Private hospital cover is a type of insurance that helps cover the cost of hospital stays, especially for elective surgery and other treatments not available in the public system. The benefits of private hospital cover are:

1. Choice of Doctor: You can choose your doctor or specialist for treatment.
2. Choice of Hospital: You can choose from a range of private and public hospitals.
3. Shorter Waiting Times: Avoid the long waiting times in the public system, especially for non-emergency elective procedures.

Hospital coverage is available on several levels, each with varying degrees of coverage and benefits. The main levels of hospital cover are:

• Basic Hospital: This covers the minimum required for essential treatment, but many services are restricted or excluded.
• Basic Plus Hospital: Adds a few more services to the Basic level but still has many limitations.
• Bronze Hospital: Covers more services, including basic treatments like joint reconstructions and hernia repairs.
• Bronze Plus Hospital: Adds more services beyond the standard Bronze level, depending on the provider.
• Silver Hospital: Includes all Bronze services plus more complex treatments like heart and lung procedures.
• Silver Plus Hospital: Adds to Silver level with some Gold level services.
• Gold Hospital: Gold Hospital is the most comprehensive hospital coverage, covering all clinical categories, including joint replacements, pregnancy, and cataract surgery.

Each level is designed to suit different healthcare needs, so you need to choose the right level of cover for your personal health and budget. Knowing what’s covered in each level will help you decide which hospital cover is best for you.

Extras Included in Hospital Cover

Private hospital cover is more than just for elective surgery. Depending on the level of cover you choose – Basic, Bronze, Silver or Gold – there are other treatments and services included. These services go beyond surgery and are important to your overall healthcare experience. Here are some common inclusions in many hospital cover policies:

1. Selected Medical Admissions: Covers non-surgical medical treatments that are directly related to services covered under your policy (e.g. treatments related to chronic conditions or acute medical needs).
2. Day Surgery: Procedures are done on a day-patient basis so you can go home the same day after treatment.
3. Overnight Accommodation: Private room accommodation when available or shared room in a private hospital.
4. Special Care Unit Accommodation: Covers the cost of intensive care or other specialist care units when required.
5. Operating Theatre Fees: Use of the operating theatre for surgery or invasive treatments.
6. Doctor’s Surgical Fees and In-Hospital Consultations: Surgeon or other specialist fees during your hospital stay.
7. Government-Approved Prosthetic Devices: Prosthetics like joint replacements, pacemakers or other government-approved devices.
8. Allied Health Services: In-hospital services like physiotherapy, occupational therapy and other rehabilitative treatments.
9. Pharmaceuticals: Medicines approved by the Pharmaceutical Benefits Scheme (PBS) are required during your hospital stay related to specific treatments.
10. Ward Drugs and Sundry Medical Supplies: These include medical supplies needed during your stay, such as bandages, painkillers, and other routine medications.
11. Nursing Care: During your hospital admission, professional nursing services for monitoring or treatment.
12. Patient Meals: Meals during your stay in the hospital are covered by most hospital insurance policies.
13. Common Treatments and Supportive Care: Routine treatments like wound care and support for associated conditions during hospitalisation.
14. Associated Treatment for Complications: Treatments that arise from complications during surgery or medical procedures and any associated unplanned treatments.

By including these extras, hospital-only cover covers everything that goes beyond surgery. So, all your hospital-related needs, from specialist treatments to recovery, are taken care of with minimal out-of-pocket expenses.

Levels of Hospital Cover

Private hospitals cover in Australia have 38 clinical categories that cover a wide range of medical procedures, from simple ones like hernia repairs to complex ones like joint replacements or cataract surgeries.

Basic Hospital

The Basic Hospital level is the most limited level of cover and covers:

• Rehabilitation (restricted)
• Hospital Psychiatric Services (restricted)
• Palliative Care (restricted)

Restricted means the cover for these services is minimal and you will only receive reduced benefits if you’re admitted to a hospital. For example, it doesn’t cover the full cost of private accommodation in public or private hospitals, so you may face significant out-of-pocket expenses for theatre fees, accommodation or other related costs if treated in a private hospital. If you’re treated as a public patient under Medicare, public hospital waiting lists will apply, so you should consult your doctor to determine the best option.

Basic Plus Hospital

The Basic Plus level includes the same restricted services as Basic but with at least one or more of the benefits from higher levels (Bronze, Silver, or Gold). Not all Basic Plus policies are the same, so read the fine print. For example, nib’s Basic Essential Hospital Plus covers 7 clinical categories in private hospitals, and Medibank’s Basic Plus Healthy Start covers 3.

