Quarterly private health insurance membership and benefits summary - December 2025

Key metrics

Hospital treatment membership

Policies increase slightly from 6.07 million in December 2024 to 6.20 million in December 2025, while insured persons rise from 12.40 million to 12.69 million, with coverage at 45.6 per cent of the population and no change over the quarter.

General Treatment membership

Policies increase from 7.48 million in December 2024 to 7.63 million in December 2025, while insured persons rise from 15.06 million to 15.38 million, with coverage at 55.3 per cent of the population and no change over the quarter.

Hospital treatment episodes

Health insurance coverage increases over the 12 months to December 2025, with policies rising by 1.9 per cent and increasing by 2.2 per cent over the quarter, while the total number of policies grows from around 5.12 million to 5.22 million.

General treatment services (ancillary)

Insured persons increase over the 12 months to December 2025, rising by 3.2 per cent and increasing by 5.5 per cent over the quarter, with total insured persons growing from around 106.6 million to 110.0 million.

Benefits

Out- of -pocket per episode/service

Membership and coverage

Hospital Treatment

At 31 December 2025, 12,688,193 people, or 45.6% of the population, were covered by hospital treatment cover. There was a slight increase compared to September 2025. There was an increase in coverage of 54,262 insured people in the December 2025 quarter compared to September 2025. Family policies increased by 7,028 and single policies by 12,253 during the quarter. The largest increase in coverage during the quarter was 8,102 for people aged between 75 and 79.

The largest net increase (taking into account movement between age groups) was for the 0-4 with an increase of 25,668 people.

Net quarterly change in insured persons

Actual and net changes in policies vary widely by age group, with a large increase for ages 0–4, moderate gains across many working‑age groups, and declines in older age groups from around 80 and above.

Lifetime health cover

The majority of adults with hospital cover (87.2%) have a certified age of entry of 30, with no LHC loading.

At the end of the 31 December 2025 quarter, there were 1,165,332 people with a certified age of entry of more than 30 and subject to a Lifetime Health Cover loading: a net increase in people paying a penalty over the preceding 12 months of 78,833. There was a net increase in people with a certified age of entry of 30 (with no penalty) over the year of 87,479. Over the year, 89,893 people had their loading removed after paying a loading for ten years.

Number of persons insured by age

Insured persons by age group and sex (persons ’000) shown as a population pyramid: numbers peak in the 40–44 and 50–54 age groups for both sexes, are lower in younger ages (0–4 to 20–24), and decline steadily from around 70–74 through 90–94, with males generally slightly higher than females in most working‑age groups.

Hospital treatment tables

Percentage of insured persons by state varies, with highest coverage in Western Australia (54.7 per cent) and the ACT (54.2 per cent), and lowest in the Northern Territory (39.0 per cent). Counts of insured persons are highest in New South Wales and Victoria, with slightly more females than males in most states. The share of single and family policies is broadly even across all states, with family policies slightly higher in most jurisdictions.

General Treatment

At 31 December 2025, 15,377,145 people or 55.3% of the population had some form of general treatment cover. There was an increase of 60,236 people when compared to the September quarter. There was an increase of General Treatment policies of 32,590 for December 2025 which was mainly driven by Single Policies which increased by 18,201. For the 12 months to 31 December 2025, the number of insured persons with general treatment cover has increased by 316,354.

The general treatment (ancillary) by age charts and data in this report show data for those people that have general treatment policies covering ancillary services, regardless of other treatment included in the product. This excludes those general treatment policies that do not cover ancillary treatment.

There was an increase of 48,314 people with general treatment (ancillary) coverage in the December 2025 quarter. The largest net increase in coverage, after accounting for movements across age groups, was 25,487 for people in the 0 to 4 age group.

Net quarterly change in insured persons (ancillary)

Number of persons insured by age (ancillary)

General treatment tables (ancillary)

Percentage of insured persons varies by state, highest in Western Australia (68.2 per cent) and the ACT (66.1 per cent), and lowest in the Northern Territory (44.0 per cent). Total insured persons are highest in New South Wales and Victoria, with more females than males across all jurisdictions. The share of single and family policies is broadly even across states, with only minor differences between them.

Benefits Paid

Hospital treatment

Benefits per episode/service

Hospital treatment	December 2025	Change from September 2025
Acute	$2,868	1.0%
Medical	$70	2.6%
Medical devices or human tissue products	$665	1.3%
Cardiac	$3,102	1.0%
Hip	$1,656	1.2%
Knee	$1,670	-0.1%

Total benefits and growth rate

Hospital treatment	December 2025	Change from September 2025
Hospital	$5,359,059,230	2.9%
General	$1,813,546,622	7.4%

During the December 2025 quarter, insurers paid $5,359.06 million in hospital treatment benefits, which was 2.89% increase compared to the September 2025 quarter. Hospital treatment benefits were comprised of:

$3,917.82 million for hospital services such as accommodation and
nursing
$765.17million for medical services
$676.06 million for medical devices or human tissue items.

