If you haven’t been to hospital very often, you may not be familiar with how the hospital system works. So we’ve created this guide, especially for you.
In this guide
With this guide, our goal is to help make your hospital experience as simple as possible. From discussing your treatment with your specialist, to making a successful recovery, there are many steps to consider before, during and after your hospital stay.
This guide will hopefully make these steps easier for you. It includes information about the hospital process - from what to pack to how to claim.
If you feel overwhelmed or need more information, feel free to call us. We’re here to help you understand and make the most of your cover. Alternatively please visit Understanding your cover.
Preparing for your stay
In most cases your admission to hospital arises from a visit to your General Practitioner (GP), who then refers you to a specialist - either a surgeon or physician. Here's what we recommend you do before going to hospital:
1.Talk to us
To get the most from your cover, like avoiding unexpected out-of-pocket expenses and confusion, call us before planning your stay.
You may want to ask us the following questions:
- Am I covered for my treatment?
- Are there any waiting periods, exclusions or restricted cover?
- Do I need to pay any excess or co-payments?
- Which hospital should I go to, and what's the difference between a 'Members First' and a 'Network' hospital?
2. Talk to your GP
There are several options you can discuss with your GP to ensure you pay minimal out-of-pocket expenses for your treatment. Ask your GP questions including:
- Can you refer me to a specialist who uses the Bupa Medical Gap scheme?
- Can you give me an open referral? This means you can choose from a list of relevant specialists. You can then call us to find a specialist who uses our Medical Gap scheme.
- Can you refer me to specialists who can treat me in a Members First or Network hospital?
3. Talk to your specialist
The next step will be a consultation with your specialist.
Before agreeing to your hospital treatment, be sure to ask the following:
- Can you tell me more about my condition?
- What are my treatment options including non-surgical options, different types of surgery and the consequences of not having treatment?
- What are the benefits and risks of each treatment option (eg potential complications)?
Other questions to ask include:
- What hospital/s do you recommend and why?
- How long will I be in hospital for?
- Do you use the Bupa Medical Gap Scheme, and if not, what will my out-of-pocket expenses be?
- Can you confirm what other specialists will be involved in my treatment (eg anaesthetist, pathologist, radiologist, assistant surgeon) and whether they use the Medical Gap scheme?
- Does my treatment involve a prosthesis (eg hip or knee replacement, cardiac stent) and, if so, will I incur an out-of-pocket expense?
- Should I continue taking the medicines I'm on?
- Can you provide me with a medical certificate (for leave from work)?
- How long will it take me to recover and will I need assistance (eg help at home or in a rehabilitation centre)?
Informed financial consent
If your hospital stay involves any out-of-pocket hospital charges, the hospital (whether private or public) should disclose the cost and obtain your agreement in writing before your admission.
If your doctors' fees include any out-of-pocket charges, your specialist should disclose the cost and obtain your agreement before your admission to hospital. They should provide advice on fees charged not only by themselves but also by other specialists or surgeons as well as by anaesthetists, assistant surgeons, pathologists and radiologists.
Bupa Medical Gap Scheme
The Medicare Benefit Schedule (MBS) fee is the amount set by the Federal Government for a medical service. When you receive treatment in hospital as a private patient, Medicare pays 75 percent of the MBS fee and Bupa pays the remaining 25 percent.
If your specialist charges more than the MBS fee, there will be an out-of-pocket expense (also known as a 'gap amount' or 'medical gap'), which you'll have to pay.
You can reduce or eliminate this gap amount if you choose a specialist who uses our Medical Gap Scheme - an arrangement designed by us for your benefit.
Whether or not your specialist uses our Medical Gap Scheme, here's how it works:
Your specialist uses our Medical Gap Scheme with no out-of-pocket expense
- Your specialist accepts Bupa's agreed payment and the Medicare benefit as full payment of their services.
- Your specialist will send your account directly to Bupa and Medicare for payment.
- You won't receive a bill and won't have to make a claim.
