Compare Private Hospital Cover

Private hospital cover is a type of health insurance policy that helps you pay for the cost of treatment as a private patient in an Australian hospital.

Hospital insurance products are divided into four private health insurance 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, to also include select covers from the above tiers. For example, a health fund may offer pregnancy and birth-related services (usually only covered by Gold) on a Silver Plus policy as well.

When purchasing hospital cover, you can get hospital only health insurance or get a combined policy which will include extras cover. You also have the option of purchasing your hospital cover and extras cover from different providers.

The treatments included on your hospital insurance will depend on what tier policy you have. For example, Basic policies are only required to include restricted cover for 3 of the 38 clinical categories, while Gold includes all 38 clinical categories on an unrestricted basis.

Using a sample of 14 of the 38 clinical categories, the below table provides a glimpse into what treatments are minimum requirements for each tier.

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

Your hospital cover only includes medically necessary treatment that you receive as an inpatient, which usually requires you to be admitted to a hospital. It typically excludes non-hospital outpatient health services, including but not limited to:

• Dental check-ups, major dental and orthodontics
• Physiotherapy sessions
• Chiropractic work
• Optical (such as prescription glasses and contact lenses).

The above treatments can be 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, assisted reproductive services and joint replacements are exclusions as they aren’t a minimum requirement of the Silver product tier. Although, as mentioned above these may be included on some select Silver Plus policies.

Whenever you take out for the first time or you upgrade your policy, you’ll need to serve waiting periods before you can make a claim on your new services and treatments. Below are the standard waiting times for most services.

Waiting periods under your Extras Policy will be set by the fund.

The highest level of hospital cover is Gold, which includes all 38 clinical categories available under private hospital insurance. With this level of cover, you’ll be able to claim a benefit 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 include all 38 clinical categories but will also pay towards select out-of-hospital services that Medicare doesn’t subsidise.

Basic hospital cover is the lowest level of private hospital insurance and is an option for avoiding the Medicare Levy Surcharge (MLS) or Lifetime Health Cover (LHC) Loading. It includes restricted coverage for hospital psychiatric services, rehabilitation for patients recovering from surgery or illness and palliative care.

If you hold this level of cover and 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’ll 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 even with insurance, you’ll 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 depending on your circumstances, 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 more clinical categories.

Depending on your state or territory of residence, ambulance services may be included by your private health insurance policy. 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.

There are two types of ambulance cover available through health funds: non-emergency and emergency. Whether you’re covered for one or both of these will depend on your policy and insurance company. 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.

Once you’ve decided that a hospital policy is the right type of private health insurance cover for you, all that’s left to do is compare your hospital cover options and find a policy that suits your personal circumstances.

Here are a few things you might like to consider while you browse:

• If you’re under the age of 30 (18-29), you might be eligible for an age-based discount, which is a discount that applies to your policy depending on your age when you first take out and maintain eligible cover.
• Hospital insurance isn’t the only type of private health cover in Australia; you might also want to consider extras cover. If you want the benefits of both hospital and extras, you can look into a combined policy.
• Although hospital insurance tiers are standardised in Australia, health funds can still differ in their gap cover schemes, additional benefits/inclusions and whether they’re a for-profit or not-for-profit fund.

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 and doctors might have a known gap or a no gap agreement in place with your health fund, meaning you may only have to pay a reduced gap or none at all. To determine if you’ll have to pay the gap, check with your health fund and doctors before receiving treatment.

Hospital cover excess is the lump sum you pay when you’re 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 dependent children on some policies; this will depend on who your provider is and the specific policy that you are on.

Sometimes you can choose a higher excess in exchange for a lower premium, and vice versa.

Similar to an excess, co-payments are an amount you pay when you’re admitted to hospital. However, these are paid for each day you stay in the hospital. For example, you may choose a co-payment of $100 per day, 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. They may also apply in addition to an excess, depending on your policy.

You could receive an Australian Government rebate (sometimes called the private health insurance offset) on the cost of your hospital cover. If eligible, you can choose to receive this with your tax return or as a discounted premium. Your eligibility for the rebate will depend on your age, income and Medicare eligibility.

The MLS is a tax levied on higher-income earners for each day of the financial year that they don’t have hospital cover. If you earn over the income threshold and want to avoid it, get covered – simple as that! You will not pay the MLS for each day that you hold an eligible hospital policy. If you have a partner and/or dependents for tax purposes, they will also need to be covered.

By taking out and maintaining hospital cover before 1 July following your 31st birthday, you won’t 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 loading on your premiums for every year after the age of 30 that you don’t have hospital cover in accordance with the government’s LHC regulations.

Above all, hospital cover gives you the confidence of knowing that when a medical event arises, you and your family have access to high-quality private care. The most important thing in life is your health. Regardless of what stage of life you’re in, you may be able to benefit from private hospital cover.