Insurance Membership: Private Or Public?

Insurance is a means of protection from financial loss, and while it is not a membership, per se, it does often involve a contractual agreement between the insurer and the insured. Privacy is an important aspect of insurance, as it involves the protection of personal information and assets. With insurance, privacy is paramount, as it ensures that personal information and assets are protected from unauthorized access or disclosure. This is particularly important in the case of health insurance, where sensitive medical information is shared and must be kept confidential.

Private health insurance statistics

The Australian Prudential Regulation Authority (APRA) publishes statistics on the private health insurance industry (PHI) on a quarterly basis. These statistics include data on membership, coverage, benefits paid, medical gap, medical devices or human tissue products, and medical services. The membership and benefits statistics contain information on policies, benefits paid for services by age group and gender, number of services, and gap benefits, on a state and territory basis. The membership and coverage statistics provide details on the number of insured persons for hospital and general treatment, as well as the proportion of the population they represent.

In the UK, there are approximately 8 million people with active private health insurance policies, which equates to around 13% of the British population. Interestingly, about 53% of people express interest in investing in some form of health insurance scheme, either for themselves and their families or as a benefit for their employees. The average cost of health insurance in the UK is £1,435 per year, according to a 2018 report by BoughtByMany. However, this cost can vary based on age and health conditions.

In Australia, Members Health represents the interests of more than 5.3 million Australians through its 25 not-for-profit or member-owned funds. This demonstrates the significant number of individuals who rely on private health insurance and the importance of organizations that advocate for their members' health and wellbeing.

Private health insurance membership

The Australian Prudential Regulation Authority (APRA) publishes statistics on the private health insurance industry on a quarterly basis. These statistics cover areas such as membership, coverage, benefits paid, medical gap, medical devices, and medical services. The data is provided on a state and territory basis, giving insights into the number of insured persons for hospital and general treatment.

One example of a private health insurance provider is Medibank, which offers benefits such as accident cover boosts, 24/7 nurse support, and rewards programs. Medibank also provides promotional offers to new members, such as gift cards and free weeks of membership. Members with eligible extras cover can also receive benefits like 100% back on dental check-ups and optical items.

Another example is Members Health, which is a not-for-profit organization that puts members' health and wellbeing first. They have 25 funds that are not-for-profit or member-owned and represent the interests of over 5.3 million Australians. Members Health aims to provide affordable premiums, higher customer satisfaction, and better value to its members.

Medical gap statistics

The Australian Prudential Regulation Authority (APRA) publishes statistics on the private health insurance industry (PHI) on a quarterly basis. The statistics cover several areas, including membership, coverage, benefits paid, medical gap, medical devices or human tissue products, and medical services.

The medical gap statistics specifically contain data on in-hospital medical services, on a state and territory basis. The statistics are published in the form of Excel spreadsheets, which are available for download on the APRA website.

The most recent publication of the medical gap statistics was on 27 August 2024, which included data up to June 2024. The spreadsheet contains various sheets with tables providing detailed information on medical gap data. The sheets are organized by state or territory, with each sheet containing data for a specific location. The data includes information such as the number of services, benefits paid, and gap benefits for different medical procedures and treatments.

The medical gap statistics provide valuable insights into the gaps in private health insurance coverage and can be used to identify areas where improvements can be made to ensure better access to medical services for insured individuals. The data is also useful for comparing the differences in medical gap coverage across different states and territories in Australia.

Medical devices and human tissue products

The Australian Government Department of Health and Aged Care maintains a Prostheses List, which includes medical devices and human tissue products that private health insurers are required to pay benefits for, provided the patient has appropriate health insurance coverage. This list is updated every March, July, and November and was last updated on 1 July 2023.

The Prostheses List includes products such as:

• Hip, knee, or shoulder joint replacement devices
• Cardiac implantable electronic devices like pacemakers and implantable cardioverter defibrillators
• Vascular and cardiac stents
• Human tissue items like bone or bone fragments, vascular grafts, corneas, and heart valves
• Insulin infusion pumps
• Cardiac ablation catheters
• Cardiac remote monitoring systems

The list provides details such as the billing code, name, description, size(s), and minimum benefit amount for each product. It is categorised based on function, design, performance, and expected outcomes.