Your specialist uses our Medical Gap Scheme but also charges an out-of-pocket expense
- Your specialist will tell you the gap amount you need to pay (also called 'Known Gap'). If not, you should ask.
- You'll need to sign a form, acknowledging that you've been told of the gap amount.
- You'll receive an invoice from your specialist for the gap amount either before or after your treatment. An account for the remainder will go to Bupa and Medicare.
Your specialist doesn't use our Medical Gap Scheme
- You should be told of the expected cost and sign a form consenting to the expense.
- You'll receive an account from your specialist after treatment.
- You can then claim up to the MBS fee from Bupa and Medicare, and pay the balance to the specialist.
Prior to your treatment, ask your specialist if they will use our Medical Gap Scheme. Alternatively, ask us or your GP for the details of specialists who use our Medical Gap scheme.
Choosing a hospital
As a Bupa member with private hospital cover, you can choose to be treated in either a private or public hospital. Your choice will depend on your level of cover and the type of treatment you're having. Keep in mind that even as a private patient in a public hospital, it's possible you'll be placed on a waiting list.
Private or public patient
|Private patient in a private hospital||Private patient in a public hospital||Public patient in public hospital|
|Covered for hospital expenses (ie accommodation, theatre and intensive care fees)||See more information below|
|Covered for specialist's fees, up to the MBS fee or our Medical Gap Scheme benefit||NOT APPLICABLE|
|Your choice of specialist|
|Your choice of hospital|
|Ability to access treatment at your convenience|
Private patient in a public hospital
If you elect to be treated as a private patient in a public hospital:
- 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. 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 the amount we pay is less than what the hospital charges you, the hospital should let you know what you will have to pay yourself. They should do so before you elect to be a private patient.
Choosing a private hospital
Get the most from your cover by selecting one of our Members First or Network hospitals and day facilities - we've entered into a special agreement with them to help reduce or eliminate your out-of-pocket hospital expenses.
At Members First hospitals and day facilities, in most instances you'll be fully covered for your hospital expenses, such as accommodation, theatre and intensive care fees. At Members First day facilities there are also no out-of-pocket expenses for medical treatments (eg your specialist's fees).*
At Members First hospitals, you'll also have access to special benefits such as our 'private room or money back offer'^, a daily newspaper, local phone calls and free-to-air TV at no additional cost.
We've also negotiated maternity care at Members First hospitals that offer obstetric services. At these hospitals you can benefit from:
- childbirth and parenting education classes prior to and after delivery;
postnatal clinics that provide support, advice and education to mothers and families for up to eight weeks after you leave hospital;
- a 24-hour postnatal support phone line;
- parenting support services; and
- breastfeeding classes for new and experienced mothers.
*Available in NSW, QLD, SA, TAS, VIC and WA.
^You must book and request a private room in a Members First hospital at least 24 hours before admission. If you don't get a private room you'll receive $50 a day from the hospital for every day you're not in a private room. Applies to overnight admissions only. Excludes 'nursing home type patients', emergency care, same-day stays or where a private room is medically inappropriate.
These are private hospitals and day facilities where, in most instances, you'll be fully covered for your hospital expenses such as accommodation, theatre and intensive care fees. At a Network hospital, you'll also have access to local phone calls and free-to-air TV at no additional cost.
To find your nearest Members First or Network hospital, visit Find A Healthcare Provider.
This is a daily charge billed by a small number of Network hospitals that you're responsible for paying. The hospital should inform you of any fee when you make a booking.
Fixed fees allow us to bring you a greater range of hospitals that provide certainty around your costs. And if you have Ultimate Health cover, you're reimbursed for any fixed fee.
These are private hospitals and day facilities that have not entered into an agreement with Bupa. Because of this, you may incur large out-of-pocket expenses when attending one of these hospitals.
Bringing you greater value and certainty
- Members First and Network hospitals - we've entered into a special agreement with them to help reduce or eliminate your out-of-pocket hospital expenses.
