Private health insurance in the Australian Capital Territory

While there are many factors that go into the hospital cover premium you pay, two of the biggest factors are your state of residence and your level of cover. Because costs are typically the same between the ACT and NSW, the Private Health Insurance Ombudsman doesn’t provide cost data for the ACT.

Here are the average costs for hospital policies in NSW by cover tier compared to the national average for a single-only hospital policy with an excess of $750 that provides an exemption from the Medicare Levy Surcharge. They don’t include any rebates, loadings or discounts. ‘Plus’ tiered policies have been grouped with their base tier (e.g. Bronze Plus is included under Bronze):¹

Unlike hospital cover, extras cover policies don’t come with standardised levels of cover. This means that the amount you’ll pay will vary more depending on the benefits offered, your annual limits and any rebates included on the policy. Your limits and rebates will ultimately determine the out-of-pocket costs you pay when you’re treated.

Like with hospital cover, the cost of an extras policy in the ACT is the same as NSW. With that said, the average cost of an extras cover policy in NSW in August 2024 was $89.19, which is marginally above the national average of $84.73.² However, keep in mind that these numbers are only a rough guide and don’t account for differences in benefits between policies and providers.

No, ambulance services aren’t free in the ACT. When you call an ambulance in the ACT, you’ll be required to pay a fee depending on whether you need treatment and transport, or just treatment.² You will also have to pay for any non-emergency ambulance services like transportation between hospitals.

Fortunately, most health insurance providers include ambulance cover with many of their hospital  or extras policies, or offer it as a standalone product. Standalone ambulance policies are typically quite affordable and can be taken out from a range of health funds.

If you’re a Health Care Concession or Pensioner Concession cardholder, you may be entitled to free emergency ambulance services within the ACT.² If you’re a Territory resident, you may also be entitled to free emergency ambulance services in other states depending on the state and your eligibility.

When you go to a public emergency room, you’ll be assigned a triage category based on the urgency of your symptoms. Each category has a recommended maximum wait time, which are:

• Resuscitation – Immediate
• Emergency – Within 10 minutes
• Urgent – Within 30 minutes
• Semi-urgent – Within an hour
• Non-urgent – Within two hours.

The below table features the average wait time for each clinical category in the ACT.³

When you book in for an elective surgery at a public hospital, you’ll be put on a public waiting list for some amount of time before you can be treated. With a private hospital cover policy, you could potentially get treated in a private hospital in a significantly shorter time.

Here are some of the typical wait times for common surgeries in the ACT and the percentage of people who waited longer than a year.

When you’re admitted to hospital for an elective surgery as a private patient and make a claim, your health fund and Medicare will together pay 100% of the Medicare Benefits Schedule (MBS) fee for your doctors. Your health fund will then pay some or all of the associated hospital charges like theatre fees.

If your doctors charge above the MBS fee, you’ll need to pay the difference yourself unless your doctor participates in your health fund’s gap cover scheme. A no gap scheme could completely cover the gap, while a known gap scheme will reduce it to a set amount.

When you take out hospital cover for the first time, or upgrade your level of cover, you’ll need to serve a waiting period before you can claim on any of your newly included medical services. These waiting periods can range between 2 and 12 months across all hospital products for certain services. Fortunately, when you switch policies to the same or a lower level of cover, you won’t be required to re-serve the same waiting periods again on your new policy. If you haven’t yet completed a waiting period, you will be required to serve the remaining time with your new health fund.

For your out-of-hospital health needs, you can get an extras cover policy. This type of cover will pay either a flat dollar amount or a percentage of the cost up to the relevant limits for general treatment that isn’t already covered by Medicare. This includes services like:

• Physiotherapy
• Chiropractic
• Dental check-ups
• Orthodontics
• Glasses and contact lenses.

While extras cover also comes with waiting periods, they aren’t standardised like hospital cover. This means you may be able to find a fund with lower waiting periods or even a promotional offer than waives them entirely.