Bronze Hospital

By law, Bronze hospital cover must include a broader range of clinical categories so you’ll have access to treatments like:

• Brain and nervous system
• Eye (excluding cataracts)
• Ear, nose, and throat
• Bone, joint and muscle
• Joint reconstructions
• Kidney and bladder
• Male reproductive system
• Gynaecology
• Chemotherapy, radiotherapy and immunotherapy for cancer
• Pain management

This level has more protection. Many common surgeries and treatments are covered, but some significant services, like heart procedures and major surgeries, may still be excluded.

Silver Hospital

Silver hospital cover adds to Bronze by covering more advanced treatments like:

• Heart and vascular system
• Lung and chest
• Back, neck and spine
• Plastic and reconstructive surgery (medically necessary)
• Dental surgery
• Hearing device implantation

Silver is for those who want a more comprehensive policy without paying for all the services covered under Gold.

Gold Hospital

Gold hospital cover is the most comprehensive and must cover all clinical categories, so it is best for those with complex medical needs. In addition to the services covered by Bronze and Silver, Gold also covers:

• Cataract surgery
• Joint replacements
• Dialysis for chronic kidney failure
• Pregnancy and Birth
• Assisted reproductive services (e.g. IVF)
• Weight loss surgery
• Insulin pumps
• Pain management devices
• Sleep studies

Gold is for families planning to have children, those with chronic health conditions or those who require frequent specialist treatments.

Understanding the differences between these levels of hospital cover is key to choosing the right policy for you. Each level is designed to cater to different healthcare needs, from basic to full coverage of high-end treatments.

Use Health Deal’s comparison tool to navigate these options and find the right hospital cover for you.

Hospital cover offers many advantages to those who have private health insurance beyond what’s available in the public system. Some of the benefits include:

Shorter Waiting Times

One of the biggest benefits of hospital cover is that you can have elective surgery much sooner than the public system. In 2022-23, public hospitals across Australia had extended waiting times for elective surgery due to the backlog caused by COVID-19 disruptions. On average, patients waited 49 days for their surgery in 2022-23, up from 40 days the previous year. For some surgeries, like hip and knee replacements, waiting times were over 365 days.

In contrast, private hospital cover allows for faster scheduling of elective procedures, often within weeks, depending on the doctor and hospital. This is especially important for non-emergency treatments that affect your quality of life, like cataract surgery or joint replacements, so you can have peace of mind and relief from pain or discomfort sooner.

Private health coverage gives you more choices and reduces the stress of long waits so you can take control of your health. For reference, 9.6% of patients in public hospitals waited over a year in 2022-23, which is over 70,000 people.

Choice of Doctor

One of the big benefits of private hospital cover is the ability to choose your doctor or specialist. This means you can pick a healthcare provider based on their expertise, reputation or familiarity with your medical history. This level of choice can make a big difference in the outcome of your treatment, as you’ll feel more comfortable and confident with a doctor you know.

Private Room Options (Where Available)

Private health insurance gives you more comfortable accommodation during hospital stays. In public hospitals, patients are put in shared rooms with other patients, separated only by curtains. With private hospital cover, you may have access to a private room (if available), which can be more private, comfortable and peaceful during your recovery. Private rooms are subject to availability, but having the option can make the hospital experience better, especially for longer stays.

Tax Benefits

Private hospital cover can also help you avoid the Medicare Levy Surcharge (MLS) which is a tax on individuals who earn over a certain income and don’t have private hospital insurance. For singles earning over $97,000 or families over $194,000, the MLS can be 1% to 1.5% of their income. By having eligible private hospital cover, you can avoid this extra tax and potentially get the Australian Government Rebate, which reduces your premium based on your income and age.

• Choosing the right hospital cover is important so you have the right support when you need medical attention and potentially avoid big out-of-pocket costs. To make the best choice you need to consider the following:

  Assess Your Health and Lifestyle

  Firstly, you need to assess your current health and lifestyle. Ask yourself:

  • Do you have any pre-existing conditions that may need hospital treatment in the next 12 months?
  • Are you planning for major life events like pregnancy that may require hospital services?
  • What’s your family health history, and could it impact your future healthcare needs?

  You may opt for basic cover if you’re generally healthy. But if you foresee needing specialist treatments or surgeries, a more comprehensive cover might be worth considering.

