Private health insurance premiums rose on April 1 by an average of 4.4 per cent, the highest increase in nearly a decade.
It’s another hit to the hip pocket for families struggling with rising petrol prices, interest rates and general inflation.
Some people may choose to drop their extras or mix and match their hospital and extras between insurers to try to get a better deal.
Others might elect to lose their hospital cover and rely on the public system. But be warned: there are tax implications and long-term penalties after age 31 if you want to get back into private health.
In some circumstances, downgrading to a more affordable policy might be an alternative, but there will be exclusions.
For those thinking about a change, we’ve compiled a list of questions to ask based on our series looking at some of the pitfalls patients are telling us they’re experiencing.
While most consumers are aware of checking for waiting periods and excesses, these are some of the other complexities that are worth investigating as well.
Are joint replacements covered under the policy?
Joint replacements, like knee and hip replacements, only legally have to be covered under expensive gold-level private health policies.
However, some insurers voluntarily offer them under silver plus policies.
As our stories reported, some patients mistakenly thought joint replacements on their policy only referred to elective replacements that could be needed from wear and tear.
Private health patients stung by exclusions after downgrading policies
As a result, they chose to downgrade from gold to save money and joint replacements were no longer covered.
Patients were under the belief they could simply upgrade later in life, with some failing to consider they might need a joint replacement in the case of an accident.
Orthopaedic surgeons tell us there also can be a fine line between a joint reconstruction, covered under cheaper policies, and joint replacements.
You might not know what’s needed until your care is well advanced.
Do I have accident cover and what does it include?
Accident cover is not to be confused with ambulance cover.
Accident cover essentially upgrades you to gold-level policy benefits if you’re injured in an accident.
But check with your insurer. As we reported, accident cover is often offered in cheaper basic and bronze-level insurance policies. It’s not always in silver policies.
Patients also say the definition of an accident varies widely between policies, with some insurers saying you need to have the surgery within 90 or 180 days or a year of the accident.
The accident also often needs to have happened in Australia and you need to have sought care within three to seven days. So check your policy or ask your insurer.
Do I need ambulance cover in my state?
Ambulance cover varies widely across Australia because state governments bill public patients differently in each state.
In Queensland and Tasmania, it’s free for residents but not visitors, with only some reciprocal agreements between states.
Other states have a maze of concession programs or roadside assistance-style subscription schemes.
Consequently, some patients in states with free ambulance choose not to add it to their private health policy, but sometimes people move interstate and forget to put it back in.
Are ambulance services free if I’m travelling interstate?
Many insurers also only cover people in an emergency, not general patient transport, unless specified.
Others only cover patients taken to hospital and not those treated at the scene.
If you get an ambulance bill, always check before handing over payment, as your insurer may cover the invoice.
Similarly, some veteran, workplace or third-party car insurance schemes may pick up the bill.
Or, you may be eligible for a concession.
Ambulance bills and fee exemptions can vary widely between the states. (Supplied: Queensland Ambulance Service)
Also, be wary of the private hospital emergency room bill. Legally, private health insurance only covers patients admitted to hospital.
If you choose to go to a private emergency room, make sure you’re going to be admitted because if you are just treated in emergency and discharged it can result in a bill.
Medicare might pick up some of the tab.
Where are your contracted hospitals?
A no-gap agreement is an agreement between a doctor and an insurer not to charge a patient a gap payment for their procedures.
A known-gap agreement allows a patient co-payment of up to $500, or $800 for obstetrics.
There are parallel agreements between hospitals and insurers for no-gap or known-gap billing for their services as well — like the room and theatre frees.
Check with your insurer where their contracted hospitals are for no-gap hospital fees because if there isn’t one nearby, you might need to a find an insurer which does to avoid out-of-pocket costs.
Customers should check which hospitals their health insurer has no-gap agreements with. (ABC News)
They usually list their network hospitals online. You also need to ask your specialist up-front if they will treat you as a no-gap or known-gap patient, you can’t do it after you get a surprise bill.
If you know what procedures you may need, check with your insurer who their no-gap doctors are — they’re online.
Query hospital and doctors’ bills as it’s illegal to charge gaps under a no-gap agreement.
Anaesthetist, surgical assistant and complex pathology testing bills are often surprise bills for patients.
Anaesthetist and surgical assistants aren’t included in treating doctor and hospital no-gap deals and need to agree separately to no-gap you.
How do you know if your medical specialist is overcharging?
Remember: once you’ve been to see a specialist, they should give you a document called an Informed Financial Consent (IFC).
You can contact your insurer and do an eligibility check online or over the phone using the details provided. Don’t wait until the day before your procedure, which is when the hospital does its own check.
We heard from lots of patients who had only 24 hours’ notice they weren’t covered who could have been on the public waiting list in the time leading up to their surgery.
What is the yearly limit and benefit for extras?
Did you know some insurers only offer a lifetime cap for orthodontics?
That’s right, it’s not a yearly cap, it’s a lifetime one of about $1,600. Some go higher. There’s a myriad of technicalities buried in extra policies and the key is to ask.
The first thing is to check the yearly limit but also the percentage paid.
So you might have a $300 yearly limit on dental but only get 40 per cent of the bill back each time.
Many insurers also offer no-gap dental clean and check-ups.
The key is to ask ahead of time for a contracted dentist.