending on the treatment you require and when you took out your policy, you may need to serve policy waiting periods before you can begin claiming. Waiting periods differ depending on the treatment you need. For example, in-hospital psychiatry services have a waiting period of 2 months, while pregnancy and birth-related services and treatments for pre-existing conditions are 12 months.

How does hospital cover work?

Hospital insurance products are divided into four tiers: Basic, Bronze, Silver and Gold. Each tier has a set number of clinical categories it must cover regardless of which health fund you’re with. That said, insurance providers have the choice of adding ‘plus’ or ‘+’ to Basic, Bronze and Silver hospital policies, which include coverage from the above tiers without covering enough to be in that tier. For example, a Silver Plus policy might cover pregnancy and birth-related services but not weight loss surgery.

What does hospital cover include?

The treatments covered by your hospital insurance will depend on what tier policy you have. For example, Basic policies only include restricted cover for 3 of the 38 clinical categories, while Gold covers all of them.

Here’s a glimpse of what each hospital insurance tier covers:

Hospital psychiatric servicesR
Palliative careR
Brain and nervous system
Ear, nose and throat
Joint reconstructions
Heart and vascular system
Back, neck and spine
Dental surgery
Joint replacements
Pregnancy and birth
Weight loss surgery
– indicates that the category is a minimum requirement of the tier

R – indicates that the category is covered on a very restricted basis

You can find the full list of hospital treatments covered by the health insurance tiers on our health insurance categories page.

What does hospital cover exclude?

Your hospital cover only includes treatment that you receive as an inpatient, which usually requires you to be admitted to a hospital. Non-hospital services are usually considered outpatient services and include, but aren’t limited to:

The above treatments are subsidised by extras cover policies, which are sometimes called ancillary policies.

The treatments you can claim on will also depend on your level of cover or ‘tier’. For example, with a Silver policy, weight loss surgery and pregnancy and birth are exclusions as they aren’t a minimum requirement of the Silver product tier.

Frequently asked questions

Are there out-of-pocket costs with hospital insurance?

Generally when you have a private hospital insurance policy, your insurer will pay 25% of the Medicare Benefit Schedule fee (MBS), while Medicare will pay the remaining 75%. Your health fund could also pay towards other hospital expenses like your theatre fees, accommodation and food.

The MBS fee is the amount that the government has deemed fair to charge for medical treatments and services. Because private hospitals and doctors are allowed to charge above the MBS, you might have to pay the gap (the difference between the MBS and what you’re charged) as an out-of-pocket expense. Some hospitals might have an agreement in place with your health fund, meaning you may only have to pay a reduced gap or even none at all. To determine if you’ll have to pay the gap, check with your health fund and doctors before receiving treatment.

What is the top hospital cover tier?

The highest level of hospital cover is Gold, which includes coverage for all 38 clinical treatments available under private hospital insurance. With this level of cover you’ll be privately covered for any medically necessary treatment performed in a hospital with a corresponding MBS item number.

While this is the maximum amount of hospital cover available, you can also take out a combined gold hospital and extras policy which will not only cover all 38 clinical categories, but will also pay towards select out-of-hospital services which Medicare doesn’t subsidise.

What is basic hospital cover?

Basic hospital cover is the lowest level of private hospital insurance and is an  option for those seeking a policy to avoid the Medicare Levy Surcharge (MLS). It includes restricted coverage for hospital psychiatric services, rehabilitation for patients recovering from surgery or illness and palliative care. If you choose to be treated as a private patient in a public hospital, you may be subject to public waiting lists for these services. In addition to this, when claiming on a restricted benefit you will only be covered to a very limited extent. If you choose to go into a private hospital, the health fund will not pay any benefits towards the theatre fees and only a small benefit towards the accommodation fee. This means that you will have considerable out-of-pocket costs.

These policies don’t offer much in the way of coverage. However, some insurance providers may offer Basic plus policies that come with additional benefits. These plus policies will likely come with a higher premium, so it might be worth going all the way up to the next tier with a Bronze hospital policy, or even a Bronze plus policy if you want coverage for some of the higher clinical categories.

Is ambulance covered by private health insurance?

Depending on your state or territory of residence, ambulance services may be covered by your private health insurance. Residents in all states and territories except for QLD and TAS) (where ambulance services are free), can take out ambulance cover through their private health insurer or their state’s ambulance authority.

People who hold a Department of Veterans’ Affairs Gold Card are entitled to free ambulance services across Australia, while residents of QLD and TAS have their ambulance costs covered by their state governments.

NSWThe NSW state government subsidises 49% of the cost of ambulance services for people who don’t have ambulance cover. However, this can still be costly, which is why ambulance cover is widely available through registered Australian health funds in NSW.

NSW residents with a Health Care Card, Pensioner Concession Card, Commonwealth Seniors Health Care Card and who otherwise meet NSW’s exemption criteria can access ambulance services at no cost.

