Physio and Private Health Insurance Extras in Australia

In Australia, physio outside hospital is paid for by private health insurance through general treatment cover, better known as extras. For each session the insurer pays a benefit, within the limits of the patient's policy and once any waiting period is over. The patient pays the difference between that benefit and your fee, often called the gap. Medicare and a health fund cannot both pay for the same service. Give the patient your fee before the first session, and leave the benefit question to their insurer.

This page is written for physios running private clinics in Australia, and for patients with extras cover. The rules are explained in general terms, and nothing here is financial or legal advice. No insurer is named or compared, and no benefit amounts or limits are quoted, because every policy sets its own. For a real figure, check the policy's Private Health Information Statement or ask the insurer.

How does private health insurance cover physio?

Private health insurance has two parts: hospital cover and general treatment cover, and a policy can include one or both. PrivateHealth.gov.au, the consumer site managed by the Private Health Insurance Ombudsman, says general treatment cover "provides insurance against some or all costs of treatment by ancillary health service providers." Physiotherapy is on the site's list of services a policy may include. Whether a given policy covers it, and at what level, is up to that policy.

Physio sits under extras because Medicare mostly leaves it out. The same site lists "most physiotherapy" among the services Medicare does not cover, and adds: "Many of these items can be covered on private health insurance general treatment (extras) policies." The Australian Government's health department says it more briefly: "Extras cover helps with the cost of out-of-hospital health services that Medicare does not cover." In a private clinic, the main Medicare exception is a GP chronic condition management plan, which comes up later.

A hospital stay is a separate matter. When someone is admitted as a private patient, each health care provider involved in their care may charge a fee, and PrivateHealth.gov.au names physiotherapists among them. Extras cover is for services outside hospital. Before admission, the site advises asking the hospital and the doctors what will be covered and what the patient will pay, and checking with the insurer as well. Everything below is about physio in a private clinic.

How much does extras cover pay for physio?

The benefit is the amount the insurer pays towards a session. You set your own fee: PrivateHealth.gov.au notes that in Australia, "doctors and health care providers decide how much to charge for their services." Whatever the patient pays above the benefit comes out of their own pocket. People often call it the gap, which is the word the site uses for out-of-pocket costs in hospital.

Extras benefits are capped. In the site's words, "Nearly all services covered under general treatment are only covered to a limited extent. There are various limits that may apply, for example a limit per service, per year, or lifetime limits." Its glossary describes a benefit limit as "the most amount of money you can claim for a service, usually in a 12 month period." After a patient has claimed up to that amount, they pay the full fee until the period starts again. The reset date varies by policy: the glossary says annual limits "can be calculated based on a calendar year, or financial year, or for every 12-month period from the anniversary date" of taking out the policy. A combined limit, found on some policies, is a single amount shared by several services.

Each policy has a Private Health Information Statement (PHIS). Its general treatment section "describes the features and limitations of general treatment cover, including which services are covered, waiting periods, benefit limits and example benefits for each type of service". The statements can be looked up and compared on PrivateHealth.gov.au. So when a patient asks what they will get back, point them to their PHIS and their insurer. You cannot answer that one for them.

Changing insurer can also eat into the limit. PrivateHealth.gov.au says: "Benefits paid by the previous insurer may be taken into account by your new insurer when it determines your annual benefit limits." Someone who changed fund part way through the year may have less left than they think.

How long is the waiting period for physio on extras?

That is up to each insurer. The glossary on PrivateHealth.gov.au explains that the government "has set maximum waiting periods for benefits for hospital services, but insurers can set their own waiting periods for general treatment benefits." The health department is blunter: "Insurers can apply any waiting period for extras cover."

As a general guide, the waiting periods page says: "Generally, waiting periods vary from two to six months for items such as general dental, optical and physiotherapy, and up to 12 months or more for major items such as orthodontics or hearing aids." That page carries no date, so treat the range as typical rather than fixed. A patient's own waiting period is set out in their PHIS and the insurer's policy terms.

Some changes restart the clock. "When you start a new private health insurance policy or increase your level of cover, you have to complete waiting periods before you can claim benefits under your new level of cover," says PrivateHealth.gov.au.

