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Last Updated on 24 February 2019

Know Your Health Insurance Rights

Australian healthcare is composed of a public system called Medicare facilitated by the federal government, and a private system provided by numerous insurance companies and private health funds. These two spheres provide enough options for anyone wishing to ensure and manage his or her healthcare and its associated costs.

Navigating through the Australian health care systems and making the right choices often involves carrying out a medical insurance comparison between different policies. This can be more effectively accomplished with enough understanding of how both systems work, what services and features are available, and the necessary requirements.

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Who can get health insurance?

Medicare is available for any Australian citizen or anyone with a permanent visa. Visitors from countries which have Reciprocal Health Care Agreements with Australia can also have access to the public health system, but only in a limited context. Any citizen is also entitled to purchase private health insurance and can voluntarily purchase policies from accredited insurers. There are several types of membership for private health funds, depending on the number of people covered by the policy. A single membership for example covers only one adult, while an extended family membership type covers a minimum of three adults and any number of dependants.

Private health coverage is something you buy on your own. Medicare on the other hand is publicly funded. That means everyone pays a Medicare Levy, which is 1.5% of one’s taxable income. A Medicare Levy Surcharge which is an additional 1% may apply to those who do not have private hospital cover and whose yearly income exceeds a certain amount. Health insurance is both a right and a responsibility.

Hospital insurance

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What can you expect of the hospital?

Both public and private health insurances provide hospital cover. The Medicare Benefits Schedule (MBS) outlines the coverage for the former. While coverage for the latter may be based on the MBS, there may be differences in the level of cover offered by particular private health insurance policies. This is why you need to compare health cover as well as premiums when it comes to private health insurance.

Another difference in the private system is that you can choose to be treated as a private patient even in a public hospital. Unlike in Medicare, you are also free to choose the staff that attends you, though you should check whether your private health fund will cover care from those professionals. Doctor and other medical professional fees, procedures, medication, accommodation, etc. – all these aspects of in-hospital treatment costs may be covered, or may be left as a gap in your coverage. It all depends on the level of cover offered by your private health insurance policy.

You have every right (and it is recommended) to inquire about such matters before proceeding with any form of private health insurance or medical treatment. This would naturally give you a better assessment of your health insurance status.

What can you expect of your insurer?

Health funds cannot refuse any eligible individual private health insurance on the basis of age, health status or claims history. This is set in the Private Health Insurance Act of 2007 and basically establishes the community rating system in Australia’s healthcare. The result is that comparably similar policies are available for more or less the same price.

Premiums are more likely to be affected by factors such as level and length of coverage or number of beneficiaries. Thus despite this equalizing factor, you may still want to compare private health insurance products from various providers to get the appropriate policy for your needs and budget.

You have the right to inquire about the terms and conditions of a policy from a prospective health fund. Be sure to ask about features such as excess and co-payments, exclusions and restrictions, as these may directly affect the premium. You also have the right to detailed information about waiting periods. Benefits do not become immediately available as soon as the policy goes into effect. This is particularly significant for pre-existing conditions but 12 months is the maximum waiting period in all hospital cover policies.

You can always upgrade your cover with the same insurer, or transfer to a different health fund. In the second case, if you’re getting a comparably similar or lower level of cover, you don’t have to be burdened with additional waiting periods. Upgrades on the other hand, whether with the same or different provider, usually trigger benefit limitation periods.


Disclaimer: The above information is correct and current at the time of publication

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