Vasectomy and Private Health Insurance

anna.jabour@mariestopes.org.au FAQs

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You can chose to use Private Health Insurance (PHI) to contribute to the cost of your vasectomy or you can use Medicare only.

However, for those looking to make the most of the PHI cover they have, it’s important to understand some basic information. Navigating the world of private health insurance can be difficult, particularly when you’re looking at how much cover you have for a specific treatment or procedure. To help you steer the murky waters of insurance towards the bright light of your vasectomy, we’ve broken it right down, so you can confidently estimate how much your vasectomy will end up costing you.

What are the types of health insurance?

There are two types of private health insurance. There’s “hospital cover” and “extras cover” (sometimes referred to as ‘general treatment,’ or ‘ancillary cover’). Extras is for dental and physio for example. Most insurance providers will offer a bundle where you’re covered for both.

We’re going to be focusing on private “Hospital” cover, as this is the coverage relevant to a vasectomy when done in one of our specialist Day Hospitals.

What is ‘hospital insurance’

Depending on your individual policy, hospital insurance is designed to help cover some, or all, of the cost of in-hospital treatment, either as a private patient in a public hospital, or in a private hospital or licensed day hospital practice.

Generally, any medical service listed under the Medicare Benefits Schedule (MBS) such as vasectomy can be claimable on some form of private hospital insurance, depending on your policy.

Almost all clients who have private health insurance “Hospital” cover who are paid up on their membership will be covered for vasectomy in all our hospitals. Our hospital will run a final check for you a few days before your procedure date to confirm this. You can also contact your insurer and have them check in advance by quoting item number 37623.

If you’re covered and you book at one of our day hospitals, you may have to pay an excess and / or a gap fee (both explained below) depending on your policy.


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What is a ‘premium’

Your premium is the amount that you pay your insurer for your coverage. Some people choose to pay this annually, while others are debited on a weekly, fortnightly, or monthly basis. If you miss payments you may not be covered for services.

What’s an ‘excess amount’

An excess is the amount that you pay towards the cost of your care, in return for lower premiums. Depending on your policy and provider you might need to pay an excess every time you are admitted to a hospital or day procedure facility. Remember to ask your health insurance provider if you have an excess amount before booking a procedure. This helps to budget accordingly for the procedure. The excess can range from $0 - $750 or more but the average is usually $250 or $500 paid once for the whole year.

How much ‘coverage’ do I need?

Before you sign up to a policy, make sure you check what it covers; especially if you have a specific procedure in mind that you want to claim, such as a vasectomy.

Not all policies are comprehensive (cover everything), and some might leave you with out of pocket expenses.

What is a ‘gap fee’

A gap fee is the amount that remains after the Medicare rebate has been applied and your insurance has paid the amount you are covered for towards the cost of your care.

Essentially, some providers will charge more for their services than what Medicare and insurance will cover, and in those instances the patient must pay the difference or the “gap”. This amount will vary depending on what the medical provider is charging.

In our case we have arrangements which mean that the highest gap you will pay is $100 and in many cases there will be no gap for your whole service including the doctor and the hospital.

This link from the Australian Health Department is also helpful in understanding Private Health Insurance out-of-pocket-costs.

https://www.health.gov.au/health-topics/private-health-insurance/what-private-health-insurance-covers/out-of-pocket-costs