Private health insurance
Private health insurance - frequently asked questions
This page contains frequently asked questions by consumers about Private Health Insurance.
What is private health insurance?
- What is private health insurance?
- What does private health insurance offer?
- Do I have to get private health insurance?
What does private health insurance cover?
- What does private health insurance cover me for?
- What doesn't private health insurance cover?
- Am I covered as soon as I take out private health insurance?
- Am I covered for a condition that I had before I bought private health insurance?
What are private health insurer obligations to members?
- What can I do if I think my private health insurer has treated me unfairly?
- Can a private health insurer refuse to insure me because I am elderly or chronically ill?
- Can I change private health insurer if I want to?
- Can I change my level of health cover?
- If I go overseas, how can I avoid waiting periods and pre-existing ailment restrictions when I get back?
- My private health insurer won't suspend my membership, what can I do?
- What if I fall behind in my contributions?
I’ve got private health insurance. Do I still have access to public healthcare?
- Can I still access Medicare if I have private health insurance?
- Can I access Medicare if I can’t afford private health insurance?
- Why do I have to pay the Medicare levy when I have private health insurance?
There are two types of private health insurance cover available, hospital cover and general treatment cover (ancillary or extras cover).
Hospital cover pays for some or all of the costs of hospital treatment as a private patient, including doctors’ fees and hospital accommodation. It applies when you are a private patient in a public or private hospital (or a day hospital facility).
General treatment cover helps with the cost of services such as physiotherapy, dental and optical treatment. Some private health insurers offer packaged products that cover both hospital and general treatment services.
Generally, the more extensive the private health insurance the greater the premium cost. When choosing your private health insurance it is important to make sure it suits your healthcare needs and budget. Private health insurers should provide you with the information to make an informed choice about the level cover that is appropriate for you.
Private health insurance also provides cover for services not covered by Medicare such as physiotherapy, optometry, general dental and podiatry services. Many people rely on private health insurance to access services they would otherwise be unable to afford.
If you don’t have private health insurance it doesn’t impact your access to Medicare. However you may be required to pay the Medicare levy surcharge if you earn over a certain amount and don’t have private health insurance hospital cover.
If you have private health insurance you are able to access the free public hospital system through Medicare by electing to be treated as public patient. You can also access certain subsidised or free out-of-hospital medical services under Medicare.
It’s important to note that you can’t access Medicare for procedures that aren’t considered clinically relevant by a doctor.
It’s recommended you check with you insurer if a treatment is covered by your private health insurance.
You can also choose to be treated as a public patient in a public hospital for free under Medicare.
Private health insurance general treatment cover (also known as ancillary or extras cover) can offer out-of-hospital services that are generally not funded by Medicare, such as:
- dental treatment;
- chiropractic treatment;
- home nursing;
- occupational therapy;
- speech therapy; and
- glasses and contact lenses.
Private health insurance may not cover the total cost of the doctors' services provided to you in hospital, which in turn may leave you with an out-of-pocket expense. This is called a ‘gap’.
Insurers can inform you whether they offer private health insurance that covers you for all or part of the gap. They can provide you with details of the doctors and hospitals they have agreements with to cover the gap.
Private Health Insurance Ombudsman on 1800 640 695.
If I go overseas, how can I avoid waiting periods and pre-existing ailment restrictions when I get back?You can ask your private health insurer if they are prepared to suspend your health cover while you are overseas.
Suspending your membership allows you to stop paying your premiums for the time that you are overseas. When you return you can resume your private health insurance cover without having to re-serve any waiting periods.
While your cover is suspended, you will remain a member with your private health insurer and you will not be required to pay premiums. However, you will not be covered during the period that your membership is suspended. This means that you can not claim.
If you have not served your waiting period or pre-existing ailment waiting period at the time your suspension is granted, you will have to serve the remainder of it when you resume contributions at the end of your suspension period.
While your private health insurance hospital cover is suspended by your insurer you are considered to have hospital cover for Lifetime Health Cover purposes. You will not be required to pay any age-based loading on your premium provided you resume your premium payments at the end of the agreed suspension period.
Suspension rules vary between private health insurers in relation to the length of time allowed and the grounds for granting the suspension.
For more information about the Medicare levy surcharge when travelling overseas, visit the overseas travel and the Medicare levy surcharge page.
For more information about private health insurers, visit the list of health funds page or call 1300 737 299.
If you are unable to suspend your membership, you may be able to lapse your cover without penalty under the Lifetime Health Cover period of absence provision.
If you are more than two months behind in your contributions, your private health insurer may consider your membership to have lapsed. You should discuss this with your insurer.
It’s important to note that you can’t access Medicare for elective procedures, that is, procedures that aren’t considered clinically relevant by a doctor.
The Government supports universal access by all Australians to public health services under Medicare, regardless of private health insurance status. People with private insurance can choose to use Medicare or private healthcare services.
Even if you elect to be treated as a private patient, you receive some Government subsidy.
Medicare funds 75 per cent of most medical services in private hospitals. The public health system also subsidises the cost of certain medicines under the Pharmaceutical Benefits Scheme.
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