Combined hospital and extras cover

Hospital cover pays towards medical conditions that require inpatient hospital treatment. This can include treatments like joint reconstructions and cataracts surgery, depending on the level of cover you choose. To claim a benefit from your health fund, the treatment must be medically necessary, listed on the Medicare Benefits Schedule (MBS), included on your policy and all relevant waiting periods completed.

Hospital insurance will pay a benefit towards your treatment as a private patient admitted to a private or public hospital. If you’re treated in a private hospital, you’ll be able to avoid public waiting lists, choose your available doctor and have a private room (depending on availability).

Hospital cover is divided into four tiers depending on the clinical categories included; these categories are Basic, Bronze, Silver and Gold. Some polices may have a ‘Plus’ or ‘+’ in the name (e.g. Basic Plus), meaning they cover more than the minimum required clinical categories without meeting the requirements for the next tier up. For example, a Silver Plus policy may provide cover for joint replacements which is ordinarily only required to be included by Gold tier policies.

Extras cover provides benefits for out-of-hospital extras services like dental check-ups, chiropractic, physiotherapy, remedial massage and podiatry, among others. It can also pay towards products like hearing aids and orthotics.

The amount you can claim will be either a percentage or a dollar amount. These benefits are typically capped to an annual limit and can include sub limits, group limits and lifetime limits, as well as per person limits and policy limits.

Waiting periods are decided by the health fund and aren’t regulated by the government. Unlike hospital cover, pre-existing conditions won’t affect your waiting periods.

Standalone extras cover won’t help you avoid the LHC loading, MLS or benefit from an aged-based discount. However, choosing to go without hospital cover and only having extras won’t affect your eligibility for the Australian Government rebate.

Policies may vary between health funds, so make sure you check the relevant policy brochure for a full list of inclusions, exclusions, limits, benefits and restrictions.

Yes, you can take out a hospital insurance policy with one health fund, and extras cover with another. This can be handy as some funds might have a hospital policy you like, but not offer a suitable cover option for the specific out-of-hospital treatments you’re looking for under an extras policy.

However, having one policy means you only need to worry about one premium payment, so it might be easier than having hospital and extras cover with different funds.

When it comes to extras cover, things work a bit differently. For instance, the services you can claim on and the amount of money you can claim are decided by the health fund, not the government. There are also no set categories like there are for hospital policies. As such, it becomes much more important to shop around to ensure your healthcare needs are met.

The level of extras cover will be specified under the policy, with the specific treatments listed on your policy brochure.

Combined hospital and extras do have waiting periods, just as standalone policies do. Once you take out cover, you’ll need to serve these waiting periods before you can claim on a specific service or treatment. When switching or upgrading to a higher level of cover you’ll only need to serve a waiting period for the new services offered.

You won’t be required to re-serve any waiting periods that you’ve already completed when switching or upgrading from an active policy. If you’re yet to complete any waiting periods, you’ll be required to serve the remaining time before claiming.

Hospital cover

The Australian Government sets the waiting periods for hospital insurance, which differ depending on the treatment. For pregnancy and birth-related services and treatment for pre-existing conditions, your waiting period will be 12 months. For all other services (e.g. mental health services, palliative care and rehabilitation), you can make a claim after just two months.

Extras cover

Waiting periods for extras are set by the health fund and can range from several months to several years, depending on the procedure or treatment. For example, orthodontics may have a waiting period of 12 months or longer.

Some health funds will waive waiting periods for certain services if you’re a new customer taking out an eligible policy, so keep an eye out for these deals.

No, Lifetime Health Cover (LHC) loading applies to the base premium of your hospital cover, if you take out health insurance after 1 July following your 31^st birthday. You don’t have to pay LHC on your extras premiums.

When you take out a combined health insurance policy before July 1 following your 31^st birthday, maintaining the hospital insurance component will help you avoid the LHC loading.

Emergency ambulance cover is often included in hospital cover and some extras policies, depending on the insurer and policy. Other insurers may also offer ambulance cover as a standalone policy. Even if your hospital or extras policy includes ambulance cover, it’s important to understand what’s included, as a standalone policy may be more comprehensive.

However, some Australians will have ambulance trips covered by their state or federal government. This includes:

• Queenslanders anywhere in Australia
• Tasmanians while they’re in Tasmania
• Some pensioners, veterans and concession cardholders.

If health insurance includes emergency transportation, limits may apply to the number of trips that can be claimed within a 12-month period. You can learn more about the rules for each state and territory in our guide to ambulance cover.