What is covered by private health insurance?

Private health insurance provides cover for health care not covered by Medicare such as physio and glasses. Depending on the policy you take out, it might let you have treatment in hospital as a private patient.

Depending on the policy you take out, private health insurance:

  • lets you have treatment in hospital as a private patient
  • can help pay medical costs that Medicare doesn’t cover

You can still choose to be a public patient in a hospital if you have private health insurance.

Types of cover

Private health insurance policies offer hospital cover and extras cover.

If you want both, you can take out combined cover or mix and match separate policies to meet your needs.

You can also take out ambulance cover if your state or territory government doesn’t cover it for you.

Hospital cover

Hospital cover helps with the costs of treatment as a private patient in hospital.

Extras and ambulance cover

Extras cover helps with the cost of out of hospital health services that Medicare does not cover.

Ambulance cover can help with the cost of emergency transport and medical care.

What isn’t covered

By law, private health insurance does not offer cover for out of hospital medical services including:

  • GP visits
  • consultations with specialists in their rooms
  • diagnostic imaging and tests

Medicare covers these services.

If your hospital, doctor or specialist charges more than the Medical Benefits Scheme (MBS) fee for a service, this might be more than Medicare and your insurer will pay. In this case you will have to pay out of pocket costs.

Waiting periods and exemptions

You might have to serve a waiting period before you can claim some medical costs. There is a once-only exemption for some mental health services and treatments.

Find out more about waiting periods and exemptions for mental health.

Cost of cover (premiums)

Your premiums will depend on the policy you take out. Your premiums will be higher if you want:

  • cover for more health services such as extras
  • top or comprehensive cover
  • zero excess or co-payments

Government rebates and loadings may also affect your premiums.

Premium increases

Your insurer must let you know in advance if your premium is going to increase. This gives you time to shop around and compare health insurance policies.

Premium increases are governed by private health insurance laws.

Problems with your cover

If you’re not happy with your health insurer’s service, contact the Commonwealth Ombudsman.

Last updated: 
23 December 2019

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