Moving to an equal policy is different. According to the health department, insurers "must not give you extra waiting periods if you switch to a new policy that offers the same level of benefits as your old policy. This applies even if you change insurer." Timing still matters, and PrivateHealth.gov.au warns: "You only have a limited time to change between insurers without losing continuity of your waiting periods." Miss that window and the waiting periods have to be served again.

None of this stops a patient in a waiting period from booking and being treated. The glossary defines a waiting period as how long someone must be a member "before you are eligible for benefits", so the patient pays in full for sessions during that time. Their insurer can say whether any benefit applies.

Preferred providers and provider recognition

Some insurers run preferred provider arrangements. The PrivateHealth.gov.au glossary describes them as arrangements "with general treatment providers (known as preferred providers) to provide services to their members at a higher benefit rate than that of a non-preferred provider." Whether to join is a business call. Read the whole agreement before signing, and know what it asks of the clinic in return.

Patient choice comes into it. In its primary care reform platform, the Australian Physiotherapy Association (APA) calls for patients to have the right to choose where, when and how they see a physiotherapist of their choice, and for insurers to include more physiotherapy services in what they offer. A patient who asks whether they must use a preferred provider will find the answer in their policy terms, or from their insurer.

Preferred provider deals aside, the law sets a floor for who can give physio that a policy covers. Under the Private Health Insurance (Accreditation) Rules 2011 (rule 9), physiotherapy must be given by someone who meets the qualification requirements Medicare sets for allied health physiotherapy services. As suggested practice, ask each insurer what it needs from you and your clinic before its members start claiming for your sessions. Ask again whenever something about your practice changes.

Claiming at the clinic or afterwards

This section describes common practice, not rules set by a government source. Many clinics can lodge the claim on the spot, so the patient pays only the gap at the desk. If the clinic cannot claim for them, the patient pays in full and then claims from their insurer with the clinic's receipt. What that receipt must show is up to each insurer, so check with it.

The shared Code of conduct says practitioners "must be honest and transparent in financial arrangements with patients", and transparent in dealings with insurers (section 8.11). Day to day, a claim should match what actually happened, including the date and which physio saw the patient. If a claim at the desk is declined or pays less than the patient expected, tell them there and then and suggest they ring their insurer. Don't guess at the reason.

Can Medicare and private health insurance both pay for a physio session?

No. MBS note MN.3.1, on Medicare allied health services for chronic conditions, is direct about it: "Patients cannot claim MBS benefits and payments under their private health insurance fund for the same service."

Over a year, though, a patient can use both. With a GP chronic condition management plan in place, MN.3.1 says patients "can access up to 5 MBS-supported individual health services each calendar year (January to December)." All 5 can be physio, or they can be split between professions; the note gives "5 physiotherapy services" and "1 dietetic and 4 podiatry services" as examples. The patient also needs a GP referral and a plan that was prepared or reviewed within the previous 18 months. Patients with an older GP management plan and team care arrangement from before 1 July 2025 can keep using them for physio until the end of 30 June 2027 (MBS item 10960). The Medicare side has its own guide to physio under a GP chronic condition management plan.

How the 5 are used is the patient's call, and some would rather save them for another profession. The note puts it plainly: "Ultimately it is up to the patient to decide how they use their MBS benefits." For sessions beyond those, it mentions extras cover, state or Primary Health Network programs, and paying privately. The same note says providers "should obtain informed financial consent from patients for the service." For a clinic, that means settling how each session is funded before it happens and recording it in the notes.

For a registered physiotherapist, financial consent sits inside informed consent. The shared Code of conduct covers registered health practitioners in 12 professions, physiotherapy among them, and section 4.2 lists as good practice that you "get financial consent by discussing fees in a manner appropriate to the professional relationship and addressing the costs of all required services and get general agreement about the level of treatment to be provided, preferably before the service is provided". The Code says its values "apply to practitioners' conduct in every setting", so a private clinic is covered. The PrivateHealth.gov.au glossary also defines informed financial consent, but that definition is about hospital admissions, so in a clinic the Code is the one to follow. MN.3.1 expects the same for Medicare care plan services.

One way to handle it at intake (suggested practice, not a list from the Code):

Put your fees in writing where patients can find them, such as your website and the front desk, for a first visit and a follow-up.
Give the patient your fee before the first session. You cannot tell them their benefit, so suggest they ask their insurer what it pays per physio session and how much of the annual limit is left. They should also check whether a waiting period still applies.
Agree how each session will be paid for: extras, Medicare under a care plan, another funder, or the patient paying privately.
Record in the notes that fees were discussed and what was agreed.
Bring it up again before costs change, for example when your fee goes up or the patient is close to their annual limit.