  Budget

  Your budget is a big factor when choosing hospital cover. You can pay premiums fortnightly, monthly, quarterly or annually. Keep these in mind:

  • Understand your level of cover: More comprehensive cover with fewer exclusions will generally cost more.
  • Look at excess and co-payment options: These can reduce your premium, but be prepared for higher out-of-pocket costs when you claim.
  • Compare health funds: Use comparison tools like Health Deal’s platform to ensure you’re getting the best value for your money for your specific needs.

  How Much Cover Do You Need

  Private hospital cover in Australia is split into four levels: Basic, Bronze, Silver and Gold. Each level covers different types of treatments:

  • Basic: Covers essential services but often at a limited level. You may have limited benefits or higher out-of-pocket costs for many treatments.
  • Bronze, Silver and Gold: These levels cover increasing levels of hospital services. Gold is the most comprehensive, covering everything from pregnancy and joint replacements to assisted reproductive services and cataracts.

  Please read the policy details to determine what is covered and what is not for each level.

Waiting periods are the time frames that start from the day you take out an Australian private health insurance policy. You can’t claim or access any of the policy’s benefits during this time. If you need medical services during this time, you’ll have to pay the full cost yourself. The length of the waiting periods varies depending on the condition.

Here are the standard waiting periods for some common health insurance benefits:

• New Conditions: 2 months
• Pre-existing Conditions: 12 months
• Rehabilitation, Psychiatric Care and Palliative Care: 2 months
• Pregnancy and Birth-related Services: 12 months
• IVF and Assisted Reproductive Services: 12 months
• Weight Loss Surgery: 12 months

If you’re switching to a new policy and have already served the waiting period with your previous insurer you won’t need to serve it again.

To make an informed decision when choosing hospital cover you need to compare policies from different insurers as they often differ in key areas like hospital networks, gap cover and added benefits. Here are the things to consider:

1. Hospital Network: Each insurer has a network of hospitals. Before choosing a provider, ensure their hospital network includes your preferred hospitals and specialists. A bigger network gives you more flexibility to choose where you get treated, especially for elective surgeries.
2. Gap Cover: Medical services can sometimes exceed the amount Medicare and your insurer will pay, leaving you with a “gap” or out-of-pocket costs. Some insurers have better gap cover arrangements with specific hospitals and doctors and can reduce or eliminate these costs. Make sure you compare the gap cover of each provider, and if they have agreements with the specialists or hospitals, you may use.
3. Clinical Category Coverage: Hospital policies are classified into tiers (Basic, Bronze, Silver and Gold), each covering different clinical categories. Make sure you compare what each provider covers fully and what services (like joint replacements, cataract surgery or heart procedures) are restricted or excluded from certain policies.
4. Additional Out-of-Hospital Benefits: Some health funds offer out-of-hospital services as part of their hospital cover. For example some insurers offer home-based healthcare services like rehabilitation, mental health support or post-surgery recovery. These services can be very beneficial as patients can get treated in the comfort of their own homes.

By considering these factors and using Health Deal’s comparison tool, you can compare different providers and find the right policy for your health and budget.

Medicare, Australia’s public healthcare system provides free or low-cost medical services for in-hospital treatments. For many procedures like joint replacements, you won’t have to pay anything for the surgery if you’re treated as a public patient in a public hospital. Medicare is often regarded as one of the best public healthcare systems in the world and ensures essential health services are available to all Australians.

However, there are limitations when you rely only on Medicare. While it covers in-hospital treatments, it has its downsides, especially for elective surgeries. One of the biggest challenges is the long public waiting lists, which can mean significant delays for non-urgent procedures. For example, depending on the surgery and hospital, you might have to wait several months or even over a year for elective treatments (9.6% of elective surgery was over a year in the public system 22-23)

Plus, when you’re admitted as a public patient under Medicare, you don’t get to choose which surgeon operates on you or which hospital you’re treated in. After surgery, you’ll likely recover in a shared room with other patients, which can be limiting in terms of privacy and comfort compared to private healthcare.

Hospital coverage from private health insurance can help fill these gaps by giving you more control over your healthcare experience. You can choose your doctor and hospital and get treated faster. You may also have the option for a private room (where available), which can enhance your overall comfort and care.

Private health insurance costs can vary greatly depending on your health fund, the level of cover you choose, and the services included in your policy. The most important cost to consider is the premium, which is the ongoing payment to keep your cover. Premiums can be paid fortnightly, monthly, quarterly, or yearly, depending on your financial situation.

