Private health insurance in New South Wales

Among the factors that affect your hospital insurance costs, two of the largest are your state of residence and the level of cover you choose.

Here are the average costs for private patient hospital cover in NSW compared to the national average for a single-only hospital policy with an excess of $750 that exempts you from the Medicare Levy Surcharge. They don’t include rebates, loadings or discounts. ’Plus’ tiered policies have been included with the four main tiers (e.g. Bronze Plus policies are included in the Bronze tier, and Silver Plus policies are included in Silver).

Since extras cover doesn’t have standardised policy levels like hospital insurance, the premiums you pay will vary depending on the benefits offered, your annual limits and any rebates included on the policy. It’s a good idea to consider how you will use your cover when comparing extras cover because the limits and rebates will ultimately determine the out-of-pocket costs you pay when treated.

With that in mind, the average cost of an extras cover policy in NSW in August 2024 was $89.18, which is slightly above the national average of $84.73. ² These figures are based on the monthly premium for single-only policies and don’t account for different dollar and percentage limits or the services provided. These figures are only a rough guide, and don’t consider differences in coverage from policy to policy.

Unlike private hospital cover, which is divided into tiers based on the hospital treatments covered, extras insurance policies vary in the general treatments covered (e.g. physio or dental) and how much they will pay toward them.

No, ambulance transport in NSW isn’t free, although the cost of an ambulance call-out is subsidised by the state government. When you call an ambulance in NSW, you’ll be charged a call-out fee and an additional charge per kilometre travelled. The state government will pay 49% of the total cost of the ambulance call-out, and you will be billed for the remaining amount. ³ You will either need to pay for this as an out-of-pocket cost or make a claim on your private ambulance cover policy, if you have one.

There are typically two types of ambulance cover available through private health funds, these are emergency and non-emergency. An Emergency-only policy will only cover you for emergency transport to a hospital, while non-emergency cover could also cover things like transport between hospitals in a non-emergency situation.

In some instances, transport by ambulance will be provided for free. You will be entitled to free ambulance transport if you’re a NSW resident that has a Health Care Card, Pensioner Concession Card or Commonwealth Seniors Health Care Card.

If you go to a hospital emergency department, your symptoms will be evaluated by a triage nurse, and you’ll be assigned a category based on urgency. These categories and their recommended maximum wait times are:⁴

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

The table below gives you an idea of the average wait times for each triage category in a NSW public hospital.⁴

Before you can receive an elective surgery in a public hospital, you’ll most likely need to serve some time on a public waiting list. Like the emergency room, waiting times are based on demand and urgency.

Here are the typical wait times for common surgeries in NSW and the percentage of people referred for the surgery who waited longer than a year.⁵

When you are admitted to hospital as a private patient and claim for a procedure included on your hospital policy, your health insurance and Medicare will together pay the full Medicare Benefit Schedule (MBS) fee for your doctors. Your health insurance will also pay some or all of your hospital fees.

However, if your doctors charge above the MBS fee, the difference is known as the gap and you’ll be responsible for paying this amount unless your doctors participate in your health fund’s no-gap scheme. Some funds will also have a known-gap scheme, which will partially cover the gap.

Before you can claim on your policy for a treatment your policy covers, you’ll need to make sure you’ve served any associated waiting periods. These periods are standardised across clinical categories and any waiting period already served can potentially be transferred between hospital insurance policies if you switch providers.

For treatment out of hospital that isn’t covered by Medicare, you may like to consider an extras cover policy. These policies will typically contribute to  services like dental check-ups, physiotherapy and optical. An extras policy will pay either a flat dollar amount or a percentage of your treatment costs up to the relevant limits when you make a claim for a covered service.

Extras cover also comes with waiting periods before you can claim for the first time for a service, which will vary between health funds and the services covered. Time served under these waiting periods may also be transferred if you switch providers, and depending on the provider, may be occasionally waived for promotional purposes to attract new members.