The age group for which most hospital benefits are paid is between 75 and 79 (top chart). Total benefits by age group is affected by the average benefits paid per person (displayed in the second chart) and the number of people in each age group.

Average hospital benefits per person increased from $1,510.35 for the year ending December 2024 to $1,577.36 for the year ending December 2025. The largest amount of benefits per person was spent on hospital accommodation and medical, followed by medical services and then medical devices or human tissue benefits.

Hospital treatment benefits paid by age 12 months to 31 December 2025

Number of persons insured by age shown as a population pyramid, with the largest populations in older working‑age and early retirement age groups (around 60–64, 70–74 and 75–79), and smaller populations in younger age groups. Numbers decline sharply from around 80–84 through 95+, with males and females broadly similar in distribution across most age groups.

Hospital treatment benefits per person covered and percentage of benefits paid by age cohort

Benefits per person increase steadily with age, rising from low levels in younger age groups to a peak around ages 85–94, before easing slightly at 95+. The share of total benefits rises with age to a peak around 75–79, then declines sharply in the oldest age groups.

Hospital treatment benefits per person

Total medical benefits per insured person increase from $1,510 in the 12 months to December 2024 to a higher overall level in 2025, with hospital treatment accounting for the largest component (about $1,150), followed by medical services (about $230) and medical devices or human tissue products (about $197).

General treatment

Benefits per service

-	December 2025	Change from September 2025
Dental	$68	0.4%
Chiropractic	$34	-2.3%
Physiotherapy	$42	-0.2%
Optical	$84	0.3%

During the December 2025 quarter, insurers paid $1,802.02 million in general treatment (ancillary) benefits. This was an increase of 7.7% compared to the September 2025 quarter. Ancillary benefits for the December 2025 quarter included the major categories of:

Dental $989.93 million
Optical $327.24 million
Physiotherapy $117.83 million
Chiropractic $68.36 million.

There is a marked difference between the distribution of benefits over age groups between hospital benefits and ancillary benefits. The major difference is the higher claiming rate in older age groups for hospital benefits while benefits per person for ancillary benefits are more evenly spread over the age groups.

General treatment (ancillary) benefits per person during the year to December 2024 were $482.93 increased to $502.08 for the year to December 2025. The largest component of ancillary benefits is dental, for which $277.87 was paid per insured.

General treatment benefits paid by age 12 months to 31 December 2025 (ancillary)

Total hospital benefits paid by age group (thousands) show a population pyramid, with the highest benefits in older age groups, particularly around 70–74 and 75–79. Benefits increase steadily with age from younger groups, then decline sharply from around 85–89 through 95+, with males and females showing similar overall patterns across age groups.

General treatment benefits per person covered and percentage of benefits paid by age cohort (ancillary)

Benefits per person increase steadily with age, rising from low levels in younger groups to a peak around 70–79, then gradually decline in older age groups. The share of total benefits follows a similar pattern, increasing through middle and older working ages before peaking and then falling sharply from around 80 onwards.

General treatment benefits per person (ancillary)

Medical benefits

Total benefits for medical services decreased by 0.8% during the December quarter 2025.

The change in medical benefits paid per service was calculated over a range of medical services and does not mean medical services overall decreased or increased in cost. The average benefits paid reflects the type of medical services utilised during the quarter as well as the volume of services. The medical service for which the greatest amount of benefits was paid was anaesthetics, comprising 25.4% of all medical benefits and totalling $196.02 million.

Medical devices or human tissue benefits

Total benefits paid for medical devices or human tissue products increased by 5.6% in December 2025 compared to September 2025. Similar to medical services, the change in benefits paid for medical devices or human tissue products was calculated over a range of medical devices or human tissue products (see chart) and does not mean medical devices or human tissue products overall changed in cost. The change in benefits paid may reflect a change in the type of medical devices or human tissue products utilised, or a change in the overall utilisation of medical devices or human tissue products. The medical devices or human tissue products group for which the greatest amount of benefits were paid was cardiac, comprising 18.3% of all medical devices or human tissue products benefits and totalling $123.82 million.

Medical benefits by Speciality group

Medical benefits by specialty are distributed across multiple categories, with anaesthesia accounting for the largest share (26 per cent), followed by specialist services (9 per cent), orthopaedics (6 per cent), pathology (6 per cent), and general surgical (5 per cent). The remaining 39 per cent is spread across smaller specialty groups, including cardiothoracic, ophthalmology, diagnostic, colorectal, urology, intensive care, plastic and reconstructive, vascular, ENT, and other categories.

