Using private health cover in a public hospital
If you’ve been admitted to a public hospital, you might be wondering: should I use Medicare or my private health insurance?
The good news is that you can use your private health insurance in a public hospital, but whether you should depends on factors like the care you need, your level of private health cover and potential out-of-pocket costs.
Here's what you need to know about using private health insurance in a public hospital.
What's the difference between a public and private hospital?
In Australia, you can receive hospital treatment in either a public or private hospital. Public hospitals are largely run by state and territory governments and receive funding from both state and federal governments, while private hospitals are owned and operated by private organisations.
If you're eligible for Medicare, treatment as a public patient in a public hospital is generally provided at no cost. You won't usually be able to choose your doctor and for planned procedures, you may need to join a waiting list.
Private hospitals can offer more choice, including the ability to choose your surgeon or specialist, depending on your cover and the hospital's arrangements. You may also have access to amenities such as private rooms, where available. However, even with private health insurance, out-of-pocket costs can still apply.
Related: Preparing for hospital: Public vs private
Do you have to use your private health insurance in a public hospital?
One of the biggest misconceptions about being admitted to a public hospital is that you have to use your private health insurance.
The truth is, if you're eligible for Medicare, the choice is generally yours. You can choose to be treated as a public patient under Medicare or use your private health insurance and be treated as a private patient. Hospital staff may ask which option you'd prefer, so it's worth understanding the differences before you need hospital treatment.
What does it mean to be a private patient in a public hospital?
Australian residents who choose to be treated as a private patient in a public hospital may have some hospital costs covered by Medicare and, depending on your cover, your health insurance will pay some or all the remaining fees for accommodation, theatre, doctors and specialists, although you may still have out-of-pocket expenses to pay.
International members will always be treated as private patients, with hospital fees covered by your OSHC or OVHC, although some out-of-pocket costs may still apply. OSHC fund rules and OVHC fund rules can help better understand hospital benefits.
Some public hospitals may offer additional amenities to private patients if you use your private health insurance for treatment. This could include newspapers or TV access, being accommodated in a single room if one is available, or choosing your specialist where this can be arranged. Availability will vary depending on the hospital and your circumstances.
Could I still have out-of-pocket costs?
Even if you choose to use your private health insurance in a public hospital, you may still have out-of-pocket costs.
The amount you pay will depend on your treatment, your doctor and your level of cover. In some cases, Medicare and your health insurer may cover some of the costs of your care, but you could still be charged a gap fee or other costs that aren't fully covered.
That's why it's important to understand any costs before treatment whenever possible. This is known as informed financial consent. It means asking about any expected out-of-pocket costs before you agree to treatment, so you can make an informed decision about your care.
When might it make sense to use your private health insurance?
You may want to consider using your private health insurance if:
You'd like more choice over your treating doctor. Services Australia notes that most private health insurance policies allow you to choose your own surgeon or specialist, although this will depend on your doctor's arrangements with the hospital.
You'd prefer access to additional amenities. Healthdirect notes that private patients in public hospitals may have a single room if one is available. Availability will depend on the hospital and your circumstances.
Your cover helps reduce some hospital costs. Medicare and private health insurance can work together to help cover some hospital costs when you're treated as a private patient in a public hospital.
You've checked the costs and are comfortable with them. Even with private health insurance, you may still have out-of-pocket expenses, such as specialist gap fees or other costs not fully covered by Medicare or your insurer. Before deciding, it's a good idea to understand what you'll be expected to pay.
You may decide that being treated as a public patient is the better option if the public hospital can provide the care you need and you'd prefer to minimise your out-of-pocket costs.
If you’re planning to use your private health insurance, it’s a good idea to know what to expect when you’re admitted. Our guide to what happens during your hospital stay can help you feel more prepared and confident.
Are there any questions I should ask?
When you’re considering whether or not to use your private health insurance in the public system, there are a few questions to ask the hospital administration:
Will I have any out-of-pocket-costs?
Do I get to choose which doctor treats me?
Can you guarantee that I will receive a private room?
What are the benefits of using my private health insurance?
Once you've got the answers you need, you'll be in a better position to decide what's right for you. Still have questions? Read some of the most commonly asked health insurance questions.
Are you heading to hospital?
If you're an nib member, our Going to Hospital tool can help you feel more prepared. You can check whether your procedure is covered, learn more about potential out-of-pocket costs and find useful questions to ask your doctor or specialist.
To review your current policy, chat with someone about your upcoming hospital visit or get tailored guidance, call us on 13 16 42.
Thinking about switching or joining nib? Explore our private health cover options and see how we can help you feel more in control of your hospital experience.
The information in this article is general in nature and doesn't take your personal circumstances into account. Before making decisions about your health cover or treatment, consider seeking advice that's appropriate for your situation.
Please note: The information throughout this article serves as broad information and should not replace any advice you have been given by your medical practitioner.