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) or if you go to a doctor or specialist in private practice anywhere in Australia.

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 Bupa.

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 and some of our products do not cover pregnancy and birth.

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 Prescribed List of Medical Devices and Human Tissue Products
• private room where available
• reimbursement on emergency department fees charged at any private or public hospital including administration fees if admitted into hospital (or in all circumstances depending on your level of cover)

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.

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:

• Overseas Visitor Working Cover: You will be covered for hospital accommodation. Shared room accommodation for restricted services, nil benefit for excluded services
• Overseas Visitor Non-Working Cover: You will be covered for hospital accommodation. For restricted services, reduced amount equivalent to shared room benefit for Australia resident. Nil benefit for excluded services.
• Both Overseas Visitor Non-Working and Working Covers:
  • 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 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 specialists 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.

Inpatient medical costs
These are the fees charged by your doctor, surgeon, anaesthetist or other specialist for any treatment given to you when you are admitted to a hospital as an inpatient. Depending on your level of cover, we cover you for either the Medicare Benefits Schedule (MBS) Fee, the Australian Medical Association (AMA) Schedule Fee, or 100% of the cost. The Schedule Fees mentioned above are the fees determined by the Australian Government and the AMA respectively, as the appropriate fee for a specific service for Australian residents. If your doctor or specialist charges more than the Schedule Fee there will be a ‘gap’ for you to pay. Please check your level of cover to determine which (if any) benefits apply.

Bupa Medical Gap Scheme
The Bupa Medical Gap Scheme is designed to remove or reduce the costs you pay for your treatment in hospital. Where a doctor chooses to use the Scheme for your treatment, they agree to only charge up to a certain fee. Bupa then pays a much higher amount than we normally would to help cover the extra cost. If a doctor uses the no-gap option, Bupa covers all of the extra charges, so you pay nothing for that doctor’s medical fees. Otherwise, for each doctor choosing to use the Gap Scheme, the most you’ll pay is up to $500 out-of-pocket on medical costs. Each doctor involved in your treatment can choose to use the Bupa Medical Gap Scheme for your admission in a Public Hospital, or a Private Hospital with which Bupa has an agreement.

See www.bupa.com.au/medicalgapscheme for more.

Outpatient medical costs
This is cover for any treatment you receive where you are not admitted into hospital in Australia from a doctor or specialist in private practice (including diagnostic services such as radiology and pathology). Depending on what is set out in your level of cover we will cover you for up to either 100%, 150% and 200% of the Medicare Benefits Schedule Fee (MBS Fee) or 100% of the cost for outpatient services. The MBS Fee is the amount determined by the Australian Government for a specific service for Australian residents. If your doctor or specialist charges more than the MBS Fee there will be a gap for you to pay.

We will determine the appropriate MBS item number for the service that has been provided, which may, in limited cases, be different from the item number provided. This can mean the amount we cover is lower than the benefit for the item number on your treatment bill, and there may be an additional cost to you.

Please check your level of cover to determine which (if any) benefits apply.

Outpatient pharmacy benefit
You can also receive benefits on selected pharmacy items prescribed as an outpatient or by a doctor or specialist. Please check your product summary to determine the benefits and co-payment that apply. This is provided the pharmacy items usage is approved by the Therapeutic Goods Administration (TGA) and not appearing on our exclusions list.

Please note for Short Stay Visitors Cover you can receive benefits for pharmacy items that are PBS listed and the usage is approved by the Therapeutic Goods Administration (TGA) and not appearing on our exclusions list.

Repatriation benefit
On selected covers, you will receive cover for repatriation to your country of origin if you become terminally ill or if you suffer a substantial life altering illness/injury up to $100,000. Or for the return of mortal remains up to $10,000. Benefits are only payable once approved by Bupa. 

No Repatriation Benefit will be paid if, within the six months prior to the date your cover commenced, you were: 

• first diagnosed as terminally ill;
• a reasonable person would have first become aware of the terminal illness; or
• if you suffered a substantial life altering illness or injury. 

Family In-Hospital Benefit
On selected covers, you could receive benefits for accommodation and meal costs if your partner, immediate family member, carer or next of kin is required to stay at hospital with you or a person on your membership. They will be covered for $60 per night for accommodation in hospital and up to $30 a day for hospital meals.

Hospital meals are covered when provided at a hospital cafeteria or patient meal menu.

Crutches and wheelchairs benefit
On selected covers, you will receive a benefit for crutches and wheelchairs.

For a benefit to be payable, the hire or purchase must be linked to an inpatient admission resulting in the requirement of the item. We will not pay benefits without evidence of a hospital admission.

