Does private health insurance cover specialist visits?
Private health insurance usually doesn't cover specialist visits in their rooms, but hospital cover helps once you're admitted. Here's why.
Many people are surprised to learn that private health insurance usually doesn't pay anything towards a specialist appointment in the specialist's rooms. That's because Australian rules don't allow insurers to cover out-of-hospital services that Medicare already pays a rebate for.
What Medicare covers outside hospital
For a specialist visit in their rooms, Medicare pays a rebate if you have a valid referral. You pay any gap between the fee and the rebate yourself. The same applies to most scans and tests done outside hospital. See Bulk billing, rebates and gap fees explained.
What hospital cover does
Hospital cover helps when you're admitted to hospital as a private patient, either in a private hospital or as a private patient in a public hospital. For your doctors' fees in hospital, Medicare pays part of the schedule fee and your insurer pays the rest of the schedule fee. Your insurer may also pay above that if your doctor uses its gap cover arrangement.
Hospital cover can also help with:
- Your hospital bed, theatre and accommodation costs
- Some medicines and devices used while you're in hospital
- Choosing your own surgeon or specialist for the admission
What you get depends on your level of cover. Some policies exclude certain treatments, such as joint replacements, cataract surgery or pregnancy, so check before you need them.
What extras cover does
Extras or general treatment cover can help pay for allied health such as Physiotherapy, Psychology, Dietetics and Podiatry. Each insurer sets its own limits, and you usually can't claim extras and a Medicare rebate for the same session.
Questions to ask your insurer
- Am I covered for this procedure, and have I served any waiting periods?
- What is my excess or co-payment?
- Does my surgeon and anaesthetist use your gap cover scheme?
- What item numbers will the doctor use, and what will I pay?
- Is the hospital one of your agreement hospitals?
Your specialist's rooms can give you item numbers and a written quote. See Understanding a surgery quote: what to ask before you agree for what a good quote should include.
Hospital cover is also worth reviewing every year or so. Your needs change over time, and a cheaper policy may leave out the treatments you are most likely to need, such as joint, eye or heart procedures. Insurers must give you a standard summary of each policy, which makes comparing easier.
If you don't have private cover, you can still be treated free as a public patient in a public hospital. See Public or private: how to choose where to see a specialist.
Common questions
Why can't my insurer pay for my specialist consult?
Australian law stops health insurers paying for out-of-hospital medical services that have a Medicare rebate. Your insurer can only help once you're admitted, or with allied health under extras cover.
Do I need a referral if I'm using private cover?
Yes. You still need a valid referral to claim Medicare for a specialist, and your hospital claim relies on Medicare too.
Can I use my private cover in a public hospital?
Yes. You can choose to be a private patient in a public hospital. Ask the hospital what this means for costs and which doctor will treat you.
General information only, not medical advice. Everyone's situation is different, so check with your GP or the provider. In an emergency call 000.