Fees for missed sessions belong in the same talk. Writing that policy, and getting the patient to agree to it at intake, is covered in the guide to cancellation policies.

When something goes wrong

Start by talking it through: the patient with their insurer, or the patient with you. If that goes nowhere, the Private Health Insurance Ombudsman may be able to help. The Commonwealth Ombudsman says: "We can look into complaints about private health insurers, brokers, healthcare providers or hospitals." That includes complaints about healthcare providers where a private health insurance arrangement is involved, such as gap fees. The service is free for consumers. It asks people to try to resolve a complaint with their private health insurer before contacting it, and it cannot look into clinical issues, such as the quality of care a provider gave.

What should patients ask before their first physio visit?

What does the clinic charge for a first visit, and for follow-ups?
Does my policy include physio, and what will my insurer pay for each session? Your insurer and your PHIS can tell you.
How much of my yearly limit for physio is left, and when does it reset?
Am I still in a waiting period for physio?
Can the clinic claim for me on the spot, or do I pay the full fee and claim later?
If I have a GP chronic condition management plan, do I want to use one of my Medicare-supported services for this visit or claim it on extras? It cannot be both.

Being in a waiting period, or having used your limit, does not stop you being seen. It means you pay the full fee yourself. Unsure what your cover includes? Ring your insurer before the visit, not after.

Which symptoms need urgent care instead of a physio booking?

Urgent symptoms come before any question about cover. Each of the eight signs listed is copied word for word from this site's condition pages. Where a sign says "call emergency services", in Australia that means triple zero (000), described by healthdirect as "the national emergency service phone number." Same-day advice comes from your GP, or from healthdirect's helpline, 1800 022 222 (NURSE-ON-CALL in Victoria).

Emergency: any sign of a stroke, even if it goes away. That means a face that droops on one side, an arm you cannot lift or keep up, slurred or muddled speech, weakness or numbness on one side of your body or face, sudden blurred vision, double vision or loss of sight, trouble swallowing, sudden dizziness with unsteadiness or falling over, a sudden severe headache, or a sudden fall where your legs give way but you do not black out (a drop attack). Call emergency services straight away.
Chest pain or tightness, which may spread to your arm, neck or jaw, or shoulder or arm pain that comes with shortness of breath, sweating or feeling sick. This can be a heart attack. Call emergency services straight away.
Emergency: pain, tingling, numbness or weakness in both legs, numbness or altered feeling around your genitals or bottom, or new trouble peeing or controlling your bladder or bowels. The same applies if you lose feeling in one leg. Call emergency services or go to an emergency department straight away. These can be signs of pressure on the nerves at the base of the spine (cauda equina syndrome).
Emergency: you have had cancer, now or in the past, and your back or neck pain feels like a tight band around your body, or comes with pain spreading down an arm or leg, weakness, numbness or pins and needles in your arms or legs, trouble walking, or trouble controlling your bladder or bowels. Call your cancer team's emergency number straight away, or go to an emergency department if you do not have one or cannot get through. This can be cancer pressing on the spinal cord (metastatic spinal cord compression), which needs treatment straight away.
Emergency: back or leg pain that started after a serious accident, such as a car crash or a fall from a height, or back pain with chest pain. Call emergency services.
Emergency: you have had a fall or an injury and now have severe hip pain, or you cannot walk or put weight on the leg. Call emergency services or go to an emergency department. This can be a sign of a broken hip (hip fracture).
A calf or thigh that is newly swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
A leg or foot that is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.

These eight are only some of the warning signs. The condition pages list the ones that matter for each body area.

Making each funded session count

An annual limit caps how many sessions a patient can afford, so much of the rehab happens between visits. A short home program that the patient has already practised with you, with the dose written down, keeps things moving when the next appointment is weeks away. There is more on exercise choice and dosing in the guide to writing a home exercise program. For long-term problems, condition pages such as low back pain or knee osteoarthritis lay out programs in stages that you can adapt.

With PocketPhysio, you build that program from a library in which every exercise has a video and a voice guide. You decide the sets and reps for each exercise, plus any hold, and can attach your own cue to it. Patients receive it through Pocket Physio Care or as a link, an SMS or an email, and WhatsApp works as well. When they return, the last program is on file, so you can review it and progress it.

