How does health insurance work in Australia?
How health insurance works
Medicare is Australia’s universal health care system that delivers affordable, accessible and high-quality health care for most Australians. You can also choose to take out private health insurance to give you more health care options and to cover items which are not covered by Medicare.
There are two types of health insurance: hospital and extras (ancillary or general treatment) cover. You can take out each of these covers separately or combine them to suit your health care needs.
Hospital
To help you decide which hospital insurance policy is right for you, all hospital policies are classified into tiers - Gold, Silver, Bronze or Basic. Each tier must meet a minimum requirement for included hospital treatments (known as clinical categories), with Gold covering all categories and Basic, covering just a few. Some policies meet the minimum requirements of a tier and provide additional coverage – these are called ‘plus’ policies – eg. Bronze Plus or Silver Plus.
Extras
Extras cover helps cover the cost of health services not covered by Medicare, including dental, optical and therapies such as physio and chiropractic. Most extras services are only covered to a limited extent. Various limits may apply, such as a limit per service, per year, or lifetime limits. If you change insurers, services you have already used with your old fund may contribute to your new fund limits. If you are new to health insurance, waits may apply before you can start claiming for services.
Protecting and informing you
Community rating
Private health insurance is community rated, meaning everyone pays the same price for the same policy (except for Lifetime Health Cover and age-based discounts) and is guaranteed the right to renew their policy. Health insurance doesn’t discriminate against members based on health status, age or claims history.
Code of conduct
Our fund is accredited under the Private Health Insurance Code of Conduct. This industry code sets out a standard of service to promote communication and understanding between private health insurers and their members. You can download a copy here.
Compare policies
To allow for simpler comparison of health insurance products all Australian health insurers must provide details of each of their products to the Private Health Insurance Ombudsman. The ombudsman operates independently of private health funds, private and public hospitals and the government. For general information about private health insurance and to compare policies across different health insurers, see privatehealth.gov.au.
The ombudsman also investigates complaints from health fund members that haven’t been resolved directly with the fund. To make a complaint, contact www.ombudsman.gov.au.