- 'Private room or money back offer'* at Members First hospitals.
- Other special benefits at Members First hospitals#.
- The Bupa Medical Gap Scheme is designed to reduce or eliminate your out-of-pocket medical expenses.
- Members First day facilities extend the no-gap arrangement to medical treatments (eg specialist's fees).
* You must book and request a private room in a Members First hospital at least 24 hours before admission. If you don't get a private room you'll receive $50 a day from the hospital for every day you're not in a private room. Applies to overnight admissions only. Excludes 'nursing home type patients', emergency care, same-day stays or where a private room is medically inappropriate.
# Includes a daily newspaper, local phone calls and free-to-air TV at no additional cost. We've also negotiated maternity care at Members First hospitals that offer obstetric services.
What to take with you
We suggest you pack:
- your Bupa membership card
- your Medicare card
- medicines you're taking, including prescription and non-prescription medicines such as complementary medicines, vitamins and over-the-counter painkillers
- X-rays or medical images
- specialist's letters or referrals
- information about your blood type
- your hospital bag for labour (if pregnant)
- your hospital's pre-admission pack (if you received one).
If you're staying in hospital overnight, don't forget the following items (and remember to keep valuable personal items at home):
- Slippers (non-slip)
- Day clothes
- Toothbrush and toothpaste
- Antiseptic soap
- Shampoo and conditioner
- Personal music player
Before hospital checklist
Call us first to discuss your cover including any waiting periods, exclusions, restricted cover, excess or co-payments
Talk to your GP about selecting an appropriate specialist.
Talk to your specialist about your condition, treatment options and any out-of-pocket expenses.
Learn about our Medical Gap Scheme, designed to reduce or eliminate your out-of-pocket medical expenses.
Choose your hospital - select one of our Members First or Network hospitals or day facilities to reduce your out-of-pocket hospital expenses.
Prepare for your stay by deciding what to take.
What to expect
While every hospital works a little differently, the following may assist you during your stay.
Ask your hospital about their visiting hours and arrangements for your family and friends. Find out who is considered 'family', arrangements for parents or guardians (if the patient is a child), and when your friends can visit.
Ask your nurse about meal times and how to order, and let the nurses know if you have any dietary restrictions. Information about meals is often included on the hospital's television information channel.
Some hospitals charge for television use and some have their own information channel explaining their services. Note that you're covered for free-to-air TV at our Members First and Network hospitals.
Some hospitals will charge you to make local, interstate and international calls. Others restrict the use of mobile phones within the hospital. Note that you'll be able to make local telephone calls for no additional cost at our Members First and Network hospitals.
Most hospitals offer wireless internet (Wi-Fi) though some may charge you to use it.
What you're covered for
Your hospital costs
If you're admitted to hospital as a private patient you're covered for the hospital's service charges, which typically include:
- accommodation for overnight or same-day stays
- operating theatre, intensive care and labour ward fees
- supplied pharmaceuticals approved by the Pharmaceutical Benefits Scheme (PBS)
- allied services including physiotherapy, occupational therapy and dietetics
- dressings and other consumables
- pathology and radiology diagnostic tests (recognised by Medicare) performed in hospital by Bupa contracted providers
- surgically implanted prostheses (eg a cardiac stent) up to the approved benefit in the Government's Prostheses List. To avoid any out-of-pocket expense, we suggest discussing prosthesis choices with your specialist before going to hospital.
Your medical costs
These are the fees charged by specialists involved in your hospital treatment.
As a private patient, you're covered for the cost of medical treatment up to the MBS fee. Medicare pays 75 percent of the MBS fee and Bupa pays the remaining 25 percent. If your specialist charges more than the MBS fee, there will be a 'gap' for you to pay.
However, if your specialist uses it, our Medical Gap scheme can help eliminate or reduce the gap for you.
In most circumstances, we'll cover you for emergency ambulance transport and on-the-spot treatment. Usually, these services are capped per calendar year at one service a year for single memberships and two services a year for family and single parent memberships.
