If you have ever paid for health insurance in Australia and then been charged in full at a physiotherapy clinic, this is almost always the reason: you have hospital cover but not extras cover, and physiotherapy lives in extras.

Extras is the least-explained part of the Australian health system and the one that decides what you pay at a physio, a dentist or an optometrist. Here is how it actually works.

Hospital and extras are two different things

Australian private health insurance is sold as two separate products. Many people buy only one and assume they bought everything.

  • Hospital cover pays towards being admitted to hospital as a private patient — surgery, a private room, choosing your own surgeon, shorter waiting lists.
  • Extras cover — also written as general treatment or ancillary — pays towards treatment you receive without being admitted: dental, optical, physiotherapy, chiropractic, podiatry, psychology, remedial massage.

A physiotherapy appointment in a clinic is an extras claim. Top-level hospital cover pays nothing towards it. This catches out people who have held insurance for a decade.

The four numbers that decide what you pay

Every extras policy is described by the same four things. Find these four and you know exactly what an appointment costs you.

1. The annual limit

A maximum amount the fund will pay for physiotherapy in a year, per person. Once you reach it, you pay the full fee for the rest of the year. Limits vary enormously between policies.

2. The benefit per visit

What you get back for one appointment — either a set dollar amount or a percentage of the fee. It is almost never the whole fee. On most policies an initial consultation attracts a higher benefit than the follow-up appointments after it.

3. The gap

The difference between the fee and the benefit. This is what you actually hand over. If an appointment is $89 and your benefit is $55, your gap is $34 — that is your real cost, and it is the number worth comparing between policies.

4. The waiting period

A period after joining during which you pay premiums but cannot claim. For general extras this is commonly around two months, though it varies by fund and by service. If you joined last week specifically because your back hurts, check this one first.

When the limit resets

Most funds reset extras limits on 1 January, but not all — some use 1 July, and some use the anniversary of your policy. It is worth knowing which, for two reasons: unused limit does not usually carry over, and a course of treatment that runs across the reset date effectively gets two years' worth of limit.

What OVHC is, and why it often has no physio

Overseas Visitor Health Cover is health insurance for temporary visa holders who are not students — skilled work visas, temporary graduate visas, working holiday visas, and visitors. Some visas carry a condition requiring you to hold adequate insurance for your stay.

Here is the part that matters. OVHC exists to stand in for Medicare, which you cannot access on most temporary visas. So it is built to cover roughly what Medicare covers: doctors and hospitals.

Medicare does not pay for ordinary physiotherapy appointments — not for you, and not for Australians either. So a basic or budget OVHC policy does not include physiotherapy. It is working as designed.

Mid-range and premium OVHC products often bundle extras cover in, and those do pay for physiotherapy. Two people can both say “I have OVHC” and be in completely different positions.

How to read your own policy

Do not rely on the product name or on what a colleague on a different policy tells you. Open your insurer's app or ring the number on your card and ask:

  • “Does my policy include extras, also called general treatment?”
  • “Is physiotherapy included, and what is the benefit for an initial appointment and for a follow-up?”
  • “Is there a waiting period, and have I served it?”
  • “How much of my annual limit is left, and when does it reset?”

Every insurer will answer those. If you would rather not do it by phone, the app usually shows the same information in writing.

What happens at reception: HICAPS

You do not have to pay the full amount and claim it back later. Australian clinics use a system called HICAPS: you hand over your health fund card, the claim goes to your fund immediately, the benefit is deducted, and you pay only the gap by card or cash before you leave.

We claim every registered Australian health fund on the spot this way. Bring the card to your first appointment — the physical card or the one in your fund's app both work.

Preferred provider agreements

With Medibank (Members' Choice Advantage), HCF (More for Muscles) and nib (First Choice) we hold a preferred provider agreement, which usually means a higher benefit and a smaller gap for members of those funds.

One thing worth knowing if you are with a smaller brand: because nib also underwrites Suncorp, AAMI, Apia, GU Health and Qantas health cover, members of those generally get the same benefit — even though nothing on the card says nib.

Is extras cover worth buying?

An honest answer rather than a sales one: it depends entirely on how much treatment you actually use.

Work out roughly what you would claim in a year — a dental check-up or two, glasses if you need them, whatever physiotherapy you realistically expect — and compare that to twelve months of premiums. For someone who visits a dentist once and nothing else, extras often costs more than it returns. For someone managing an ongoing problem, or a family with children in sport, it usually does not.

It is your call, and we have no stake in it. We are not insurance brokers and we do not receive anything from any fund.

If you have no extras cover

You pay for the appointment yourself, which is what a great many people do. Our current fees are on the payment options page, and new patients can currently book a reduced-price initial consultation with our physiotherapist Saloni — conditions are on the new patient offer page.

Before you assume you are paying, check whether one of these applies:

  • A work injury as an employee — a ReturnToWorkSA claim may cover the treatment rather than you.
  • A car accident in South Australia — Compulsory Third Party insurance may cover treatment, including for passengers, cyclists and pedestrians.
  • Medicare plus a long-term condition — a GP can write a Chronic Condition Management Plan, and we bulk bill those sessions in full. This one needs Medicare, so it does not help most temporary visa holders.
  • NDIS or DVA — see the NDIS and DVA pages.

Where to start

You do not need a referral to see a physiotherapist in Australia. Ring us on 0403 907 587 and ask what an appointment will cost in your situation — we would rather tell you before you come than surprise you at reception. Or book online.

We are at 177 Trimmer Parade, Seaton SA 5023, with free parking. Our physiotherapists speak English, Hindi and Gujarati between them — see languages we speak.

If you are on a student visa, the OSHC rules are slightly different — see does OSHC cover physiotherapy. For the whole picture, start with Medicare, private health and OSHC: who pays for your physio.

This article is general information about health insurance in Australia. It is not financial advice, not a recommendation to buy or not buy any insurance product, and not individual medical advice. Policies differ between funds and between products; waiting periods, limits and reset dates mentioned here are typical rather than universal, and the only reliable description of your cover is the one your own insurer gives you. Fees mentioned are correct at the time of writing.

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