Using private health cover in a public hospital

If you’ve been admitted into a public hospital, should you use Medicare or your insurance?

It’s a topic that can be confusing at times, so we’re keeping it simple by giving you the facts – that way, you can make up your own mind.

If you’ve been admitted into a public hospital, whether you’ve had an accident or 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 give public hospitals the opportunity to secure extra cash flow.

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

One of the biggest misconceptions when it comes to being admitted is that you MUST use your private health insurance.

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

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 also have out of pocket expenses to pay.

International members will always be treated as a private patient, with hospital fees covered by your OSHC or OVHC, although some out of pocket costs may apply.

Some public hospitals might offer you a few ‘bonuses’ if you use your private health insurance to get treated. This could be free newspapers and TV access and different meal options. You might also have 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.

You can also request to have a private room, however, priority for private rooms will always be given to patients who need them, so it’s really all down to availability.

When you use your private health insurance in a public hospital, Medicare and your insurer will cover the Medicare recommended fee (MBS fee) for the doctor or specialist providing your treatment. However, you may have to pay your insurance excess. Related: What is the Medicare Benefits Schedule (MBS)?

Other hospital charges like accommodation and theatre fees are likely to be covered under your insurer, provided the treatment is covered on your policy, but you should always check your nib cover before going to hospital in your member account or by calling 13 16 42. On top of this, your doctor might also charge a higher fee for being a private patient, which isn’t covered by Medicare and may not be covered by your health insurer.

However, if you choose to be treated as a public patient, all your hospital costs as an in-patient will be covered so long as they are clinically necessary.

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 receive a private room?

• What are the benefits to me for using my private health insurance?

Once you’ve had these answered, you can make an informed choice based on your personal circumstances.

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 find out the details of your current policy, chat with someone about your upcoming hospital visit or get some guidance, call us on 13 16 42.