All Bupa hospital cover features:
Accommodation for overnight and same day stays
Operating theatre, intensive care, ward fees
Bupa Medical Gap Scheme available
How to read our table:
Important product changes in 2018
|Changes from 1 July 2018|
|Impacted treatment type or feature||Description|
|Clinically Necessary Cosmetic Surgery||
Cosmetic Surgery & Reconstructive Surgery
We continue to cover you for Reconstructive Surgery, including procedures like breast reconstruction after breast cancer, and abdominoplasty due to abdominal muscle separation.From 1 July 2018, we’re updating our Fund Rules to clarify the definition of Cosmetic Surgery so you have a better idea of what is excluded and deemed as Cosmetic Surgery.
|Changes from 1 August 2018|
|Bupa Medical Gap Scheme||
Bupa Medical Gap Scheme
Our medical gap scheme helps you reduce the medical costs you pay yourself for in-hospital treatment. From 1 Aug, this will only apply in Members First, Network and Fixed Fee Hospitals. Find one of these hospitals or a Medical Gap Scheme provider here.Where the Medical Gap Scheme applies is changing.
Understanding Your Hospital Cover
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 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 60 days of their birth.
What we will pay for
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.
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.
What we won't pay for
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.
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.
Medicare Levy Surcharge
**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.
How to read our table:
$280 Non-Members First
$1,400 Per membership
Defined Appliances include TENS Machines, blood pressure monitors, insoles, orthopaedic and corrective footware, pressure garments, braces, artificial limbs. Limits apply per item. CPAP Devices subject to eligibility.
To receive benefits for health aids and appliances you'll need to visit a recognised provider. You will also need to meet the eligibility criteria, provide proof of purchase and a clinical referral where required.
Benefits are not claimable when a prescribed treatment is not custom made (eg. orthotics, surgical shoes). Call us if you would like any additional information on other criteria that applies to claiming health aids and appliances.
A benefit is also payable for the hire, repair and maintenance of health appliances. Restrictions and sub-limits apply. Benefits are not payable in the first 12 months after purchasing an item, within 12 months following the repair, or on items where hire and repair is deemed inappropriate.
Contact us for a full list of health aids and appliances that may be payable and for details of the limits that apply per item.
Couples = 2 services
(per calendar year)
Understanding Your Extras Cover
What is covered
Once you have served any applicable waiting periods you can claim benefits for those services included on your cover and that are not claimable elsewhere (e.g. from a third party like Medicare).
For example, Medicare does not provide benefits for:
- most dental examinations and treatment
- most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services
- acupuncture (unless part of a doctor’s consultation) or other natural therapies
- glasses and contact lenses
- most health aids and appliances
- home nursing.
Extras cover allows you to claim benefits for extras services as long as:
- the treatment is given by a private practice provider who is recognised and registered with us for benefit purposes
- they meet the criteria set out in our policies and Fund Rules.
We recommend you contact us before making a booking to confirm how much you can claim and to check that your chosen provider is registered with us.
What is not covered
Extras benefits will not be payable:
- during a waiting period
- where a third party, including Medicare, a Government body, or an insurance company provided a benefit (except for hearing aids and breast prosthesis items)
- for different services within the same service type from the same provider on the same day. For example, if you went to see an acupuncturist and then received a massage from the same provider on the same day, you cannot claim for both services
- when a prescribed treatment is not fully custom made (e.g. orthotics, surgical shoes)
- when a provider is not recognised by us for benefit purposes
- for any treatment or service rendered outside Australia
- when you have reached the maximums on your product including annual, lifetime or service limits for the service you are claiming.
A waiting period is the time between when you joined us and when you are covered for a service or treatment. If you receive a service treatment during this time, you are not eligible to receive a benefit payment from us, regardless of when you submit the claim. Different waiting periods apply for different services.
If you're changing from another Australian health fund to Bupa, you'll continue to be covered for all benefit entitlements that you had on you old cover, as long as these services are offered on your new cover with us.This is referred to as 'continuity of cover'. To receive continuity of cover, you'll need to transfer to us within 60 days of leaving your old fund.
