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 your level of cover, the potential costs and the care you need.

We’re here to clear things up and give you the facts you need to make an informed choice. 

Will you get asked if you want to use your private health insurance? 

If you’ve been admitted into a public hospital, whether for an accident or an emergency, one of the first questions the administration staff might ask is whether you want to use your private health insurance. 

Public hospitals operate on a budget that’s set by the State Government, and some governments even have a quota for how many insured patients they treat. Admitting private patients could help give public hospitals the opportunity to improve their cash flow and funding.  

For example, when Alex went to a public hospital for an emergency, the staff offered the option to use their private health insurance. Alex chose to use it and be treated by a trusted specialist they knew, but it did add some out-of-pocket costs. Alex was happy to pay the specialist gap fee, as they felt it was worthwhile for a faster recovery and the reassurance of being treated by a doctor they trusted. 

It’s a big decision to make during a potentially painful and stressful time, which is why it’s so important that you have all the information beforehand. 

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 when it comes to being admitted is that you MUST use your private health insurance.  

The truth is, it’s completely up to you whether you use your insurance or whether you opt for Medicare – to be treated as a public patient – in the public system. 

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 will 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 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. 

Some public hospitals might offer you a few ‘bonuses’ if you use your private health insurance for treatment. This could include newspapers or TV access, or the option to choose your doctor – but this is all dependent on your condition, the size of the hospital and whether the doctor has practising rights at the hospital. 

While using private health insurance in a public hospital can offer you extra comforts, like a private room, it’s important to remember that some of these upgrades may come with additional out-of-pocket costs. For instance, while your insurance might cover most of the hospital fees, you may need to pay an extra $50 per day for a private room. Before making a decision, check with your insurer and hospital to fully understand any potential costs. 

When it makes sense to use your private cover 

You can claim the benefits of private health insurance in a public hospital - and in some cases, it’s worth considering. Before deciding, you should weigh these factors: 

• Choice of doctor/specialist: If the public hospital allows you to choose insurance, it may be worth using private cover. 

• Room type and comfort: Private cover might allow you a private or semi-private room (if available) - something many public-only patients can't access. 

• Reduced wait times for surgery or elective procedures: If public waiting lists are long, using private cover might help you get treated  

• More control over costs: In some policies, your insurer covers certain hospital costs (like accommodation, theatre, specialist fees) once Medicare’s portion is paid.  

• Affordability of out-of-pocket costs: Even with private cover, you could face excesses or gap fees. Choosing private cover only makes sense if the expected out-of-pocket costs don’t outweigh the benefits. You should always check your nib cover before going to hospital- either in your member account or by calling 13 16 42. Your doctor might charge a higher fee for being a private patient, which isn’t covered by Medicare and may not be covered by your health insurer.

• When the public option is strong enough: If your condition is urgent and the public system offers same-level care with minimal extra costs, using Medicare might be more simple and cost-effective. 

 If you’re planning to use your private health insurance, it’s a good idea to know what to expect while you’re admitted. Our guide to what happens during your hospital stay can help you feel more prepared and confident. 

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. 

Related: What is the Medicare Benefits Schedule (MBS)?  

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 receive any out-of-pocket costs or invoices? 

• Do I get to choose which doctor treats me? 

• Can you guarantee that I will receive a private room? 

• What are the benefits of my private health insurance? 

Once you’ve had these answered, you can make an informed decision based you’re still feeling unsure, you can find answers to some of the most commonly asked health insurance questions on our website.  

Are you heading to hospital?

If you're an nib member heading to hospital soon, make sure you check out our Going to Hospital page. This tool gives you information on health insurance, tips on how to reduce any out-of-pocket expenses and helpful questions to ask your specialist.

To review your current policy, chat with someone about your upcoming hospital visit or get tailored guidance, call us on 13 16 42.