Additionally, the Australian Government has committed $22 million to reforming the Prostheses List by 2025 to make it more efficient, transparent, and adaptable to technological advancements.

The Prescribed List of Medical Devices and Human Tissue Products, effective from 8 August 2024, outlines the medical devices and human tissue products that private health insurers must cover for patients with appropriate insurance policies. This list is published under the authority of subsections 72-1, 72-10, and 333-20 of the PHI Act and is divided into four parts:

Part A: Medical devices that meet the criteria agreed upon by the Medical Devices and Human Tissue Advisory Committee (MDHTAC) and approved by the Minister. These include surgically implantable medical devices, aids for implanting medical devices, and critical components for the function of implanted devices.

Part B: Human tissue products, including those derived from human tissue and governed by state or territory law.

Part C: Medical devices that satisfy Part C criteria, such as insulin infusion pumps, implantable cardiac event recorders, cardiac monitoring systems, and cardiac ablation catheters.

Part D: General use items.

The Prescribed List is typically published three times per year and contains over 11,000 items, detailing the benefits payable for each.

Medical services

Private health insurance is a contract between an individual and a private health insurance company. It mandates that the insurer pays some or all of the individual's medical expenses as long as they pay their premium. Private health insurance is the most common way Americans get coverage, with an estimated 66% of Americans having a private health plan.

Private health insurance plans typically cover medical, hospital, and preventive care. They can vary significantly in terms of coverage but can help pay for a range of medical services, such as:

• Hospital services: Costs related to hospital stays, surgeries, and treatments received in a hospital.
• Medical services: Consultations, doctor visits, outpatient treatment, and preventive care expenses.
• Mental health services: Bills for mental health treatment, including therapy and counseling.
• Prescription drugs: Partial or full payment for prescription medication.
• Rehabilitation and physical therapy: Costs for occupational and physical therapy.
• Specialist care: Visits to specialists, such as cardiologists or dermatologists.

Private health insurance offers several benefits that enhance an individual's healthcare experience. These include:

• Choice of doctors and hospitals: Private health insurance often provides a broader choice of healthcare providers, allowing individuals to select doctors, specialists, and hospitals based on their preferences and needs.
• Comprehensive coverage options: Private health insurance plans offer various tiers and coverage levels, allowing individuals to choose a plan that suits their healthcare needs and budget.
• Faster access to healthcare services: Private health insurance often provides quicker access to appointments, medical procedures, and consultations.
• Access to advanced treatments: Private health insurance plans may cover advanced and innovative treatments not available through public healthcare programs.
• Reduced wait times: Private insurance can help reduce wait times for elective surgeries and specialized treatments, which may have longer waitlists in public healthcare systems.
• Coverage for additional services: Many private plans offer coverage for services not typically covered by public healthcare, such as chiropractic care, alternative therapies, and wellness programs.

The cost of private health insurance depends on several factors, including age, lifestyle choices, the number of individuals covered, and the region in which the plan is purchased. Private health insurance is typically more expensive than government-backed health insurance.

There are several types of private health insurance available:

• Individual health insurance: Designed for a single person and provides coverage solely for the policyholder.
• Family health insurance: Covers multiple family members, typically including a spouse and dependent children, under a single policy.
• Group health insurance: Provided by employers to their employees, covering a group of people and often resulting in lower premiums due to group purchasing power.
• Medicare Advantage (Medicare Part C): Offered by private insurers as an alternative to traditional Medicare, often including additional benefits like prescription drug coverage.
• Short-term health insurance: Provides temporary coverage for individuals experiencing a coverage gap, such as during a job transition, but offers limited benefits and is not a substitute for comprehensive major medical plans.
• Catastrophic health insurance: Designed for young, healthy individuals to protect against major medical expenses, with low premiums but high deductibles, mainly covering severe health events like accidents or serious illnesses.

Private health insurance can be obtained through an employer, the Affordable Care Act (ACA) marketplace, or directly from a health insurance company. It is important to carefully review and compare plans to find one that aligns with an individual's healthcare needs, budget, and preferences.

Frequently asked questions