Hospital Cover

In Australia there are two types of private health insurance: Hospital cover and Extras cover (also known as ancillary cover). You can mix n’ match all of our policy options until you find a combination that suits your needs.

Hospital cover is private health insurance that includes cover if you need overnight or same-day treatment in hospital as a private patient. It helps cover the cost of treatment in hospital as well as other costs such as accommodation, and theatre fees which are itemised in the Medicare Benefit Schedule (MBS).

Your level of cover determines which specific hospital treatments and services are included in your hospital cover. These services reflect the Clinical Categories which sit within the Government’s Basic, Bronze, Silver & Gold tier structure for hospital products.

When you have Hospital cover and treatment is required, the Australian Government will pay 75% of the MBS fee that your doctor charges and your hospital insurance policy will cover the remaining 25%. In cases where the doctor charges more than the MBS fee, there may be a “gap”. That’s why most health insurers like us have a “gap cover” arrangement in place. Our AccessGap Cover allows you to find a doctor who may agree to opt-in to an arrangement with us prior to undergoing your treatment – this can help to minimise any potential out-of-pocket expenses. Find out more about AccessGap cover here.

When you have Hospital cover, you can choose to be treated as a patient in a private hospital, or as a private patient in a public hospital. As a private patient in a public hospital, you’ll be able to choose your own doctor, rather than being allocated a doctor that the hospital chooses. Unless you’re getting your choice of doctor or a private room, we suggest that you consider not using your private health cover in a public hospital.

Taking out Hospital-only insurance means you hold Hospital cover on its own without Extras cover. People often decide to choose hospital-only cover to avoid MLS and LHC loading, and for peace of mind in case they ever need to stay in hospital.

We have contracts in place with hundreds of private hospitals in Australia. Under these contracts, a schedule of fees for treatments and services is already agreed upon. In most cases, the hospital will send the invoices directly to HIF and we’ll pay the account on your behalf. Of course, your level of cover and what’s included will depend on the Hospital policy you hold. Find out more about which hospitals you can go to.

Hospital cover includes cover if you need overnight or same-day treatment in hospital as a private patient, while Extras cover is health insurance that includes everyday treatments outside of hospital. Your specific health insurance policy and level of cover determines which treatments are included, but Extras cover typically includes services such as dental, optical, physiotherapy and speech therapy.

Does HIF have combined Hospital and Extras cover?

Hospital and Extras cover can be bundled together into what’s known as “combined cover”. However, we want you to be able to mix and match any of our policy covers to suit your needs and budget.

Lifetime Health Cover (LHC) age loading was designed by the Government to encourage Australians to take out private hospital insurance at a younger age and encourage them to maintain it. Essentially, if you don't have private hospital insurance by the 30th June following your 31st birthday you’ll have to pay an additional 2% loading on your premiums for every year you didn’t have Hospital cover, up to a maximum of 70%! LHC will later be removed from your hospital insurance premium once you’ve paid it for 10 consecutive years. To check your LHC eligibility, use our handy online calculator.

Australian residents who earn over $93,000 per year as a single or $186,000 as a couple/family (plus $1500 for each dependent child after the first one) and don’t have private hospital cover will pay an additional tax called the Medicare Levy Surcharge (MLS). Depending on your income, the MLS can be as high as an additional 1.5% of your annual income.

The Australian government introduced the MLS to give people an incentive to take out private hospital insurance. If you hold basic level Hospital cover for the entire tax year, you can avoid paying the MLS completely. For some people this can be a tax saving of thousands of dollars each year. To estimate your tax savings, use our interactive online calculator.

No, Medicare only pays for treatment in public hospitals. Public patients in public hospitals don’t have any choice over which doctor they see or the date of their treatment or surgery. The hospital appoints the doctor, and treatment dates will depend on availability and waiting lists. In some areas the waiting list for non-emergency surgery can be over 12 months. 

If your doctor charges more than the Medicare Benefits Schedule (MBS) and does not opt-in to participate in Access Gap, you may incur significantly more out-of-pocket expenses. That’s why we always encourage our Members to ask their doctors or specialists if they’re treating them as an Access Gap patient. We have arrangements in place with more than 30,000 doctors. Find out more about gap cover here.

Whether we’re answering your call, or helping you switch from another health fund, we don’t like to keep people waiting. But unfortunately waiting periods (the time you have to wait before you can claim for treatment) are a necessity. We wouldn't be able to offer our affordable premiums and generous benefits without them.

Waiting periods exist so we can protect our members against people who simply join us, claim large amounts and then leave. But we always try to keep waiting periods to an absolute minimum. That’s why, if you join us from another health fund, we’ll take your previous membership into account, so you won’t have to re-serve waiting periods on an equivalent level or lower level of health cover.

For HIF Hospital cover, the waiting periods are as follows:

• 1 day: Emergency ambulance
• 30 days: Non-emergency ambulance
• 2 months: General hospitalisation
• 2 months: Psychiatric care, rehabilitation & palliative care (regardless of whether it's pre-existing or not)
• 12 months: All pregnancy and birth related services
• 12 months: Pre-existing conditions or ailments

Waiting period exemption for Psychiatric Care: New members transferring from another health fund who previously had limited psychiatric cover, can now upgrade their policy without serving a two-month waiting period for the higher or additional benefits. The waiting period exemption for psychiatric care benefits can only be accessed once in a lifetime and is only available after a person has served their initial two month waiting period for any psychiatric treatment.

If you’re taking out maternity cover for the first time, the waiting period for Pregnancy and Birth is 12 months. That means you’ll need to have held maternity cover for 12 months prior to your due date.

With HIF pregnancy and birth cover you can:

• Choose your hospital, obstetrician and other in-hospital specialists
• Choose a natural birth or an elective caesarean (not always an option in the public system)
• Enjoy private-room accommodation during your stay in hospital (please refer to our Gold Top factsheet for accommodation benefits on childbirth).
• Claim for all your labour ward fees
• Your partner may be able to stay with you in hospital as a boarder at no extra cost.

Find out more.

The Pre-Existing Condition waiting period applies to new members and existing members who upgrade their policy to access higher-level benefits. The test applied under the law relies on the presence of signs or symptoms of the illness, ailment or condition, not on a diagnosis (i.e. it’s not necessary for the member or their doctor to know what their condition is or for it to be diagnosed).

In forming an opinion about whether or not an illness is a pre-existing condition, an HIF-appointed medical practitioner will
take into account information provided by the member’s treating doctor.

A pre-existing condition is defined as: ‘Any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of six months ending on the day on which the person became insured under the policy.’

If you choose Hospital Cover with an excess, you’ll only need to pay the excess per‑person per calendar year (to a maximum of twice per couple or family policy) if admitted to hospital. For some covers, the excess does not apply for same-day admissions and/or dependent children under the age of 18. Please refer to the individual product factsheets for more detail on the excesses that apply.

The Australian Government offers a Private Health Insurance Rebate to help people pay for their private health insurance. It’s intended to reduce the strain on Medicare (our public health care system) whilst making premiums more affordable.

Eligibility for the rebate is determined on a tiered system that is based on your age and taxable income. Claiming the rebate can be done in your annual tax return or we can make it easy for you by deducting it straight from your health insurance premium.

Learn more about the rebate here.

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