More than half of Australians have private health insurance; however, many people have difficulty understanding what their private insurance covers. Private health insurance provides cover for in-hospital health care services not covered by Medicare.
Australian law prevents private insurance from covering any out-of-hospital medical services, including consultations with specialists in their rooms. Private health insurance won’t cover the cost of a specialist appointment for a consult when it relates to a procedure whilst you are an in-patient. If you receive treatment from a specialist in a public or private hospital, your private insurance may cover all or a portion of your costs if you have coverage for the service provided.
Hospital cover
Hospital cover applies to medical expenses to receive treatment as a private patient in a public or private hospital or a day hospital facility. Depending on the coverage you select, your private health insurance will cover all or a portion of your hospital accommodation and theatre costs that are not covered by Medicare when you receive treatment as a private patient.
Your private insurance will cover at least 25% of the Medicare Benefits Schedule fees for services that are covered by Medicare. Medicare pays the remaining 75%. This includes coverage for a specialist.
Restrictions
Can private health insurance cover specialist treatment as an in-patient if the service is restricted on your policy? When a medical procedure is restricted on a private health insurance policy, the policy usually only partially covers the service. This means any specialist fees you incur for in-hospital services that are restricted may not be fully covered. You must pay any portion of your medical expenses not covered by Medicare or your private insurance out of pocket.
Exclusions
Any medical service that is excluded from your policy will not be covered by your private insurance at all. Excluded services vary by policy. Some policies have restrictions or exclusions; some have both. Several types of services are commonly restricted or excluded on private insurance policies:
- Cardiac issues
- Pregnancy and birth
- Hip and knee replacements
- Plastic and reconstructive surgery
- Cataract and eye lens procedures
- Assisted reproductive services
- Rehabilitation and psychiatric services
If you need to see a specialist for a restricted or excluded service, you may have to pay out of pocket.
Private Health Insurance product tiers
As of April 2020, all private hospital insurance is classified into a four-tier system:
- Gold
- Silver
- Bronze
- Basic
The tiers correspond to the minimum level of cover the policy offers for various clinical categories. The higher your tier is, the more services your private insurance covers.
Extras cover
Can private health insurance cover services that are not covered by Medicare? If you purchase extras cover on your policy, a portion of your expenses for treatments that are not covered by Medicare may be covered by your policy.
There are several types of services that are typically not covered by Medicare:
- Physiotherapy
- Home nursing
- Orthodontics
- Glasses and contact lenses
- Chiropractic treatment
- Dental treatment
- Speech therapy
Typically, your private insurance will cover either a specific percentage of the cost for these services or a flat rate per year.
Which medical services do you have to pay for?
If you receive medical treatment in a public hospital as a public patient, you do not have to pay any of your medical expenses out of pocket. You may have out-of-pocket expenses if you receive treatment:
- As a private patient in a public or private hospital
- In a facility that is not a hospital
- In a private hospital
Medicare and private insurance may pay a portion of your expenses in these circumstances, but usually not all of them. Private insurance only covers doctor's fees for treatment received in hospital. The amount your private insurance will cover varies by insurance company and policy.
Services outside hospital
Medicare pays 85% of the MBS fee for out-of-hospital services that are listed in the MBS. Medicare does not pay for out-of-hospital services that are not listed in the MBS, such as physiotherapy and podiatry. Though private health insurance covers some services that Medicare does not, it cannot cover all services received outside of a hospital. If you see a specialist outside of a hospital, private insurance will not cover this expense.
Gap arrangements
Can private health insurance cover specialist services if they are in hospital if the specialist charges more than the MBS fee? Doctors, including specialists, decide what to charge patients for private medical services. In some cases, charges may exceed the MBS fee. The difference between the fee your doctor charges and the MBS fee is called the gap. If your private health insurer has a gap arrangement with the doctor, your private insurance may cover all or a portion of the gap. You must pay any remaining gap amount out of pocket.
Private insurance may provide either no gap cover or known gap cover. If you have no gap cover, your insurer will pay up to a specified amount of the gap. If your doctor charges an amount that is higher than the MBS fee, but lower than the gap limit, you will not have to pay out of pocket.
If your doctor charges an amount that exceeds the no-gap limit, your private insurance may cover an additional amount under known gap cover. You must pay any amount that exceeds the known gap cover.
Specialist booking or administration fees
Neither private insurance nor Medicare covers any fees you must pay to schedule an appointment with a specialist. Request a written estimate of your total costs from your specialist before you receive treatment.
How do I know how much my medical bills will be?
Except for emergency services, patients have a right to informed financial consent. This means that your healthcare providers, including specialists, should provide you with an estimate of your costs, including any expenses you may have to pay out of pocket, before you receive treatment. The government also provides an online tool to help you estimate your costs.
Can Private Health Insurance cover specialist appointments with Health Partners?
Health Partners Access Gap Scheme can reduce or eliminate your specialist's bill for in-hospital treatments when you use an Access Gap specialist. Call us or use our specialist search tool to find out if your provider participates in this program.
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Sources:
Department of Health and Aged Care (2022) https://www.health.gov.au/health-topics/private-health-insurance/what-private-health-insurance-covers
Department of Health and Aged Care (2022) https://www.health.gov.au/health-topics/private-health-insurance/what-private-health-insurance-covers/hospital-cover-and-product-tiers
Department of Health and Aged Care (2022) http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home
Australian Government Services Australia (2022) https://www.servicesaustralia.gov.au/health-care-and-medicare?context=60092
Department of Health and Aged Care (2021) https://www.health.gov.au/health-topics/private-health-insurance/what-private-health-insurance-covers/out-of-pocket-costs
Department of Health and Aged Care (2022 https://www.health.gov.au/health-topics/private-health-insurance/private-health-insurance-reforms
Commonwealth Ombudsman https://www.ombudsman.gov.au/p...
Department of Health and Aged Care (2019) Private Patients Hospital Charter. Retrieved from https://www.health.gov.au/resources/publications/private-patients-hospital-charter
Posted: Mar 08 2022
Disclaimer
The information contained here is of a general nature and does not take into account your personal medical situation. The information is not a substitute for independent professional medical advice and is not intended to diagnose, treat, cure or prevent any disease or used for therapeutic purposes. Should you require specific medical information, please seek advice from your healthcare practitioner. Health Partners does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information provided.
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© Copyright Health Partners. 2024 All Rights Reserved.
Health Partners is committed to providing quality and affordable health care, and we value our members and our obligation to protect your privacy. As part of our responsibility in protecting your privacy, from time to time we review our policies to ensure we are meeting our obligations. We have recently made some updates to our Privacy Policy. Please click here to view the Health Partners Privacy Policy.