Gold Ultimate Health Cover

The information below is general information which applies to all our hospital products - not just yours. It includes descriptions that may not be relevant to your product (for example, if your product does not include an excess, the description of an “excess” and how it works is not relevant to you). Read this information together with the list above to understand how your product works.

You are an inpatient when you are admitted to hospital. We will pay for treatment included in your chosen product once the hospital admits you. You are not an inpatient if you only receive treatment in a hospital emergency department.

You are an outpatient if you go to hospital to receive treatment but the hospital does not admit you (for example, you only undergo pathology tests or radiology services at the hospital and go home). You may be able to make a claim from Medicare to pay for those types of services as some of them are eligible for Medicare rebates.

If you have been a Bupa member for less than 12 months on your current hospital cover, it is important to contact us before you are admitted to hospital to find out whether the pre-existing condition waiting period applies to you. We need about five working days to make the pre-existing condition assessment, subject to the timely receipt of information from your treating medical practitioner/s. Make sure you allow for this timeframe when you agree to a hospital admission date. If you proceed with the admission without confirming benefit entitlements and we (the health fund) subsequently determine your condition to be pre-existing, you will be required to pay all hospital charges and medical charges not covered by Medicare.

If you are thinking about starting a family, we recommend you contact us in advance to confirm whether your cover includes pregnancy. This is because a 12-month waiting period applies to pregnancy and birth (including childbirth).

If you need assisted reproductive services, or IVF, these services have a 2 month waiting period. If these services are needed due to a pre-existing condition, a 12 month waiting period applies.

No waiting periods apply to your new baby provided they have been added to your hospital cover within 90 days of their birth.

Hospital costs are charges that are incurred as part of your treatment in hospital. Some common hospital costs include:

• accommodation for overnight or same-day stays
• operating theatre, intensive care and labour ward fees
• supplied pharmaceuticals approved by the Pharmaceutical Benefits Scheme
• physiotherapy, occupational therapy, speech therapy and other allied health services
• surgically implanted prostheses up to the approved benefits in the Government’s Prostheses List
• private room where available.

What happens if I am treated in a private hospital that Bupa has an agreement with?

Once you have served any waiting periods for your product, we will pay for medical treatment provided when you are a patient in private hospitals that Bupa has an agreement with, if it is included in your cover.

A small number of these hospitals may charge a fixed daily fee, which you must pay. This fee is capped at a maximum number of days for overnight stays. The hospital should inform you of this fee when you make a booking. This fee is in addition to any excess or co-payment you may have as part of your hospital cover.

At Members First Day Hospitals, you have the added benefit of no medical gaps in addition to being covered for hospital costs, provided the treatment is recognised by Medicare and there are no exclusions on your level of cover.^#

^{# Not available in NT. Any co-payment or excess related to your level of cover will still apply.}

Any co-payment or excess related to your level of cover will still apply. We recommend you call us first before making a booking to confirm that your chosen hospital gives certainty of full cover. We can also discuss any excess or co-payment that might apply to your level of cover. You can find out if a hospital has an agreement with us by checking the find a healthcare provider section of this website.

Can I choose to be treated as a private patient in a public hospital or at a private hospital that Bupa does not have an agreement with?

If you elect to be treated as a private patient in a public hospital or are admitted to a private hospital that Bupa does not have an agreement with, you are covered as set out below for any treatment recognised by Medicare unless it is excluded or restricted under your cover.

In these circumstances, you are likely to incur out-of-pocket expenses for your hospital costs.

What happens if I choose a private hospital that Bupa doesn’t have an agreement with?

If you are admitted to these hospitals for any treatment recognised by Medicare that is included in your cover:

• You will have restricted cover for your hospital costs. At these hospitals, this means that you are likely to have large out of pocket costs.
• You will still be covered for prostheses up to the amount listed on the Government Prostheses List.

How do I pay these costs?

It is important to note that you will be responsible for the cost of your stay and may be charged directly for your hospital accommodation, doctor’s services (including any diagnostic tests), surgically implanted prostheses (such as artificial hips) and personal expenses such as TV hire and telephone calls. Some of these hospitals bill Bupa directly for the limited benefits we pay.

Please check the medical costs section to understand how you’re covered for medical costs, like specialists fees.

What happens if I choose to be a private patient in a public hospital?

What we pay for

If you are admitted to these hospitals for any treatment recognised by Medicare that is included in your cover:

• You will have restricted cover for your hospital costs, which means that we will pay minimum benefits for shared room accommodation as set by the Australian Government. This will usually cover you for a shared room, but you may still have an amount to pay yourself.
• Depending on your level of cover, if you choose to stay in a private room, Bupa may pay an additional fixed amount towards the cost of your stay. If this amount is less than what the hospital charges you, the hospital should let you know what you will have to pay yourself.
• You will still be covered for prostheses up to the amount listed on the Government Prostheses List. If your specialist charges more than this amount, you will need to pay it yourself.

For what medical costs (like specialist’s fees) we pay for, check the medical costs section.

Other costs I might have to pay myself

As a private patient in a public hospital you will also be responsible for personal expenses such as TV hire and telephone calls together with any Medical Gaps your doctor/surgeon charges.

Will I get a private room?

It is important to note that in public hospitals, private rooms are generally allocated to people who medically need them.

What does this mean for my choice of doctor?

As a private patient in a public hospital you are entitled to choose your doctor, if they are available. Depending on your illness or condition, this may be the same doctor who would have been allocated to you by the hospital as a public patient. Additionally, whether a doctor provides treatment at a public hospital, or performs a particular procedure in a public hospital, is outside of Bupa’s control.

What does this mean for when I can get treatment?

At a public hospital, even if you are treated as a private patient - it is important to understand that you may still be subject to public hospital waiting lists.