VICResidents of VIC can take out ambulance cover through a registered Australian health fund or a subscription from the state ambulance service.

VIC residents who hold a Pensioner Concession Card or Healthcare Card are entitled to free ambulance cover.

QLDThe QLD state government covers ambulance services for their residents in both QLD and around Australia.

If you receive a bill for ambulance services in another state or territory, you can forward it, along with proof of QLD residency, to the Queensland Ambulance Service.

WAResidents of WA can take out ambulance cover through a registered Australian health fund or a subscription from the state ambulance service. WA residents who are aged Pensioner concession holders you may be are entitled to free ambulance transport services

Western Australians over 65, and in receipt of an Australian Government pension, are entitled to free ambulance services

Western Australians over 65, who do not receive an Australian Government pension, are entitled to a 50% discount off the cost of ambulance service

SAResidents of SA can take out ambulance cover through a registered Australian health fund or a subscription from the state ambulance service.
TASAmbulance services in TAS are free to residents, except for motor vehicle or workplace accidents which are covered by insurance. Unlike QLD, Tasmanians can only receive free ambulance cover in their state.
ACTResidents of ACT can take out ambulance cover through a registered Australian health fund.

People who meet the ACT Ambulance Service’s exemption criteria are entitled to free ambulance services. ACT residents who hold a Pensioner Concession Card or Healthcare Card are entitled to free ambulance cover.

NTResidents of NT can take out ambulance cover through a registered Australian health fund or a subscription from the state ambulance service. NT residents who are Pensioner Concession Card or Commonwealth Seniors Health Card holders are entitled to free ambulance cover.

What is hospital cover excess?

Hospital cover excess is the lump sum you pay when you get admitted to hospital. Sometimes you can choose a higher excess in exchange for a lower premium, and vice versa. You will only be required to pay the excess if you are admitted to hospital. This payment is often limited to once per person per year. In addition to this, many providers won’t charge an excess for any dependant children on your policy. This will depend on who your provider is and the specific policy that you are on.

What are hospital cover co-payments?

Similar to excess, co-payments are an amount you pay when you’re admitted to hospital. However, these are paid for each day you’re in the hospital. For example, you may choose a co-payment of $100 per day in hospital, which would result in a $500 payment if you’re admitted for five days.

Co-payments can also be capped per admission, per year of membership or both.

Is private hospital cover worth it?

Whether private hospital cover is worth it to you will depend on your individual circumstances. However, here are some of the main factors you’ll want to consider when deciding if you should take out cover.

You could be eligible for a rebate
Depending on your age and income, you could receive an Australian Government Rebate on the cost of your hospital cover. You can choose to receive this with your tax return or as a discounted premium.

Avoid extra tax
The MLS is a tax levied on higher-income earners ($93,001+ for singles and $186,001+ for families) who don’t have hospital cover. If you want to avoid it, get covered – simple as that!

Avoid Lifetime Health Cover loading
By taking out hospital cover before 1 July following your 31st birthday, you will not be subject to the Lifetime Health Cover (LHC) loading for as long as you hold the cover, even if you switch between health funds. Conversely, purchasing private hospital insurance after this age may subject you to a 2% loading on your premiums for every year you don’t have cover as part of the government’s LHC regulations. LHC loading caps out at 70% and is removed once you’ve held continuous cover for 10 years. After you take out hospital insurance before 1 July following your 31st birthday, you’re able to let the policy lapse for up to 1,094 days in your lifetime without incurring the loading.

Peace of mind
Above all, hospital cover gives you the confidence of knowing that when a medical event arises, you and your family are covered with high-quality private care. The most important thing in life is your health. Regardless of what stage of life you’re in, everyone can benefit from private hospital cover.

Tips on hospital cover from our health insurance expert, Lana Hambilton

  1. It can be tempting to get just ‘the basics’ when taking out health cover for yourself. To ensure you don’t find yourself underinsured, consider any previous admissions you have had into hospital along with your family’s medical history when looking at different levels of cover. Instead of sacrificing inclusions on your cover, consider increasing your excess to lower costs.
  2. Shop around and do your research. Prices vary from fund to fund, and there are plenty of options to choose from. If you need assistance, speak to an expert, they are there to help!
  3. You may be glad to know that many health funds cover hospital treatment as the result of an accident along with ambulance cover with only a one-day waiting period after starting your hospital policy. It’s always a good idea to check the fund’s policy brochure for more details on their coverage and waiting periods.

How can I get hospital cover?

A great way to find a good deal on hospital cover is by shopping around and comparing your options – which we can help you do right now with our health insurance comparison service.

Our service is quick, simple and completely free to use, so you can search and compare policies all day long if you want to. Simply enter in some details about yourself and the type of coverage you’re after to get the ball rolling.

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