The short version

Extras cover is how private health insurance pays towards physio outside hospital, and each policy sets its own benefits and limits. Waiting periods are up to the insurer; PrivateHealth.gov.au gives two to six months as a general range for physio waiting periods, but the patient's PHIS has the real figures. The gap between your fee and the benefit is the patient's to pay. A single session cannot be funded by both Medicare and a health fund, so a patient with a GP chronic condition management plan picks one for each visit. Talk about fees before the first session, as the shared Code of conduct expects, and write down what was agreed.

References

Private Health Insurance Ombudsman. PrivateHealth.gov.au. What is covered by private health insurance? No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/health_insurance/what_is_covered/privatehealth.htm
Private Health Insurance Ombudsman. PrivateHealth.gov.au. What is covered by Medicare? No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/health_insurance/what_is_covered/medicare.htm
Private Health Insurance Ombudsman. PrivateHealth.gov.au. Waiting periods. No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/health_insurance/howitworks/waiting_periods.htm
Private Health Insurance Ombudsman. PrivateHealth.gov.au. Private Health Information Statements. No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/health_insurance/howitworks/phis_guide.htm
Private Health Insurance Ombudsman. PrivateHealth.gov.au. Out of pocket costs. No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/health_insurance/howitworks/out_of_pocket.htm
Private Health Insurance Ombudsman. PrivateHealth.gov.au. Managing your policy. No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/health_insurance/howitworks/managing_your_policy.htm
Private Health Insurance Ombudsman. PrivateHealth.gov.au. Glossary. No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/footer/glossary.htm
Private Health Insurance Ombudsman. PrivateHealth.gov.au. About this site. No date shown. Accessed 28 September 2026. https://www.privatehealth.gov.au/footer/about/index.htm
Australian Government Department of Health, Disability and Ageing. What private health insurance covers. Published 29 November 2022. Accessed 28 September 2026. https://www.health.gov.au/topics/private-health-insurance/what-private-health-insurance-covers
Australian Government Department of Health, Disability and Ageing. Waiting periods and exemptions. Published 26 April 2023. Accessed 28 September 2026. https://www.health.gov.au/topics/private-health-insurance/what-private-health-insurance-covers/waiting-periods-and-exemptions
Australian Government Department of Health, Disability and Ageing. MBS Online. Note MN.3.1, Individual allied health and Aboriginal and Torres Strait Islander health and wellbeing services (health services) for treating chronic conditions. Publication date 1 November 2025. Accessed 28 September 2026. https://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=MN.3.1
Australian Government Department of Health, Disability and Ageing. MBS Online. Item 10960 (physiotherapy health service). Description updated 1 July 2025. Accessed 28 September 2026. https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=10960
Commonwealth Ombudsman. Private health insurance complaints. No date shown. Accessed 28 September 2026. https://www.ombudsman.gov.au/complaints/private-health-insurance-complaints
Australian Health Practitioner Regulation Agency and National Boards. Shared Code of conduct, June 2022, section 4.2 (Informed consent) and section 8.11 (Financial and commercial dealings). Accessed 28 September 2026. https://www.ahpra.gov.au/Resources/Code-of-conduct/Shared-Code-of-conduct.aspx
Physiotherapy Board of Australia. Code of conduct. Page reviewed 29 June 2022. Accessed 28 September 2026. https://www.physiotherapyboard.gov.au/Codes-Guidelines/Code-of-conduct.aspx
Australian Physiotherapy Association. Primary care reform: private health insurance. No date shown. Accessed 28 September 2026. https://australian.physio/advocacy/primary-care-reform
Private Health Insurance (Accreditation) Rules 2011, rule 9. Federal Register of Legislation, compilation No. 3, compilation date 13 February 2019. Accessed 28 September 2026. https://www.legislation.gov.au/F2011L02241/latest/text
healthdirect Australia. Calling triple zero (000). No date shown. Accessed 28 September 2026. https://www.healthdirect.gov.au/calling-triple-zero
healthdirect Australia. How healthdirect can help you. No date shown. Accessed 28 September 2026. https://www.healthdirect.gov.au/how-healthdirect-can-help-you

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.

Private health insurance and physio in Australia: how extras cover works