There are different state ambulance arrangements across Australia - learn more about these by contacting your state's ambulance service.
What's not covered
While your hospital cover helps pay for a wide range of services you may receive as a private patient, there are occasions when you won't be fully covered and may experience out-of-pocket expenses.
At a non-agreement hospital
A small number of hospitals in Australia are not part of Bupa's network. If you choose to be treated at a non-agreement hospital, you may face large out-of-pocket expenses.
During a waiting period
A waiting period starts from the date you take out your health insurance or upgrade your cover. If a treatment has a waiting period, you won't be covered during that time.If you've upgraded your cover, during a waiting period, you'll still be able to access the benefit you had on your lower level of cover, but will have to serve the waiting period before having access to the higher benefit.
No waiting period
Accidents sustained after joining
- No waiting period applies to a service you need due to an accident sustained after joining. Benefits for these services are paid according to your level of cover (no benefit applies for an excluded service). Check your product sheet for what's included in your cover.
- For how we define an accident, please click here.
- Initial waiting period, palliative care, psychiatric and rehabilitation services.
- Assisted reproductive services (e.g. IVF)
- Generally the circumstances in which assisted reproductive services are required are due to an underlying pre-existing condition. Therefore, in most instances, a 12 month pre-existing waiting period applies before you can receive benefits for these services
- All other treatments included in your cover other than accidents.
- Pregnancy and birth related services.
- Pre-existing conditions ailments, illnesses.
- Laser eye surgery (where related to a pre-existing condition) covered under Ultimate Health Cover and Ultimate Corporate Health Cover.
A pre-existing condition is any condition, ailment or illness that you had signs or symptoms of during the six months before you joined or upgraded to a higher level of cover with us. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed.
If you knew you weren’t well, or had signs of a condition that a doctor would have detected (if you had seen one) during the six months prior to joining or upgrading, then the condition would be classed as pre-existing.
A doctor appointed by us decides whether your condition is pre-existing, not you or your doctor. The appointed doctor must consider your treating doctor’s opinion on the signs and symptoms of your condition, but is not bound to agree with them.
Coverage for your baby
No waiting periods apply to your newborn if they have been added to the appropriate family hospital cover within two months of their birth.
Exclusions and restricted cover
Sometimes specific services or treatments are excluded under your level of cover. In these cases, you'll be responsible for all expenses related to your hospital admission for that procedure or service.
If you have restricted cover for a treatment, you're covered for shared-room minimum benefits in a public hospital only, with your choice of specialist. If you attend a private hospital or request a private room in a public hospital you'll incur out-of-pocket expenses, because the amount we pay (the minimum benefit amount set by the Government), won't be enough to cover your costs.
Excess and co-payments
Depending on your level of cover, you may need to pay an excess and/or co-payment for your hospital admission. Some levels of cover are excess and co-payment free. And with most hospital covers, there's no excess or co-payment for dependent children on your membership. Check with us to see what excess and/or co-payment (if any) will apply to your hospital stay.
This is a daily charge billed by a small number of Network hospitals that you're responsible for paying. The hospital should inform you of any fee when you make a booking.
While in most cases you'll be covered for emergency ambulance services, some ambulance services won't be covered. These include:
- transport from a hospital to your home, a nursing home or another hospital where you've been admitted to the transferring (first) hospital; and
- transport from your home, a nursing home or a hospital for ongoing medical treatment (eg chemotherapy, dialysis).
You're not covered for cosmetic surgery which isn't clinically required. If you’re unsure, ask your doctor.
When leaving hospital
You may need to pay for certain services or products when you are discharged from hospital. Depending on your level of cover and the hospital you attend, these may include:
- pharmacy items not opened at the point of leaving hospital
- aids supplied for use at home (eg a raised toilet seat or a splint)
- pay TV, internet access, movies and non-local phone calls
- patient-requested non-emergency ambulance transportation.