These are the fees charged by a doctor, surgeon, anaesthetist or other specialist for any treatment given when you are in hospital. You are covered for the cost of these medical treatments up to the Medicare Benefit Schedule (MBS) fee. The MBS fee is the amount set by the Federal Government for each medical service covered by Medicare. You must be eligible for Medicare in order to be covered up to the MBS fee.

How benefit is calculated

If you choose to be treated as a private patient in a hospital (public or private), Medicare will cover you for 75% of the MBS fee for associated medical costs and we will cover the remaining 25%.

Bupa Medical Gap Scheme

The Bupa Medical Gap Scheme is an arrangement Bupa has with some medical specialists/doctors such as an anaesthetist to help minimise the amount you’ll need to pay for your medical costs in hospital.

No Gap

If you see a “No Gap” doctor that uses the Bupa Medical Gap Scheme you won’t have to pay any medical costs as your medical specialist or doctor will bill Bupa directly. Check with them that they will use this for your upcoming admission upfront. Known Gap If you see a ‘Known Gap’ doctor that uses the Bupa Medical Gap Scheme with you, you will need to pay up to $500 towards your medical costs.

Without the Gap Scheme

If your doctor is not using the gap scheme, Medicare will pay 75% and Bupa will pay 25% of the MBS fee. Any charge above that will be your gap.

Your choice of network

We are partnered with Genesis Heart Care, a network of cardiologists across VIC, QLD, SA and WA that focus on providing quality, evidence based cardiology services. When you see a cardiologist from Genesis Heart Care you will have certainty of no out-of-pocket expenses for your in-hospital cardiologist treatment. You’ll also be provided with information and advice so you can make informed decisions about your treatment and lifestyle.

Situations when you will not be covered include:

• when you have not been admitted into a hospital and are treated as an outpatient (e.g. emergency room treatment, outpatient ante-natal consultations with an obstetrician)
• during a waiting period
• when a service is excluded from your cover
• when a service is covered as a minimum benefit and you are admitted to a private hospital, you will not be covered above the minimum benefit
  
• for the fixed fee charged by a fixed fee hospital or a hospital that has a fixed fee service
  
• for psychiatric and rehabilitation day programs, at a hospital Bupa does not have an agreement with
  
• hospital treatment provided by a practitioner not authorised by a hospital to provide that treatment
  
• hospital treatment for which Medicare pays no benefit, including: medical costs related to surgical podiatry (including the fees charged by the podiatric surgeon); cosmetic surgery where not clinically necessary; respite care; experimental treatment and/or any treatment/procedure not approved by the Medical Services Advisory Committee (MSAC)
  
• personal expenses such as: pay TV, internet access, non-local phone calls, newspapers, boarder fees, meals ordered for your visitors, hairdressing and any other personal expenses charged to you unless included in your cover
  
• if you are in hospital for more than 35 days and you have been classified as a ‘nursing home type’ patient. (In this situation you may receive limited benefits and be required to make a personal contribution towards the cost of your care) if you choose to use your own allied health provider rather than the hospital’s practitioner for services that form part of your in-hospital treatment (eg chiropractors, dieticians or psychologists)
  
• where compensation, damages or benefits may be claimed by another source (eg workers compensation)
  
• for any amount charged by a public or non-agreement hospital which is not included by us or which is above the benefit that we pay
  
• for any treatment or service provided outside Australia
  
• for some non-PBS, high cost drugs
  
• for pharmacy items not opened at the point of leaving the hospital.
  

Please note that no cover is provided for Cosmetic Surgery. See our glossary for a definition.

We will not pay for medical treatment where a third party is already required to pay for that treatment. This includes where Medicare, workers compensation, transport accident or other types of insurance pay for some reason. There are also rules about what we are allowed to pay as a health insurer that we must abide by. We are not able to pay for medical treatment by a GP, for example or emergency room treatment even if it is in a hospital.

Doctors set their own fees for medical treatment. We pay for medical treatment up to an amount based on Medicare requirements. That is, Medicare pay part and we pay part of the Doctor’s fee up to a Medicare specified amount. We will not pay any part of a Doctor’s fee charged that is above the Medicare specified fee unless your medical specialist/doctor participates in our Medical Gap Scheme. To ensure peace of mind: ask your doctor about their fees and whether they participate in and use our Medical Gap Scheme before your medical treatment. Remember to ask your doctor about fees for other practitioners that may be involved in your medical treatment, such as the anaesthetist and assistant surgeons as they each charge separately.

You will not be covered for:

• medical services for surgical procedures performed by a dentist, surgical podiatrist, or any other practitioner or service that is not eligible for a rebate through Medicare.

A waiting period is a set amount of time during which you will not receive a benefit from us for a service or treatment included on your policy. You can switch from another health insurer to us and we will generally recognise any waiting periods that you have served on your old policy. We call this "portability". Different waiting periods apply for different services.

The following waiting periods apply for hospital cover:

• palliative care, psychiatric and rehabilitation services – two months
• pre-existing conditions, ailments or illnesses and pregnancy (including childbirth) – 12 months
• all other treatments included in your cover – two months.

Covers you against paying an additional levy known as the Medicare Levy Surcharge. This levy is tiered according to your level of income and whether you hold an appropriate level of private hospital cover. The income levels and surcharges are: singles earning more than $90,000 (1%), $105,000 (1.25%) and more than $140,000 (1.5%) or couples and families with combined taxable incomes greater than $180,000** (1%), $210,000** (1.25%) and $280,000** (1.5%).

**Family income thresholds increase by $1,500 for each additional child after the first child. Thresholds are effective 1 July 2014 and are indexed annually.

You should ask your tax adviser for more information or visit the Australian Taxation Office website.