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.
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.
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.
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.
|NSW||The 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.
|VIC||Residents 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.
|QLD||The 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.
|WA||Residents 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
|SA||Residents of SA can take out ambulance cover through a registered Australian health fund or a subscription from the state ambulance service.|
|TAS||Ambulance 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.|
|ACT||Residents 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.
|NT||Residents 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.|
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.
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.