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When you’re admitted to the hospital as a private patient, your hospital cover helps with a range of costs, including hospital accommodation, theatre fees, prostheses, intensive care, and medical services.

 

Private health insurers in Australia offer hospital products classified into four tiers: Basic, Bronze, Silver, or Gold. The Australian Government sets the minimum and mandatory inclusions for each tier, ensuring a consistent standard across all insurers. These inclusions cover specific clinical categories that your insurer is required to pay benefits towards.

 

If a policy meets the minimum requirements of a tier, but also includes additional coverage, then it can be called a ‘Plus’ policy – for example, Bronze Plus or Silver Plus.

 

To understand exactly what your policy covers, it’s important to refer to your Product Fact Sheet. This will outline what is included, restricted, and excluded under your specific policy.

As an Australian resident with private health insurance, you have the flexibility to choose how you can receive your treatment. You can be treated as a private patient in either a public or private hospital, depending on the services covered by your policy, or you can opt to be treated as a public patient in a public hospital.

 

Download our Going to Hospital guide to learn about your options and what’s included in different scenarios. 

The Medicare Benefit Schedule (MBS) is a list of essential medical procedures that can be performed in Australia. The government and Medicare set a recommended fee for each procedure, which serves as a guide for doctors treating patients in the public system. However, in the private system, doctors and surgeons can set their own fees.

 

For services listed on the MBS that are included or restricted under your policy, Medicare covers 75% of the MBS fee, and AIA Health covers the remaining 25%. If your doctor charges more than the MBS fee, you may have to pay the difference, known as the ‘gap’. However, if your doctors participate in AIA Health’s Access Gap Cover, your out-of-pocket expenses may be lower or eliminated altogether.

AIA Health has agreements with a vast network of private hospitals and day surgeries across Australia. When you’re treated for an included service as a private patient in one of our participating hospitals, we generally cover all hospital accommodation charges as part of our agreement with that hospital.

 

This means your out-of-pocket expenses are usually limited to your excess, co-payment, any fees related to your medical provider, gaps for medical devices or human tissue products, high-cost drugs, and inpatient pathology or imaging services.

 

To find a participating hospital, visit our Find a Provider page.

If your doctor participates in Access Gap Cover, they’ll agree to either remove (No Gap) or reduce (Known Gap) your out-of-pocket medical expenses. Where a Known Gap has been agreed to, the maximum out-of-pocket cost a doctor can charge per MBS item is $500 per episode or $800 for pregnancy and birth.

 

To find an Access Gap Cover doctor, visit our Find a Provider page.

Depending on your level of cover, you may be required to pay an excess and/or a co-payment  when you’re admitted to the hospital. 

 

If you’ve held an AIA Health policy for at least six months and your AIA Vitality Status is Silver or above at the time of admission, we’ll refund your excess or one day’s co-payment, depending on your cover and treatment. To claim your refund, simply use the AIA Health portal or AIA Health app to submit your invoice and receipt.

 

Please note, that Excess Refund and Co-Payment Refund are not available for certain clinical categories. For more information, please refer to your Product Fact Sheet.

Before undergoing any treatment, you have the right to be fully informed about the costs you may incur. These details are provided in a summary of costs known as your Informed Financial Consent, or a written estimate of fees, which should be given to you in writing before your admission.

 

By signing the Informed Financial Consent, you’re acknowledging that you’ve been advised of, understood, and agreed to the treatment plan, its costs, and any estimated out-of-pocket expenses. 

If you have an AIA Health policy, you will generally be covered for all clinically necessary ambulance services for emergencies in Australia. This applies to situations where immediate hospital care or on-site treatment is required. However, if you need an ambulance for non-emergency transport, significant out-of-pocket costs can arise without the right level of cover. 

 

Each state has different rules, so it’s important to check with your state ambulance authority to ensure you’re fully covered for both emergency and non-emergency ambulance transport. 

 

Note: Tasmania and Queensland have state schemes to cover ambulance services for residents of those states. AIA Health will not pay benefits towards ambulance services where it is provided by the state. We recommend that members purchase state-based ambulance membership where applicable to ensure they are fully protected against the cost of ambulance transport and treatment by paramedics. This is not required for Queensland and Tasmanian residents, where ambulance services are provided under state schemes. It may also not be required for New South Wales and Australian Capital Territory residents as when members have Hospital cover in those states, they pay a government-imposed ambulance levy as part of their health insurance premium. Check with your state ambulance authority to ensure you have the right level of cover for emergency treatment and non-emergency ambulance transport by paramedics within Australia.