Visiting the emergency department and calling an ambulance – what’s covered?
Medical emergencies are unexpected events that can be extremely distressing. No-one plans to have a medical emergency, so understanding how your private health insurance and Medicare cover emergency services can be beneficial if one was to occur.
Emergency departments are hospital units that accept and treat patients who experience a medical emergency and require urgent medical care. While you are on a hospital site, you aren’t considered an admitted patient while being treated in an emergency department.
Private health insurance in general is unable to pay benefits towards services received in a public or private emergency department. This is because you are treated as an outpatient during this time and not an admitted patient in hospital. Medicare can cover some services received while in emergency.
Public hospital emergency departments
Most public hospitals across the country have emergency departments, many operating 24 hours a day 7 days a week. They are often busy with long wait times, determined by your triage category. Services received in public hospital emergency departments will be generally covered by Medicare in full if you are eligible for Medicare. This can include treatment by doctors, specialists and nurses, and any tests you may be required to undergo as part of your emergency treatment.
If you call an ambulance for a medical emergency, you will usually be taken to the nearest public hospital emergency department. If you go by private vehicle, you might be able to choose whether you attend a public or private hospital emergency department.
Private hospital emergency departments
Not every private hospital has an emergency department, but for those that do, patients should expect to be more out-of-pocket if choosing this option. Private hospital emergency departments are generally quieter and many charge an out-of-pocket facility fee to the patient, which generally can’t be claimed with private health insurance or Medicare.
For any medical services received in a private emergency department, a portion of these may be covered by Medicare, however out-of-pocket costs or gaps are highly likely. Depending on your required treatment, this can include a specialist assessment and/or services such as radiology or other tests.
Your private health cover begins if you become an inpatient
Your private health cover begins if your treating doctor makes the assessment that you require ongoing hospital care, and formally categorises you as an inpatient. This means you are moved out of the emergency department and are admitted into hospital – either into a private hospital or public hospital as a private patient.
Ambulance cover
Cover for ambulance services can be provided through private health insurance, subscriptions with state-based ambulance services or funding arrangements in certain states and territories. Medicare does not provide benefits towards ambulance or other emergency transportation services.
Detailed information about how each state and territory operates their own arrangements for funding ambulance services can be found at privatehealth.gov.au. The services respond differently depending on your state of residence, and your eligibility for a concession.
It’s important to note that ambulance cover differs with each health fund and policy. This can be in regards to benefits limitations and any restrictions for use, and whether it is part of a hospital policy, extras policy or offered as its own ambulance-only policy. It’s important that you refer to your own health fund to understand the ambulance cover available to you.
All Doctors’ Health Fund hospital policies include unlimited national cover for emergency and medically necessary ambulance services. Contact us on 1800 226 126 or by email to info@doctorshealthfund.com.au to find out more.
1Health Direct. Hospital Emergency Departments, source: https://www.healthdirect.gov.au/hospital-emergency-departments
Date published: 11 November 2023
IMPORTANT: Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy, available at www.doctorshealthfund.com.au/our-cover. The information in this publication does not constitute professional advice and should not be relied upon as such. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular circumstances.