Private Health Insurance vs. Medicare: Who pays for what?
We're lucky to live in a country where we have access to excellent health care. But, understanding how the costs work within our public and private healthcare system can sometimes be tricky.
Watch our useful video to help you navigate your health cover and understand who pays for what...
How Medicare works, and what private health insurance can do for you.
- Private health cover is divided into three areas: hospital, extras and ambulance
- Hospital cover enables you to choose your doctor and hospital
- Extras cover can help with the cost of services not covered by Medicare
Medicare is available to Australian citizens and most permanent residents. It covers part of the cost of seeing a GP or specialist (or the full cost if they bulk bill), and most prescription medicines. It also provides free medical treatment in public hospitals.
As a public patient in a public hospital you’ll be treated by hospital-appointed doctors and subject to waitlists for non-emergency treatment. The government will cover all costs related to your hospital admission and you won’t be charged any out-of-pocket costs.
Medicare doesn’t cover the cost of ambulances, glasses/contact lenses or hearing aids. It also excludes therapies such as speech pathology, osteopathy and remedial massage.
Private health insurance can fill the gaps in Medicare’s coverage and give you more choice about your treatment.
Hospital cover enables you to be treated as a private patient in a public or private hospital. As a private patient you can choose your own doctor.
At a public hospital it’s likely you’ll have to wait for non-emergency treatment; private hospitals usually provide faster access.
Your entitlements (which treatments and procedures you can claim for) will depend on your level of cover.
It’s wise to find out upfront if your insurance will cover the full cost of your treatment so you’re not left with unexpected out-of-pocket expenses, known as ‘the gap’.
Single rooms in public hospitals
On and from 1 July 2023 HCF will pay the same benefit when you’re admitted to a public hospital as a private patient, whether you’re in a shared or a single room.
Where single rooms are available, public hospitals allocate them based on patient need and there’s no guarantee a single room will be available in a public hospital.
If you're allocated a single room and the public hospital requires you to pay a gap, they need to get your consent to the charge first. If you're charged a gap for a single room, please contact us to see how we can help.
You can avoid extra hospital costs if you go to a private hospital in the HCF network.
If you decide to go to a private hospital that isn’t in our network, or a public hospital, please ask what your treatment will cost before you’re treated, so you can understand what your gap payment will be.
Extras cover allows you to claim for a range of day-to-day services, such as dental treatment, glasses and contact lenses, and a range of therapies not covered by Medicare.
The treatments you can claim for, and how much you can claim (your limits), are determined by your level of cover.
Ambulance cover covers the cost of emergency ambulance services (which aren’t covered by Medicare). It’s included on all levels of HCF hospital and extras cover. If you want ambulance-only cover, we do that too.
Depending on your income, hospital cover could help you avoid the Medicare Levy Surcharge (extra tax). If you get cover before the age of 31 you’ll avoid Lifetime Health Cover loading, lowering the cost of your premium. The Australian Government Rebate is also designed to make private health insurance more affordable.
Community rating and health insurance
Private health insurance in Australia is community-rated. This means you pay the same premium for the same level of cover as everyone else in your state, regardless of your age or health status, or the number of claims you make. This helps make private health insurance more accessible for everyone.
Charges and paying the gap
How to avoid out-of-pocket costs for hospital treatment.
Your go-to guide on private healthcare, managing your membership and more.
How the government rebate works
Why your income affects your health insurance premium.
Choosing an excess
How it works, and how to decide what’s right for you.