What private health insurance covers 

Private health insurance may pay all or part of a private patient's healthcare costs in Victoria's hospitals and health services. Hospital insurance policies may not cover private patients for all of their hospital costs. Private patients may also be charged for some or all of the costs of:

  • hospital accommodation
  • theatre fees
  • intensive care
  • drugs, dressings and other consumables
  • prostheses (surgically implanted)
  • diagnostic tests
  • pharmaceuticals
  • any additional doctor's fees.

Patients are advised to check their entitlements with their health fund, and whether they are liable for any fees or charges.

Private health insurance generally covers the full cost of shared ward accommodation but – depending on the level of cover – may not fully cover the cost of a single room. 

Medicare covers 75 per cent of the Commonwealth Medical Benefits Schedule fee for the medical services provided to private patients while in hospital, and private health insurance generally covers the remaining 25 per cent. The actual out-of-pocket cost to patients with private health insurance depends on the services provided and the type of insurance cover held. Private patients should check with their insurance company regarding any possible out-of-pocket expenses. 

Where a doctor charges a fee that exceeds the Commonwealth Medical Benefits Schedule fee, the patient is responsible for paying the difference between the fee charged by the doctor and the scheduled fee. Find out more about out-of-pocket expenses from the Commonwealth Department of Health website.

Private patients without insurance are liable for the full cost of accommodation and related expenses.

Overnight and same-day stays

Fees for overnight stays and same-day stays are aligned with the Commonwealth's default minimum benefits (shared room).

Informed financial consent

For people who elect to be treated as private patients, hospitals must make all reasonable effort to: 

  • encourage patients to contact their doctor and health fund to discuss the financial implications of an upcoming episode of hospitalisation and any co-payment they may be willing to pay as a private patient
  • make provision in hospital admission papers (for public hospitals this is the standard in-patient election form) for patients to sign an acknowledgement that they have given informed financial consent
  • except where the admission is an emergency, ensure hospital admission procedures, information systems and admission forms facilitate the effective operation of the process, including an informed financial consent proforma with other admission papers for patients to sign (if one has not been signed prior to admission).

Patients have the right to obtain advice from their doctor on the likely cost of treatment before it starts. If the practitioner does not discuss fees, the patient should ask what fees they will be charged.

Find out more about informed financial consent from the Commonwealth Department of Health website.

Treatment in the emergency department

Part 3 Section 8(b) of the Private Health Insurance (Health Insurance Business) Rules 2010 states that treatment provided to a person in an emergency department of a hospital is excluded treatment for the purposes of private health insurance. Health services should ensure that private health funds are not billed for services provided to private patients within the emergency department.