Australian Health Insurance: The top 10 things you need to know

The Australian Health Insurance industry works a little differently to other countries, so we’ve summarised the top 10 things you need to know.

1. You have to register with Medicare

Medicare is the Australian Government’s health scheme.

Medicare gives you access to:

  • free or subsidised treatment by health professionals such as doctors and  specialists,
  • free treatment and accommodation as a public (Medicare) patient in a public hospital
  • 75 per cent of the Medicare Schedule fee for services and procedures if you are a private patient in a public or private hospital.

However, it is still important to have private health insurance as there are many things that Medicare does not provide care for:

  • Medicare doesn’t cover you as a patient in a private hospital;
  • Medicare doesn’t give you a choice of doctor in hospital;
  • Medicare doesn’t cover for all extras like dental and physiotherapy.

So, private health insurance gives you real peace of mind.

To register with Medicare, go to a Medicare office within 7 to 10 days of your arrival in Australia and bring your passport and travel documents.

2. You’ll need a bank account

Your private health insurance premiums come out of your bank account and claim payments go into your account. So you need an account. But you will probably have one anyway.

3. Your policies include ambulance cover

One of the things Medicare does not cover is ambulance, so if an ambulance transports you to hospital it can cost you thousands of dollars. All policies also cover you for all medically necessary ambulance trips to hospital.

4. What are ‘Waiting periods’?

A waiting period is the period of time after you first take our private health insurance when certain claims won’t be paid. The Government sets out maximum waiting periods that health funds can impose for some hospital treatments. The most important ones are twelve months for pre-existing conditions (we’ll talk about pre-existing conditions a little later on), twelve months for pregnancy related treatments and two months for psychiatric care, rehabilitation and palliative care. There are also waiting periods for ancillary services like dental and physiotherapy. These waiting periods vary from two to twelve months.

5. The Gap

For every medical service you might receive in hospital sets a Medicare fee. Medicare pays you 75% of this fee. All private health insurers, including, are only able, by law, to pay 25% of the Medicare fee. However medical practitioners are able to charge what they like. If your bill is more than the MBS fee you’ll have to pay the difference or “The Gap”.

Our Access Gap Cover scheme allows you to reduce or eliminate the gap. On a case by case basis medical practitioners can decide if they will participate in our scheme. Almost 9 out of 10 medical services under the Access Gap Cover scheme have no gaps.

The best thing to do is ask your doctor what their charges will be to ensure you’re not encountering any unexpected expenses.

There might also be a gap when you have a hospital stay. The good news is most health funds have arrangements with hospitals that result in little or no out of pocket expense. has contracts with practically all Australian private hospitals. The best thing to do is check with your health fund if they have an agreement with the hospital you have chosen.

6. Check restrictions and exclusions

Not all policies cover every possible treatment – some have restrictions and some treatments are excluded from cover. Restricted items have a limited amount of cover, while policies with exclusions provide no cover for those items. However, this isn’t a bad thing! The idea is to keep the cost down for you so you’re not paying for cover you don’t need.

7. Are you pre-existing conditions covered?

A pre-existing condition is any ailment, illness or condition that you had signs or symptoms of in the 6 months before you took out a hospital policy or upgraded to a higher policy. has appointed an independent medical practitioner who will determine whether an illness is pre-existing. Even if it is pre-existing you will be covered for it after serving the 12 month waiting period.

8. Understand the Pharmaceutical Benefits Scheme

The Australian Government Pharmaceutical Scheme (PBS) schedule lists all of the medicines available to be dispensed to patients at a Government subsidised price. The Scheme is available to all Australian residents who hold a current Medicare card whether or not you have private health insurance.

Private health insurance covers many of the pharmaceuticals that don’t come under the PBS, allowing you to pay less for certain prescriptions than those without private health cover.

9. Does your policy cover pharmacy/medication?

Certain policies will not include cover for pharmacy and medication, so once again it’s best to look closely at each policy’s features to ensure you have the most comprehensive cover.

10. If in doubt, check out our online help via our website.   

For any questions that weren’t answered here, check out the website to access our knowledge centre