With the exception of a limited range of specific programs, your hospital cover only applies when you're admitted to hospital as an 'inpatient'. Your hospital can tell you if you're covered by a specified out-patient program but if you're unsure, contact us.
Sometimes people visit an emergency department in a private hospital but are not admitted after being assessed. If you're not admitted you're considered an 'out-patient' and won't be covered by Bupa. In this case, you may be out-of-pocket. If out-of-pocket, check whether you're eligible for a rebate under the Medicare Safety Net.
Where you receive benefits from another source
Your health insurance doesn't apply where compensation, damages or benefits may be claimed from another source in relation to a condition, injury or ailment (eg workers' compensation, travel insurance).
As a nursing home type patient
If you're assessed during your hospital stay as no longer needing acute care or are in hospital for more than 35 days, you'll be classed as a nursing home type patient. In this case, Bupa will pay benefits that are much lower than normal hospital benefits and you'll be required to make a personal contribution towards the cost of your care.
Where Medicare pays no benefit
There are certain hospital procedures performed by a dentist, surgical podiatrist or other practitioner that are not eligible for a Medicare rebate and which are not covered by your hospital cover. Contact us for further information.
During hospital checklist
Learn more about your hospital including visiting hours and how to order meals
Take note of what you're covered for in hospital
Be aware of which costs you may not be covered for
Getting back on track
You may not feel 100 percent well when you leave hospital and it's possible you might need further treatment. Most of all, you'll probably need to take time out to rest and recover. We're here to help you get back on your feet and stay well once you've recovered.
Before leaving hospital, ask your specialist the following questions:
- What medicines will I need during my recovery?
- When can I resume day-to-day activities?
- When is my next appointment?
- What complications might arise and what should I do if this happens?
- Will I need help at home, and how can I organise it?
If you have extras cover, don't forget to use it if you need ongoing treatment (eg physiotherapy). By using our Members First network providers you can save money and claim most services on the spot by swiping your membership card.
Also take advantage of our range of health and wellness programs.
How to claim
The following information will help you work through the claims process so you can return home without the worry of extra paperwork and unexpected bills.
Your hospital costs
All Members First and Network hospitals will ask you to complete claim forms, which they will submit directly to Bupa on your behalf. The hospital would have asked you to pay any excess, co-payment or fixed fee upon your admission.
If you're treated at a non-agreement hospital, you'll have out-of-pocket expenses and may be asked to pay the whole amount up front. If that's the case, you can submit a claim form to Bupa to be reimbursed for some of these fees.
Your medical costs
If your specialist doesn't use our Medical Gap Scheme, you'll need to complete a 'two-way claim form' for all your medical costs. The form is available at any Medicare or Bupa centre. Medicare will process your claim and pay you the benefit, and liaise with Bupa to pay a portion of the bill. If you can't visit a Medicare office during your recovery, contact either Bupa or Medicare and ask for the relevant forms to be sent to you.
Statement of Benefits
After your hospital and medical (from doctors and specialists) claims have been processed, we'll send you statements showing what has been paid on your behalf. Please check that these details are correct and contact us straight away if you have any queries. Your medical statement may include costs charged by specialists you may not have seen directly such as pathologists.
Medicare and PBS Safety Nets
The Government's Medicare Safety Net provides financial assistance to people with high out-of-pocket expenses for out-patient services that pay a Medicare benefit. Once you reach a threshold, you may be eligible for additional Medicare benefits for the rest of the calendar year. The PBS Safety Net is also available to those who need a lot of medicines each year. For more information or to register for these schemes visit humanservices.gov.au
After hospital checklist
Talk to your specialist about how to maximise your recovery. Also call us to find out how you can benefit from your extras cover and our health and wellness programs.
If treated at a Members First or Network hospital, you'll be asked to complete a claim form which the hospital will send to us.
If your specialist hasn't used our Medical Gap Scheme and you receive a medical bill, complete Medicare's two-way claim form to be reimbursed.
When you receive your Statement of Benefits from us, check that the details are correct and contact us if you have any queries.