What Does Private Health Insurance Cover?

The coverage of health insurance depends on your choice of policy type, insurance provider, and more. Canstar explains what health insurance covers.

What does health insurance cover?

Private health insurance coverage depends on whether you choose a Hospital Only, Hospital + Extras, Extras Only policy, or Ambulance Cover policy.

Hospital policies cover a patient to be treated as a private patient in either a public hospital or a private hospital. This covers the patient for elective surgeries as well as emergency or medically necessary surgeries. Hospital policies can be added to Extras policies or purchased separately as Hospital Only policies.

Extras policies cover a patient to receive treatment from non-medical services or allied health services. Depending on the level of cover chosen, the services covered may include optometrists, dentists, physiotherapists, chiropractors, acupuncture, and more. Extras policies can be added to Hospital policies or purchased separately as Extras Only policies.

Ambulance cover may be purchased separately as an Ambulance Only policy or combined with Hospital or Extras policies.

We explain these policy options in more detail below. The government has been contemplating switching to an easier-to-understand ‘Gold, Silver, Bronze’ system for the coverage level categories, so watch this space.

Compare Health Insurance

What does health insurance cover in hospital?

Hospital policies cover a patient to be treated as a private patient in either a public hospital or a private hospital. This helps patients to cover the cost of in-hospital treatment by the doctor of their choice, accommodation to stay in a ward, and the theatre fees for surgery.

Generally, any medical services listed under the Medicare Benefits Schedule (MBS) should be covered by private hospital insurance. This includes treatments such as doctors and specialists, tests and examinations such as X-rays and blood tests, eye tests, surgeries and other therapeutical procedures performed by doctors, some dental surgeries, Cleft Lip and Palate treatment, and certain allied health services (e.g. psychologists, psychiatrists, chronic disease management). However, make sure you read the Product Disclosure Statement (PDS) and the terms and conditions of your policy.

Hospital policies provide four different levels of coverage of health insurance depending on your choice of policy:

hospital policy Top Private Hospital Cover has no restrictions or exclusions on MBS-payable items (medical services provided by doctors in hospital).
Medium Private Hospital Cover does not exclude any items on the MBS, but has restrictions on some MBS items; only limited benefits are paid for restricted items.
Basic Private Hospital Cover excludes one or more MBS items; no benefits are paid for excluded items.
Public Hospital Cover covers default benefits for treatment in public hospital only.

Source: Health.gov.au

Why do you need health insurance if the item is on the Medicare Benefits Schedule (MBS), you may be asking? Well, whilst Medicare will pay a benefit towards your treatment in a public hospital, private health insurance will allow you to choose your own doctor and hospital – and perhaps even the timing of any elective surgery that may need.

Compare Hospital Only Health Insurance

Compare Hospital & Extras Health Insurance

What does health insurance cover outside of hospital?

General treatment policies (also known as ancillary cover or extras cover) cover a patient for part or all of the cost of non-medical health services such as dental, optical, physiotherapy, and chiropractic treatment. Extras cover can be added to Hospital cover in a combined policy or can be bought separately as an Extras Only policy.

Extras policies provide three levels of coverage of health insurance depending on your choice of policy:

what does health insurance cover outside of hospital Comprehensive Cover includes most or all of general dental, major dental, orthodontics, optical, physiotherapy, chiropractic, occupational therapy, pharmaceuticals, podiatry, and hearing aids.
Medium Cover includes most or all of general dental, major dental, optical, physiotherapy, chiropractic, podiatry, and occupational therapy services.
Basic Cover includes at least one of general dental, optical, physiotherapy, and/or chiropractic.

Source: Health.gov.au

Compare Hospital & Extras Health Insurance

Compare Extras Only Health Insurance

What do Ambulance policies cover?

Ambulance policies cover patients for the cost of riding in an ambulance and the cost of paramedics giving them emergency treatment before and during transport to hospital. Ambulance policies are provided by health insurers because ambulance services cost money for patients in most states and territories in Australia.

what do ambulance policies cover All states and territories in Australia: Ambulance services are free for veterans with a Gold Card in all states and territories in Australia.
ACT, NSW, NT, SA, Victoria, WA: Ambulance services are free for specific Concession Card holders. Other patients must either buy ambulance cover or pay out-of-pocket if use an ambulance. Check the PrivateHealth.gov.au website to find out whether your Concession Card is covered for free ambulance services in your region.
Queensland, Tasmania: Ambulance services are free for residents. These services are paid by the state governments.

Canstar does not currently research and rate ambulance cover policies, but if you would like us to rate the policies on offer in your state or territory, please use our online Contact Us form to get in touch.

What is not covered by private health insurance?

In general, health insurance policies may not cover the following:

  • Exclusions: Some health conditions or treatment services may not be covered at all by the policy.
  • Restrictions: Some health conditions or treatment services may only be covered to a limited extent, so there is a gap payment between the fees charged and what the insurer will pay. This means that patients will pay some of the fees out-of-pocket if they choose to use these services or treat these conditions.
  • Benefit limitation periods: Some policies pay reduced benefits on claims for certain services for a certain period of time after the waiting period, and then pay full benefits on claims for those services after that period.

In additional to the general exclusions or restrictions, a Hospital policy may not cover the following:

  • Surgeries or hospital treatments not covered by Medicare: Surgeries or treatments not on the MBS list above may not be covered by your health insurance. Items not on the MBS list include elective cosmetic surgery and surgeries or treatments that are not necessary to maintain your health.
  • Long stays in hospital: Patients who stay in hospital for more than 35 days in a row are called ‘long stay patients’ or ‘nursing home patients’, and they will have to pay more out-of-pocket costs for hospital accommodation after the first 35 days.
  • Single or shared room: Depending on your choice of policy, you may be covered to stay in hospital in a shared room (a room you share with other patients) but not a single room (a room to yourself). If you have to be admitted to a single room for some reason (e.g. contagious quarantine), the hospital must tell you that you will need to pay the gap between your fund’s benefit and the hospital fees.

In additional to the general exclusions or restrictions, an Extras policy may not cover the following:

  • Alternative therapies: Most Extras policies only cover certain services. Your policy may cover only dental, optical, and chiropractic – or it may cover different services – or it may cover those things plus a long list of other treatments.
  • Benefit limits: Many Extras policies will limit the coverage of health insurance for each service. For example, you may be covered for a benefit limit of up to $100/year to spend on dental services, $300/year to spend on optical services, and $200/year to spend on chiropractic services. There may also be lifetime benefit limits so that you can only receive a certain amount of benefits as long as you hold that policy.

An Ambulance policy may not cover the following:

  • Call out fees: Some Ambulance policies do not cover the call out fee that is charged if the paramedic treats you at the scene but does not transport you in ambulance to the hospital.

Check the product disclosure statement (PDS) on your health insurance policy to find out what services are not covered, as well as any exclusions, restrictions, and terms and conditions that apply. You can compare the coverage of health insurance provided by different insurers and policies on the Canstar website:

Compare Health Insurance

Share this article

Enjoyed reading this article?

Sign up to receive more news like this straight to your inbox

By subscribing you agree to the Canstar Privacy Policy.

Thanks for signing up!

Good things are coming your way.