If you are an existing member and you change your health cover, you may need to wait before you can access your new benifit. Where your new level of cover is higher than what you previously held, the lower level of benefits applies.
Waiting periods apply to services as listed below. Please refer to the fully policy details to determine the specific services that are covered under your level of cover, including the associated waiting periods for those services.
The following waiting periods apply for extras cover:
- initial waiting period - two months
- hire, repair and maintenance of health aids and appliances; and Health Management extras service - six months
- major dental, root fillings, orthodontics, selected health aids and appliances - 12 months
Understanding Your Ambulance Cover
When you, your partner or your family take out our hospital cover, extras cover or packaged cover, you will receive capped cover for recognised emergency ambulance transport and on-the-spot treatment.
An emergency is when there is reason to believe that the patient’s life may be in danger or the patient should be attended to without undue delay.
Transportation means a journey from the place where immediate medical treatment is sought to the casualty department of a receiving hospital.
Emergency ambulance transportation is defined as air or road transportation by a Recognised Ambulance Provider of an unplanned and of a non-routine nature for the purpose of providing immediate medical attention to a person.
Whether the transportation is deemed an emergency is determined by the paramedic and usually recorded on the account.
Benefits are not payable for:
- transportation from a hospital to your home
- transportation from a hospital to a nursing home
- transportation from a hospital to another hospital where the customer has been admitted to the transferring (first) hospital
- transportation from the person’s home, a nursing home or hospital for ongoing medical treatment, (eg chemotherapy, dialysis).
We recommend that you take out an ambulance subscription with your recognised State Ambulance Provider if it’s available in your state (VIC, SA, NT and rural postcodes in WA). We will only provide ambulance benefits, in accordance with your level of cover, when you do not hold a subscription with an ambulance provider and a state ambulance scheme does not provide cover.
NSW and ACT members: If you reside in New South Wales or the Australian Capital Territory and you have hospital cover, you pay an ambulance levy as part of your premium. This entitles you to free emergency ambulance transport under the State Government ambulance transport schemes.When you receive an account for ambulance transport, simply send it to us and we’ll endorse it for you to send back to the appropriate ambulance transport scheme.
QLD and TAS members: If you reside in Queensland or Tasmania, you are covered under your state service scheme.
VIC, SA, WA and NT members: If you reside in Victoria, South Australia, Western Australia or the Northern Territory you will receive cover for recognised emergency ambulance transport and on-the-spot treatment from us.This is as long as you don’t have an ambulance subscription with your state ambulance service or cover through a state-based arrangement.
Most state schemes cover their respective residents within their state of residence only. However, some states have entered into reciprocal agreements that allow you to be covered for ambulance services when you travel outside your state of residence. You should check with your state ambulance provider for when these reciprocal arrangements apply and the level of cover offered.
If you fall outside your state-based arrangement (including any reciprocal agreement) and are not covered for emergency ambulance services, you will be covered by Bupa up to the annual cap, as long as your level of cover contains ambulance cover and the services are provided by a recognised provider.
Why choose Bupa?
Some policies out there have so many exclusions that you’ll wonder what you are paying for. If you’re getting health cover, get quality health cover. Read more about what ‘quality’ really means, then see for yourself how our cover options offer both value and quality.Learn more
Privacy when it counts
We believe that the word ‘private’ should actually mean private. That’s why whether you choose a basic or top hospital cover with us, you’ll be covered for a private room in most private hospitals across Australia for the services included on your policy*. Plus if you pre-book at a Members First hospital you’ll receive a private room or you’ll get $50 back per night~.
Even when you’re in great health, there are still plenty of ways to get everyday value thanks to Bupa Plus. An exclusive range of rewarding health discounts, tools and more to help you live a healthier, happier life.Visit bupaplus.com.au
~Subject to availability and eligibility. Private room must be booked and requested at least 24hrs before admission. For every night a private room is unavailable, you’ll receive $50 back per night from the hospital. Applies to overnight admissions only. Excludes 'nursing home type patients', emergency care, same-day stays or where a private room is medically inappropriate.
What you need to join Bupa
Bank account details or a credit card
Australian Medicare details
A few minutes of your time