What does private health insurance cover?
Discover the treatments private health insurance can cover in hospital and extras health services. Learn about your insurance benefits with GMHBA.
What does private health insurance cover?
Australians are lucky to have access to a range of health services that can be accessed through either the public or private health system.
These two systems work together to support the community, giving Australians a choice in their health care.
In Australia, it doesn’t matter who you are, your lifestyle or health status – health insurance is community rated, which means everyone in each state, on the same cover type, pays the same base premium for their level of cover.
For over 90 years, GMHBA has been operating as a not-for-profit private health insurer, helping members cover their hospital and medical costs, as well as paying benefits towards extras services.
Understanding the two types of private health insurance
Private health insurance covers two separate types of care – hospital cover as a private patient and extras cover (sometimes called ancillary or general treatment).
Private health insurance covers two separate types of care – hospital cover as a private patient and extras cover (sometimes called ancillary or general treatment).
Hospital cover is used when you’re admitted as a private patient in either a public or private hospital. The private health insurance kicks in to cover your hospital costs - which can include accommodation and theatre costs, and benefits towards your inpatient medical costs up to MBS fees, such as doctor or surgeon’s fees, imaging, anaesthetic or pathology.
GMHBA have a range of hospital cover product tiers – Gold, Silver, Bronze and Basic hospital cover. These covers are classified by the number of clinical categories they include, ranging from a Gold tier with comprehensive cover, through to Basic cover which offers only restricted benefits as a private patient in public hospital.
Extras cover pays benefits towards the cost of allied health services such as dental and orthodontics, prescription glasses or contacts, physiotherapy and other ancillaries depending on your level of cover.
Unlike hospital cover which many people take out ‘just in case’, extras cover is best selected for your current life stage and needs.
There’s a range of extras cover to suit all lifestyles.
Do I need both?
GMHBA has a range of covers, so you can find one that best suits your needs. It’s your cover, for the life you choose, and the one you don’t.
Whether you’re looking for a mid-tier hospital cover, or a comprehensive combined extras and hospital cover, GMHBA has options to suit a variety of different needs.
What private health insurance doesn't cover
By law, private health cover can’t pay for doctor and specialist services when you’re not an inpatient in hospital – even if it relates to you going to hospital. Services such as visits to your GP or specialist rooms, diagnostic tests or imaging may be partially covered by Medicare.
When receiving diagnostic tests, no benefits are paid by health insurance unless you’ve been admitted as a private in-patient.
This includes x-rays or other scans and any blood tests or other pathology tests.
Often Medicare will cover a portion of these services. Read more about what Medicare covers.
You’ll only be covered for services listed on your cover that you have served waiting periods for.
Check the fact sheet for your cover and contact your health insurer before an elective visit to hospital as a private patient.
Some private hospitals have an emergency department and many of these hospitals charge a fee to be seen there.
Private health insurance is limited legally in paying benefits towards most of these fees.
Your hospital cover helps cover you for medically necessary treatments as an inpatient.
Private health insurance can’t cover non-medically necessary procedures like cosmetic surgery.
While GMHBA may cover a hospital admission, there are services like TV hire, WIFI, newspapers, parking and guest meals that GMHBA doesn’t cover. A hospital should provide information on additional costs to you before offering you these services.
Private health insurance and ambulance transportation
Understanding ambulance services and ambulance subscription cover can be tricky depending on where you live. While GMHBA covers Emergency Ambulance Transport under eligible extras policies and all hospital policies, there are different recommendations for comprehensive cover depending on your situation and state.
In Victoria, Western Australia, South Australia or Northern Territory you’re required to self-insure through the purchase of a subscription. Some extras covers offer a benefit towards these subscriptions. If you live in these states and want full cover for all ambulance trips, we recommend taking out your own subscription directly with the provider in addition to any access to cover for emergency trips.
If you’re a NSW or ACT resident and have any GMHBA hospital cover, you are automatically covered for emergency transportation within NSW or ACT. It is a Levy Based Scheme (health insurers pay a levy to the State government on behalf of eligible members) which is why it operates under your hospital cover. People in Queensland or Tasmania are covered for ambulance services by their state government.
Some concession card holders are eligible for free, clinically necessary ambulance coverage throughout Australia, depending on where you live, your subscription and private health insurance cover.
Learn more about private health insurance and ambulance cover.
Medicare and private health insurance
Medicare offers Australian citizens and permanent residents a comprehensive health care system alongside private health insurance. These two systems work together to support one another, giving you greater choice in your health care.
Medicare, Australia’s public health care system, is funded by the Medicare Levy, an income tax of 2% that most Australians pay.
In addition to this Levy, the Medicare Levy Surcharge (MLS) is an additional surcharge paid by higher income earners who don’t have private health insurance hospital cover.
Learn more about MLS and how to avoid paying it.
Why choose private health insurance?
We’ve got you covered with all the private health insurance basics to get started.
Learn more about private health insurance.
Find out how private health insurance works in Australia and if it’s right for you, now or in the future.
Learn more about the value of private health insurance.
No, it isn’t tax deductible but there are two tax-related government incentives – Medicare Levy Surcharge and the Australian Government Rebate on private health insurance.
Learn more about private health insurance and tax.
Learn more about Medicare and the flexibility that private health insurance can offer.
Learn more about public vs private healthcare in Australia.
Advantages of private health insurance
As well as the financial considerations of health insurance, private health insurance provides you the peace of mind that it’s there if you need it. It also offers a level of flexibility in your health care.
Key considerations for picking the right cover for you
Family cover is designed to protect your whole family at all stages, with peace of mind and flexibility to meet the changing needs of a growing family.
Looking for cover just for one? Take control of your private health insurance with cover to suit you.
Whether you’re getting your teeth cleaned or looking to start a family, GMHBA has couples cover to suit your budget and lifestyle.
Single parent cover can be a great way to get health insurance for you and your kids. It’s flexible, lets you choose what’s important to you, and offers the same coverage as a family insurance policy.
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FAQs
There are potential financial benefits to taking out hospital cover, such as minimising tax through avoiding paying the Medicare Levy Surcharge (if you’re a higher income earner) and avoiding paying the Lifetime Health Cover Loading after you turn 31.
You can also be treated as a private patient in a public or private hospital with hospital cover, having greater choice of who treats you compared to public patients in a public hospital and peace of mind knowing you have options.
For extras cover, depending on your level of cover, you’ll receive benefits for common allied health services that Medicare doesn’t cover, like dental, physiotherapy and optical.
In Australia, Medicare doesn’t cover private patient hospital costs, ambulance transportation or other non-hospital services like physiotherapy, dental, glasses and contact lenses.
With hospital cover, you can only claim for in-patient medical services included on your cover that are deemed clinically necessary.
For extras cover, however, you can claim allied health services not covered under Medicare such as optical, dental and remedial massage.
No, Medicare covers bulk-billed consultations and pays a set amount towards other visits.
When you take out private health insurance, you might need to serve waiting periods before you can claim benefits for medical costs.
Learn more about waiting periods.