Understanding What Your Health Insurance Covers

By  //  October 5, 2021

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In Australia, Medicare, the public health system, covers Australian residents for health care. Unfortunately, Medicare doesn’t cover everything, and you can choose to purchase private health insurance that offers you a wider range of health care options.

If you’re interested in more comprehensive care for your family, consider hospital or general treatment insurance.

The 3 Types of Private Health Insurance Coverage

In Australia, private health insurance can cover one or both sections of health:

1. Hospital Treatment Coverage

Under Medicare, you are treated as a public patient in public hospitals, at no charge, by doctors at the hospital. You can choose whether you want to be considered a public patient, even when you’re privately insured.

Public patients cannot choose their doctor and must be placed on a public hospital waiting list, where they’ll wait their turn based on number and severity.

On Medicare, public citizens will not receive the following unless they have private insurance:

■ Compensated private hospital costs, like accommodations and theater fees

■ Hospital and medical insurance coverage overseas

■ Paid-off cosmetic or non-necessary clinical surgeries

■ Ambulance services (calling, being picked up, medicine administered in ambulance)

■ Facility fees or emergency department administration fees

2. Extras and Ambulance Coverage

Under Medicare, the majority of your medical costs are paid for by your tax dollars or will be compensated at a later date. When you visit most doctors outside of the hospital, Medicare will reimburse your costs unless you go to a specialist.

However, If your specialist doctor bills Medicare directly through bulk billing, you won’t have to pay for that service.

Medicare will also provide comprehensive benefits for the following procedures: 

■ Examination and tests administered by the doctor at the time of your appointment

■ Scheduled eye tests performed by an optometrist

■ Specialists and doctor consultation fees

■ Most surgical or other therapeutic procedures performed outside of the hospital

■ Surgical procedures performed in the hospital that are considered life-threatening

■ Certain surgical procedures performed by public health dentists

■ Specific items under the EPC program, Cleft lip, and Palate Scheme

■ Things that deal with health management, like the Chronic Disease Management Plan

■ While ambulance fees can be covered in hospital treatment coverage, they may also be added to an “extra and ambulance” coverage package.

Under extra insurance coverage, you’ll receive:

■ Anything that another comprehensive insurer would cover 

■ Ambulance services (if not covered by Hospital Treatment Coverage)

■ Routine dental examinations and treatments unless they’re life-threatening 

■ Most speech, eye, or occupational therapy, physiotherapy, or chiropractic services

■ The majority of podiatry or psychological services unless you’re referred

■ Acupuncture appointments that aren’t part of a doctor’s consultation

■ Hearing aids and appliances that aid the senses

■ Contact lenses, glasses, and their subsequent replacements

■ Home nursing care, nursing homes, and most other elder care

The majority of the above options are covered by “add-on” coverage which is typically not comprehensive. You’ll need to add on to your insurance plan if you require subsequent care.

3. Pharmaceutical Coverage

The majority of Australians pay only a portion of their medications under the Pharmaceutical Benefits Scheme. Most medications will cost Australians around $5, but they may pay more for controlled drugs. If they have a Government-issued concession card, they’ll pay less for drugs.

Cost of Private Health Insurance Coverage

The cost of your premiums depends on the policy you take out as well as the Government rebates that are issued to you. Some add-ons will cost more than others.

For example, psychiatric care is usually expensive because you’re required to make more than one appointment each month. If you want zero excess or co-payments, you’ll pay much more.

Under most Lifetime Health Coverage costs, you’ll pay more on your premiums after 30, but if you’re eligible for the Private Health Insurance rebate, you’ll have access to lower premiums.