If eligible, we will pay 100% of the cost up to a maximum limit of $500 per person per calendar year for any hire or purchase of crutches or wheelchairs.

Excess
On selected covers there may be an excess option which may lower the amount that you pay for your cover. Excesses are only payable on overnight and same-day inpatient hospital admissions in any hospital.

The total excess amount is paid each time a person on your membership is admitted into hospital, to a maximum of once per person and twice per membership each calendar year unless otherwise specified. If the total excess amount for an individual is not reached in a single hospital admission, the remaining balance of that excess is payable in any subsequent hospital admission. No excess applies to your dependent children. Please contact us for further details.

Situations when you are likely not be covered or may incur significant additional expenses include:

• depending on your level of cover, if 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) you may not be covered.
• 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 restricted services.
• 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 (e.g. chiropractors, dieticians or psychologists)
• where compensation, damages or benefits may be claimed by another source (e.g. 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 unless covered on your visitors or extras cover
• labour ward fees and pre-existing conditions on Short Stay Visitors Cover
• when you are treated at a non-agreement hospital you will not be fully covered
• some hospital-substitute treatment and operative services that are a continuation of care associated with an early discharge from hospital
• for any treatments arranged in advance of your arrival in Australia
• if you do not hold a valid visa at the time of admission to hospital and for the duration of your hospital stay.

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

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
• Costs for medical examinations, x-rays, inoculation or vaccinations and other treatments required relating to acquiring a visa for entry into Australia or permanent residency visa.
• Outpatient pregnancy services when provided out of hospital (including hospital outpatient clinics when you are not admitted) on Essential Lite Visitors Cover, Essential Visitors Cover and Essential 50 Visitors Cover.
• Outpatient psychiatric services when provided out of hospital (including hospital outpatient clinics when you are not admitted) on Essential Lite Visitors Cover, Essential Visitors Cover and Essential 50 Visitors Cover.

A waiting period is the time when you are not covered for a particular service. It starts on the date that you enter Australia or the date that you start your membership, whichever is later. If you receive a service or treatment during a waiting period, you are not eligible to receive a benefit payment from us, regardless of when you submit the claim.

If you’re changing your cover or switching from another insurer, waiting periods you've already served may be recognised on your new cover.

Different waiting periods apply for different services. You can find waiting period information in the cover summary document.

The following waiting periods may apply for hospital cover:

Working Cover
Waiting periods for Essential Lite Visitors Cover, Essential Visitors Cover, Essential 50 Visitors Cover, and Mid 60 Visitors Cover:

• Pre-existing conditions – 12 months
• Pregnancy and birth (obstetrics) – 12 months
• Palliative care, rehabilitation and hospital psychiatric services – 2 months
• Travel and accommodation – 2 months
• All other treatments – no waiting period

Corporate Overseas Visitors Cover
Waiting periods for Ultimate Corporate Visitors Cover, Top Corporate Visitors Cover, Top 90 Corporate Visitors Cover, Premium Visitors Cover and Premium 90 Visitors Cover:

• Pre-existing conditions – 12 months
• Pregnancy and birth (obstetrics) – 12 months
• Palliative care, rehabilitation, and hospital psychiatric services – 2 months
• Assisted reproductive services – 2 months (this service is not included in Premium Visitors Cover or Premium 90 Visitors Cover)
• Travel and accommodation – 2 months
• All other treatments – no waiting period

Visiting Cover
Waiting periods for Explorer Visitors Cover and Explorer 50 Visitors Cover:

• Pre-existing conditions – 12 months
• Hospital psychiatric treatments – 12 months
• All other inpatient treatments – 14 days
• Travel and accommodation – 2 months
• Emergency and non-emergency ambulance cover – 1 day
• Accidents sustained after joining – no waiting period

Waiting periods for Short Stay Visitors Cover:

• Palliative care, psychiatric and rehabilitation services – 12 months
• Travel and accommodation – 2 months
• All other treatments – no waiting period

You will receive unlimited emergency ambulance services. That means we will pay 100% of the charges for emergency transportation and on-the spot treatment, by our recognised providers^**.

You will receive limited non-emergency ambulance services. This means your cover will be limited to three times per person, per calendar year, for non-emergency transportation by our recognised providers. Please refer to your policy information for more information^**.

^**Short Stay Visitors Cover has emergency only ambulance cover.

A 1 day waiting period applies for emergency ambulance and on-the-spot treatment and non-emergency ambulance transportation on Explorer Visitors Cover and Explorer 50 Visitors Cover.

Recognised Ambulance Providers

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

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