What is hospital cover? Your questions, answered

Published December 2025
Expert contributor Peta Gane, RT Health Consultant
Words by Angela Tufvesson

Private hospital cover can seem confusing at first. But understanding the basics can give you peace of mind and the confidence to use it when it matters most.

So if you find yourself wondering, 'What does hospital cover include?', 'Can I be a private patient in a public hospital?' and 'What counts as a pre-existing condition?', RT Health Consultant Peta Gane has the answers.

1. What’s hospital cover (and what does it include)?

Private hospital cover pays some or all of the costs for you to be treated in hospital as a private patient. Depending on your level of cover, Peta says this can include things like staying in a private room, theatre and surgery fees, and services provided by doctors, specialists and other health professionals while you’re in hospital.

2. What are the benefits of private hospital cover?

“You can choose your own doctor rather than being assigned one through the public system,” Peta explains. “You can usually have your treatment or procedure done a lot quicker than someone on a public waiting list, and you’re eligible for a private room if one is available and it’s included on your policy.”

3. What’s the difference between public and private hospital care?

Medicare, Australia’s public health system, is one of the best in the world. But you don’t usually get to choose your doctor and you may also be subject to longer waiting times for common procedures.

Private health cover offers faster access to specialists and elective procedures, with shorter wait times and more flexibility in choosing doctors and hospitals. “While public patients are assigned doctors, private insurance allows continuity of care with preferred providers,” Peta says.

 4. Can you be a private patient in a public hospital?

Yes – if you have hospital cover, you can be treated as a private patient in a public hospital.  Peta says this is especially helpful for people living in rural and regional areas without a nearby private hospital.

“As a private patient in a public hospital, you may be able to choose your doctor or specialist if they work at that particular hospital,” she explains, noting that in this situation you might not be able to skip the public waiting list for planned procedures.

“You may also get a private room if one is available – this isn’t guaranteed, especially in a busy public hospital – and you’ll need to check whether your policy includes cover for this.”

5. Does private hospital cover work in emergencies?

If you call an ambulance, the government will cover the cost in some states. In others, you’ll need private health cover to avoid receiving a bill. Ambulance cover is included in all levels of our hospital cover (except for Queenslanders who are covered under a state-based scheme).

If you visit the emergency department, you’ll only receive the benefits of your hospital cover if you’re admitted to hospital – which is called being an inpatient. If you receive treatment or care at the hospital, like X-rays or blood tests without being admitted, you’re considered an outpatient, and your hospital cover won’t apply because these services are generally covered by Medicare.

“If you go through emergency and are seen there, but are not admitted to hospital, you’re not covered,” Peta explains. “If you’re admitted to hospital, then you’ll be covered, as long as it’s an inclusion on your policy.”

6. What’s a hospital cover waiting period?

When you take out hospital cover, you may have to wait before you can make a claim and receive benefits. These waiting periods are standard across Australia: 12 months for pregnancy and birth and pre-existing conditions, and two months for other services.

7. Does switching policies affect waiting periods?

“If you're coming across to RT Health for a like-for-like cover, and you served your waiting period with the previous fund, you won’t serve the waiting period. It’s called ‘portability of cover’,” Peta explains.

You’ll only serve a waiting period for treatments or procedures that weren’t in your old policy.

8. What’s a pre-existing condition?

A pre-existing condition is any illness or condition that you had (or experienced symptoms of) at any time in the six months before you started or upgraded your health cover.

Remember: a condition can be pre-existing even if you don’t yet know about it. It may not have been diagnosed by a doctor or specialist, but it can still incur a waiting period of up to 12 months.

9. What’s hospital excess and how does it affect how much you pay?

Hospital excess is the amount you agree to pay towards your treatment before your health insurer starts covering the costs.

If you choose a higher excess when you take out cover, this can lower your premium – but it also means you’ll pay more if you need to make a claim later.

10. What are out-of-pocket expenses and how can you reduce them?

Out-of-pocket expenses (sometimes called ‘gap payments’) are the costs you might need to pay when you go to hospital, even if you have private hospital cover.

Sometimes, health funds have agreements with doctors and hospitals to cover all or part of these costs, or ‘gaps’, which remove or reduce your out-of-pocket expenses.

Because doctors can decide on their own fees, Peta recommends getting quotes for a procedure from more than one specialist.

Learn more about how to reduce your out-of-pocket expenses.

11. What’s the private health insurance rebate and how does it affect what you pay?

The private health insurance rebate is a government contribution that helps reduce the cost of your health insurance premiums. How much you get depends on your age and income.

12. What’s the Medicare Levy Surcharge? Does hospital cover help you avoid it?

The Medicare Levy Surcharge is an extra tax you may have to pay if you earn above a certain income and don’t have private hospital cover. By taking out private hospital cover, you can avoid paying this additional surcharge, while also enjoying the benefits of choosing your doctor, shorter waiting times and getting a private room.

“In most cases, any form of private hospital cover will alleviate the Medicare Levy Surcharge,” Peta says.

Still have questions?

If you need some advice or want to know more, we’re here with you every step of the way to help you get more value from your cover. Our Member Care team can answer any questions you have. Give them a call on 1300 886 123 or get in touch via email to help@rthealth.com.au

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