While cost is important, value for money is key. You want to choose a policy that covers what you need and not pay for extras you don’t. For example, if you’re over 50, you probably don’t need a policy that includes pregnancy and birth services. Choosing a policy that’s right for your life stage and health needs means you get the best return on your investment.

Other costs to consider are the level of cover (Basic, Bronze, Silver or Gold), services included (elective surgeries or rehabilitation) and excess level (the amount you pay upfront before your insurance kicks in). Also, some health funds offer discounts if you pay your premium annually or via direct debit, so it’s worth asking about these when you sign up.

The Australian Government offers several incentives and rebates to make private health insurance more affordable, especially for individuals and families who would otherwise pay higher premiums. Knowing these can help reduce your costs:

1. Private Health Insurance Rebate (AGR – Australian Government Rebate) The Private Health Insurance Rebate is the most well known incentive to make health insurance more affordable. The rebate is income-tested and calculated based on your age and taxable income. Generally, the rebate decreases as your income increases. Seniors get a higher rebate as they have more healthcare needs, while younger people with higher incomes may get a lower rebate or none at all. The rebate can be applied to your premiums or claimed at tax time as a refundable offset.
2. Medicare Levy Surcharge (MLS) The Medicare Levy Surcharge is a tax penalty imposed on higher income earners who don’t have eligible private hospital cover. It’s 1% to 1.5% of your income, depending on how much you earn. The MLS encourages Australians to take out private hospital insurance as it forces people to either pay for health insurance or a higher tax. Having private hospital cover helps you avoid the surcharge and get access to benefits like faster treatment.
3. Lifetime Health Cover (LHC) The Lifetime Health Cover Loading is a government initiative to encourage people to take out hospital cover earlier in life. If you don’t take out private hospital insurance by July 1st, following your 31st birthday, you’ll get a 2% loading on your premium for every year you delay, up to a maximum of 70%. This loading stays in effect for 10 years once you take out cover. Avoiding this fee is a big reason to consider hospital cover early in life.
4. Young Persons Discount (YPD) The Young Persons Discount is available for individuals 18-29 who take out private hospital cover. It reduces premiums by up to 10%, decreasing by 2% each year until 40. This incentive encourages younger Australians to invest in private health coverage, stay insured long-term, and benefit from lower costs earlier in life.

By using government incentives, you can save a lot on private health insurance. Make sure you assess your needs and qualify for these rebates and benefits. That way, you’ll get the most savings and cover for you and your family.

For personalised advice on how to get the most out of your private health insurance and access these government incentives, contact Health Deal at enquiries@healthdeal.com.au or call 1300 369 399

Changing hospital cover is super easy with Health Deal. Health Deal will do the whole process for you, so you don’t have to do a thing. When you sign up for a hospital cover insurance policy through Health Deal, they will ask for your Medicare card number, your previous health fund member number and payment details. Once you submit your application, Health Deal will:

1. Send all your information securely to your new health fund.
2. Send you a welcome email with your new health fund details.
3. Your new health fund will request a transfer certificate from your old health fund. This is the document that outlines all the waiting periods you have already served.
4. Your old health fund will cancel your ongoing direct debit and refund you any money you have pre-paid them for the fortnight/month/quarter/year on a pro-rata basis (this takes about 10 working days to receive the refund)
5. Your new health fund will post you a card and you’ll receive an onboarding welcome call from someone in their customer service team.
6. All your payments will have been set up during the signup process, so you can sit back, relax, and enjoy your new health fund.

Remember, when you switch health funds, you won’t have to re-serve any waiting periods you’ve already served, and any money you’ve pre-paid will be refunded to you.

As you go through different life stages, your health insurance needs change. Make sure you align your hospital cover with these changes so you get the right cover without paying for services you don’t need. Below is a guide to help you choose the right hospital cover for each life stage:

