Gold Ultimate Health Cover

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.

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 benefit. 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
• emergency ambulance transport or on-the-spot treatment – one day

Emergency ambulance is for an unplanned event where you’ve been injured or you have a medical emergency where your life may be at risk, or where you need medical treatment right away. The ambulance provider will confirm whether the transport or medical treatment was an emergency. 

Non-emergency ambulance is for situations when you need an ambulance but don’t need treatment right away. Non-emergency ambulance cover is not included as part of Bupa’s hospital and extras covers.

For example:

• Transport from a hospital to your home or nursing home.  
• Transport to a hospital, your home or nursing home for ongoing treatment, like dialysis or chemotherapy.  
• Where you’re admitted to one hospital and need to be taken to another.

Unlimited emergency ambulance services Australia-wide is included in most of our hospital and extras covers. That means we will pay 100% of the charges for emergency ambulance transportation and on-the-spot treatment by our recognised providers. A one-day waiting period applies.

If you can claim for an ambulance service with another provider, Bupa won’t pay a benefit. This includes state government ambulance subscriptions, or where the state government covers ambulance transport.

Find out more about ambulance cover in your state.

Recognised ambulance providers

Bupa will only pay benefits towards ambulance services when they are provided by any of the following providers:

• ACT Ambulance Service
• Ambulance Service of NSW
• Ambulance Victoria
• Queensland Ambulance Service
• South Australia Ambulance Service
• St John Ambulance Service NT
• St John Ambulance Service WA
• Tasmanian Ambulance Service.

From time to time, there may be changes to our Network Hospitals. Please visit Find a Provider to find out more about our Network Hospitals.

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 are thinking about starting a family, we recommend you contact us in advance to confirm whether your cover includes pregnancy. Starting from the date you add pregnancy cover, a 12-month waiting period applies to pregnancy and birth (including childbirth).

If you need Assisted Reproductive Services, or IVF, you’ll have to serve the waiting periods which are 12-months if your condition is deemed pre-existing by a Bupa appointed medical practitioner, or 2-months if deemed non-pre-existing. If you are in your first 12-months, please allow some time for Bupa to complete a pre-existing condition assessment before your admission.

When your baby is born, if you add them within 90 days of their birth, they won’t have any waiting periods.

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 Prescribed List of Medical Devices and Human Tissue Products
• 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.^#

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.

^#Customers must hold a Bupa hospital product that includes cover for their planned procedure. Waiting periods, fund and policy rules apply. Any co-payment or excess as part of your cover will still apply. Not available in the Northern Territory. Does not apply to: (a) services for surgical procedures performed by a dentist, oral surgeon, podiatrist, podiatric surgeon or any other practitioners which are not eligible for a Medicare rebate; or (b) services for treatment where the treatment doesn't satisfy the description and criteria of the relevant items listed in the Medicare Benefits Schedule.

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 Prescribed List of Medical Devices and Human Tissue Products.

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 Prescribed List of Medical Devices and Human Tissue Products. 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 Advara, a network of cardiologists across VIC, QLD, SA, NSW, and WA that focus on providing quality, evidence based cardiology services. When you see a cardiologist from Advara 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.
• emergency ambulance transport or on-the-spot treatment – one day

If you earn over a certain amount and have private hospital cover, you can avoid extra fees at tax time. This is called the Medicare Levy Surcharge (MLS).

The MLS is set by the Australian Government and is designed to ease stress on the public system by encouraging people to use private hospital services.

To avoid paying the MLS, you need private health cover that includes hospital treatments, not just extras or ambulance.

Applicable rebate percentages and income thresholds are reviewed annually by the Australian Government. Single parents and couples (including de facto couples) are subject to family tiers. For families with children, income thresholds are increased by $1,500 for each Medicare Levy Surcharge dependant child after the first child.

Learn more about the MLS.