Benefits paid for medical devices or human tissue products

Hospital benefits by procedure category shown as a pie chart, with the largest shares from cardiac (18%), other (14%), knee (12%) and orthopaedic (12%), followed by hip (10%) and general miscellaneous (11%). Smaller shares include spinal (6%), ophthalmic (5%), vascular (3%), urogenital (2%), neurosurgical (2%), ENT (2%), and very small shares for plastic/reconstructive (1%) and cardiothoracic (1%).

Service utilisation

Episodes/Services by type

Episode/Service	December 2025	Change from September 2025
Hospital Episodes	1,365,591	2.2%
Hospital Days	3,311,678	1.1%
Medical Services	11,002,976	-3.3%
Medical devices or human tissue Item	1,016,058	4.2%
Specialist Orthopaedic	187,125	-1.8%
Ophthalmic	116,323	4.6%
Spinal	60,144	10.1%
General Treatment	28,351,227	5.5%
Dental	14,553,364	4.0%
Chiropractic	2,014,261	-10.3%
Physiotherapy	2,830,559	-9.5%
Optical	3,910,744	52.7%

During the December 2025 quarter, insurers paid benefits for 3.3 million days in hospital, arising from 1.4 million hospital episodes of care.

Hospital utilisation is distributed over four categories of hospital - public, private, day only facilities and hospital-substitute. During the December 2025 quarter, hospital episodes were distributed as follows:

public hospitals 185,846 episodes
private hospitals 920,271 episodes
day hospital facilities 74,382 episodes

For the December 2025 quarter, hospital utilisation (measured in episodes) increased by 2.2 % which was mainly driven by hospitals-substitute.

-	Quarter change	Year change
Public hospitals	+4.4%	-0.7%
Private hospitals	+2.0%	+1.8%
Day hospital facilities	+1.5%	+2.8%
Hospital-substitute	+0.7%	+8.6%

Day-only episodes in the four categories of hospital totalled 964,313 with a 2.2% change compared to September 2025.

Hospital treatment services per 1,000 insured persons

Quarterly trends in hospital activity and related services show moderate fluctuation over time: medical services remain the highest and generally increase overall with a dip around March 2025, acute days follow a similar but lower pattern with minor variation, acute episodes remain relatively stable with slight growth, and prostheses items show gradual, modest increases throughout the period.

General treatment services (ancillary) per 1,000 insured persons

Dental benefits remain the highest and show a gradual upward trend over time, while optical benefits fluctuate more noticeably with periodic peaks and dips. Physiotherapy benefits remain relatively stable with minor variation, and chiropractic benefits are consistently the lowest, showing only small gradual changes across the period.

Out-of-pocket payments

Average out-of-pocket per episode/service

-	December 2025	Change from September 25	Change from December 24
Hospital treatment	$471.29	-1.6%	7.7%
Hospital-substitute treatment	$3.60	-3.6%	-3.8%
General treatment ancillary	$62.87	-1.0%	5.6%
Medical gap where gap was paid	$277.36	2.3%	0.3%

The average out-of-pocket (gap) payment for a hospital episode was $471.29 in the December 2025 quarter. This included out-of-pocket payments for medical services, in addition to any excess or co-payment amounts relating to hospital accommodation.

The out-of-pocket payments for hospital episodes increased by 7.7% compared to the same quarter for the previous year. Out-of-pocket payments for medical services were $277.36 where an out-of-pocket payment was payable. The amount of gap for medical services varies depending on the specialty group. The specialty group with the largest out-of-pocket payment was Orthopaedic with an average gap of $847.36. Gap incurred for the various medical services is displayed in the first chart. Medical gap also varies by state and territory, and these differences are shown in the bottom chart.

Medical benefits and out-of-pocket by specialty group

Benefits as a share of charges vary widely by specialty, with most procedures having benefits covering a high proportion of charges (often 85–100%), including ICU (100%), specialist consultants (99%), and plastic/reconstructive (100%). Lower coverage is observed in some areas such as urology (61%), ENT (62%), and orthopaedics (61%), which have larger gap percentages.

Proportion of services and average out-of-pocket payments

Proportion of medical services with no gap is highest in NSW (87.3%) and lowest in the ACT (71.0%) and NT (73.8%). Average gap payments are highest in the ACT ($382.31 where a gap was paid; $111.05 across all services) and lowest in South Australia ($190.63 where a gap was paid; $28.12 across all services), with Australia overall at 85.7% no gap and average gaps of $277.45 (where paid) and $39.58 (across all services).