• Young Adults (Under 30s): Basic or Basic Plus hospital cover is usually sufficient at this stage if you’re healthy and don’t require a lot of medical care. It covers restricted core services like psychiatric care, rehabilitation and palliative care with limited coverage for other procedures. As an added bonus, young adults can qualify for the Young Persons Discount (YPD), which can reduce premiums by up to 10% if you take out cover before age 30. This makes hospital cover more affordable and encourages early uptake of private health insurance.
• Starting a Family (20s-40s): If you’re planning to start or grow your family, upgrade to Gold hospital cover. Gold-level policies cover all essential services, including pregnancy, birth-related services, and assisted reproductive technologies like IVF. As birth and related services are only covered under top-tier policies, it’s important to plan ahead and serve the waiting periods (usually 12 months) before you need these services.
• Middle-Aged Adults (40s-50s): As you get into your 40s, you may need more comprehensive cover to protect against age-related conditions like cardiac care, joint reconstructions and other complex procedures. Bronze or Silver hospital cover is a good balance between affordability and a broad range of services. If you haven’t already, make sure you take out hospital cover by age 31 to avoid the Lifetime Health Cover (LHC) loading, which adds a 2% annual surcharge for every year you delay taking out hospital cover after your 30th birthday.
• Finished Having Kids (40s-50s): Once you’ve finished having kids, review your hospital cover to make sure you’re not paying for services you no longer need, like pregnancy and birth-related services. Silver Plus hospital cover could be a good option as it covers all common health conditions but excludes obstetrics. This way you’re not overpaying for cover you won’t use while still having access to necessary medical treatments.
• Empty Nesters (50s-60s): As your kids become independent and move out, your health priorities may shift towards managing chronic conditions or preventive care. Silver Plus or Gold cover is ideal for this stage as it covers all common age-related procedures like cataract surgeries, hip and knee replacements and weight loss surgery. Depending on your health history and lifestyle, you may also want to consider policies that cover podiatry, cardiac services, and joint reconstructions.
• Seniors (60+): You’ll need more medical attention in your senior years. Opt for some Silver Plus cover to protect you from complex procedures like joint replacements, dialysis, cataract surgeries and chronic illness management. At this stage, eliminate any unnecessary services like assisted reproductive services or pregnancy cover to manage costs while prioritising essential healthcare services.

Check your policy carefully, as ‘Plus’ levels of hospital cover (like Silver Plus) don’t have to be the same across providers. For example, not all Silver Plus hospital policies cover joint replacements or cataract surgeries, so check the inclusions before you decide.

When having an elective procedure in Australia, here’s how you can manage the claims process:

1. Before the Procedure: Confirm your coverage with your health fund, including your hospital’s and doctor’s agreements with your insurer. Check if you’ll have any out-of-pocket costs, called “gaps.”
2. At the Hospital: Depending on your policy, you may need to pay an excess or co-payment upfront.
3. Post-Procedure Bills: If your doctor sends you a bill, lodge the claim through your health fund’s website, app or phone. Keep your receipts, invoices and treatment details handy.
4. Direct Claims by the Doctor: The hospital and doctor often submit the claim to your health fund. In this case, the process is managed between the health fund and the hospital, and you’ll only need to pay the gap fees, if any.
5. Post-Claim: Even if the claim is processed, check for any gap payments. Keep all bills and claims for future reference.

Always ensure your health fund knows your doctor and hospital and checks the gap fees so you don’t get surprises.

What is Gap Cover?

Gap cover reduces out of pocket costs when a doctor or hospital charges more than the Medicare Benefits Schedule (MBS) fee. There are two types:

• No Gap: The insurer covers the full difference, so you pay nothing.
• Known Gap: If the doctor charges more than the insurer’s no-gap limit but within their known gap limit, you pay the remaining amount.

I’ve Been Told I Have a Gap From My Doctor; What Can I Do?

You can ask your doctor if they participate in another health fund’s gap cover. Switching funds can reduce or eliminate your gap fees. You won’t have to re-serve waiting periods even for pre-existing conditions (Provided you’ve served the initial waiting period).

Can I Change My Doctor If I Have a Gap?

You can change doctors before surgery if you’re not happy with the gap fee. Contact your health fund or use their online tools to find doctors who participate in their gap cover arrangement.

What’s Covered in Hospital-Only Cover?

Hospital only cover includes treatments that require in-patient care, meaning you are formally admitted to the hospital. This usually includes day surgeries, overnight stays and some procedures that require a hospital setting. However, it doesn’t include outpatient services such as consultations or follow-up visits where you’re not admitted. Coverage varies depending on your policy tier (Basic, Bronze, Silver or Gold). Check your health fund’s clinical category coverage to see what’s fully covered.

Hospital coverage can be very beneficial, and the best way to choose your hospital-only insurance provider is by using the Health Deal Insurance Comparison tool. Here, you can compare health insurance plans, costs, and providers. For expert advice on hospital coverage insurance, you can contact Health Deal at enquiries@healthdeal.com.au. You can speak to our experts at 1300 369 399 or fill out the online form here. Get in touch now to speak with an insurance expert for tailored advice and support in making viable health insurance decisions.

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