What does my private health insurance cover?

More than money

Of course, having private health insurance offers you peace-of-mind and financial security when going to hospital, but there are other benefits too. Private health insurance also provides you with:

• the ability to choose your doctor or specialist.
• coverage for a greater range of health services than what is covered by Medicare, such as dental services.
• more choice about the timing of your surgery – often the wait time for a private hospital or day facility can be much shorter than a public hospital. You may also get choice about location if your surgeon operates in more than one hospital.
• you may be able to choose a private room, depending on the hospital, clinical need and availability.
• reduction in taxes – if you meet the eligibility criteria you won’t have to pay the Medicare levy surcharge and you may receive a private health insurance rebate.

It is also helpful to remember that even if you have private health insurance, you can choose to be treated as a public patient if you go to a public hospital. The decision is yours each time you need to go to hospital.

What do the different types of private health insurance cover?

Private health insurance uses Medicare as the basis for what type of healthcare is covered. In addition it also covers other health care like dental care (which is not necessarily covered by Medicare). It is separated into two main areas – hospital and extras cover. Some people choose to have just one type of cover or both.

Private health insurers offer a range of choices regarding policies so you can select the level of cover, premiums, and excess that suits your needs. As your level of cover and included benefits increase, generally your premiums increase as well. You can choose to have either hospital or extras cover, or have them combined as a package.

Hospital Cover

Hospital cover helps pay for costs when you are admitted to hospital as a private patient for either day surgery or overnight procedures for services like:

• your accommodation fees
• your theatre, labour ward and intensive care fees
• doctor’s fees for procedures performed in the hospital
• tests performed, medical devices and human tissue products used in relation to your procedure, and surgery related medications prescribed whilst in hospital (e.g. pain relief)

Extras Cover

Extras cover helps with the cost of out-of-hospital health services that Medicare does not cover. The included benefits will vary depending on the level of extras cover you have chosen, and typically include services such as dental check-ups and major dental, the cost of prescription optical eyewear, as well as physio and pharmacy.

How much is covered will depend on the level of extras cover you hold or choose to take out.

What is not covered?

By law, private health insurance cannot cover out-of-hospital medical services including:

• GP visits
• consultations with specialists in their rooms
• out-of-hospital diagnostic imaging and tests
• visiting an emergency department

These are services covered or subsidised by Medicare. There may be a gap between the fee that is charged for these services and the amount which Medicare covers, and will also depend on whether you are being treated as an in-patient or out-patient.

What you can expect

Consultations and imaging

Imagine you are heading to your GP because you have a sore knee. During your consultation, your GP might choose to send you to get some imaging done on the area, or they might refer you to a specialist. These appointments – the GP, specialist and imaging – by law cannot be covered by your private health insurance. Depending on the circumstances they may be covered by Medicare. To save money on these appointments, ask for bulk billing where possible.

Surgery

Your specialist may recommend surgery. If you choose to have this procedure performed at a private hospital and you are admitted as an “in-patient”, then your stay will be covered by your private health insurance (if it includes a benefit for this surgery).

Your insurance will also subsidise your doctor’s fees however you may have a gap here if the doctor charges a fee higher than the Medicare scheduled fee, does not bulk bill or use our Access Gap scheme. It also covers theatre, accommodation fees for the procedure and the cost of any tests that need to be performed while admitted as an in-patient. Find out more about out of pocket costs>

You may also have an Excess or Co-payment amount which will need to be paid directly to the hospital. Check your cover details for more information on what procedures are covered under your level of hospital cover.

Pharmaceuticals

If you require pharmaceuticals while you are in hospital, related to your admission (e.g. pain relief) these will also be covered. This does not include any medications you were already taking before surgery.

Post-surgery appointments

Once you are discharged out of hospital, you are considered an “out-patient” so any post-surgery appointments you may have will be subsidised or covered by Medicare, not private health insurance.

3 ways to save money

1. Check your hospital cover
   If you’re planning surgery, call us first – we can help you check what you are covered for, provide some tips on how to keep out-of-pocket costs to a minimum, help you plan better and understand your recovery options. We’ll be able to give you all the information regarding what you’re covered for in relation to your procedure if you have your item number and hospital name handy. Call us on 1300 113 113.
   
2. Get a quote from your specialist
   You can choose your specialist, so we recommend you ask for an itemised quote, including Medicare item numbers in writing from them. You are entitled to know what they will charge you and any potential out-of-pocket costs before you have surgery.
   
3. Ask your doctor about Access Gap
   If you are concerned about your doctor’s fees, ask whether they will participate in Health Partners’ Access Gap Scheme which limits the out-of-pocket gap you pay. If you are unhappy with the fees they are quoting you could get a second opinion – check with your GP.