Mistakes, Disputes and Official Sources
Public or private patient in hospital? What changes when you use your cover
Choosing between public and private patient status in Australian hospitals: costs, choice of doctor, elective waiting lists, emergencies and using private cover in a public hospital.
In an Australian hospital you choose, on admission, whether to be a public patient or a private patient, and having private health insurance does not force you to use it. As a public patient in a public hospital you pay nothing for treatment by doctors the hospital appoints, and you join the public waiting list for planned surgery. As a private patient, in a private or public hospital, you can choose your specialist, your insurer pays hospital charges for covered treatment, Medicare pays 75% of doctors' MBS fees, and you pay your excess and any gap fees. In a genuine emergency, the public system treats everyone first; questions about cover come later.
This guide is part of private health insurance mistakes.
The two options compared
| Public patient, public hospital | Private patient, private hospital | Private patient, public hospital | |
|---|---|---|---|
| Doctor | Appointed by the hospital | Your choice | Usually your choice, subject to hospital arrangements |
| Cost of treatment | Free for Medicare-eligible patients | Excess plus any gaps | Excess, possibly reduced or waived by the hospital, plus any gaps |
| Elective surgery timing | Public waiting list, by clinical urgency | Usually scheduled with your surgeon | Generally public hospital scheduling applies |
| Room | Shared or single, allocated by need | Often a private room, if available | Private room if available, not guaranteed |
| Medicare | Covers everything | 75% of MBS fees for doctors | 75% of MBS fees for doctors |
| Insurer | Not involved | Pays covered hospital charges and 25% of MBS fees | Pays hospital charges and 25% of MBS fees |
Emergency care
If you arrive at a public emergency department, you are treated on clinical need. Emergency department care is free for Medicare-eligible patients. If you are then admitted, staff may ask whether you want to be a private patient. You can say no. Some public hospitals encourage insured patients to elect private status because it brings revenue to the hospital; you should be told what, if anything, it will cost you.
When being private in a public hospital makes sense
- The hospital waives your excess and any gaps, so it costs you nothing.
- You want a specific specialist who also works at the public hospital.
- You prefer a private room and one is available.
Ask in writing before agreeing: "Will electing private status cost me anything: excess, gap fees, or charges not covered by my policy?"
When being a public patient may be better
- Your policy restricts or excludes the category of treatment. See restricted cover and exclusions.
- You are still in a waiting period.
- You are being treated for something urgent in a public hospital and would face gap fees as a private patient.
- You want to avoid using your annual excess.
Elective surgery: the main reason people buy cover
Public elective surgery waiting times depend on clinical urgency, the procedure, the hospital and the state. Each state publishes its own waiting time data. Private patients usually schedule surgery when it suits them and their surgeon, once waiting periods are served.
Worked example (illustrative). A planned procedure in a category covered by your Silver policy:
| Route | Your cost |
|---|---|
| Public patient, public hospital | $0 for the operation; out-of-hospital consultations and scans before referral still have Medicare gaps |
| Private patient, private agreement hospital, surgeon and anaesthetist on the insurer's no-gap scheme | Excess only, say $500 |
| Private patient, private hospital, surgeon not on a gap scheme | Excess plus gaps; in the gap fee example the total was $2,120 |
The value of private cover here is time and choice, not cost: the public route is cheapest in dollars.
Out-of-hospital care is the same either way
GP visits, specialist consultations in rooms, scans and pathology out of hospital are covered by Medicare's out-of-hospital benefits and cannot be paid by hospital insurance. Whether the specialist bulk bills or charges a gap is unrelated to your insurance.
When to talk to a doctor
Your GP can explain the likely urgency of your treatment, which affects how long you might wait in the public system, and can refer you to a public clinic or a named private specialist. That conversation should come before any decision about using insurance.
FAQ
Can a public hospital require me to use my private cover?
No. Choosing private patient status is voluntary. You must give informed consent.
Will choosing to be private in a public hospital get me treated faster?
Not usually for emergency or urgent care, which is based on clinical need.
Do I pay my excess as a private patient in a public hospital?
It depends on the hospital and your insurer. Many public hospitals waive the excess and gaps for insured patients, but ask first.
Can I switch from private to public during an admission?
Talk to the hospital's patient liaison or billing staff; the rules vary between hospitals and states.
Sources
- PrivateHealth.gov.au — public and private patient options and out-of-pocket costs
- Services Australia — Medicare benefits in and out of hospital
- Australian Institute of Health and Welfare — national data on hospitals and elective surgery waiting times
- healthdirect — find a GP or hospital
