Going to hospital with Bupa health insurance

Before you receive any treatment you are entitled to ask your doctor, your health insurer, and your hospital about how much your treatment will cost, including any extra money you may have to pay out of your own pocket, commonly known as a ‘gap’ payment.

Informed financial consent must be confirmed in writing so it’s clear that you have received and understood this information and agreed to it.

The clinical consent form (for your consent to the procedure itself) comes with the hospital’s Admission Information pack.

In your hospitals Admission Information pack, you’ll have to fill out the Clinical consent form. It’ll mean you’ve been given accurate information that you clearly understand and that you agree to the procedure itself.

The Bupa Medical Gap Scheme is all about reducing the medical costs you need to pay for treatment when you’re admitted to hospital. If your specialist uses our scheme, you’ll never pay more than $500 per doctor.

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.

The ‘gap’ is the amount you’ll need to pay yourself if your doctor or specialist charges more than what Bupa and Medicare will pay (Health funds pay 25% of this fee, and Medicare pays 75%).

Find out all the details about the Bupa Medical Gap Scheme.

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 (i.e. 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

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.

Get the most from your cover by selecting one of our Members First or Network hospitals - we've entered into a special agreement with them to help reduce or eliminate your out-of-pocket hospital expenses.

Members First

At Members First hospitals and day hospitals, in most instances you'll be fully covered for your hospital expenses, such as accommodation, theatre and intensive care fees. At Members First day hospitals there are also no out-of-pocket expenses for medical treatments (e.g. 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;
• parenting support services; and
• breastfeeding classes for new and experienced mothers.

*Not available in NT, any excess or co-payment related to your cover will still apply.

^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.

Network

These are private hospitals and day hospitals where, in most instances, you'll be fully covered for your hospital expenses such as accommodation, theatre and intensive care fees for services included on your cover. 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.

Fixed fees

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.

Non-agreement hospitals

These are private hospitals and day hospitals 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.

We suggest you pack:

Bupa TeleHealth offers a range of health coaching services to help support you throughout your health journey, including after a hospital admission. We know that there is often a lot to take in when you have a hospital stay, so having someone support you during this time can be beneficial and may also help prevent a further unplanned hospital admission.

Our telephone-based health coaching programs and services are delivered by health coaches who are specially trained and qualified nurses, dietitians or other health professionals, at no cost to you.

To find out what support you may be eligible for, complete a Bupa TeleHealth Request a call form, or contact us on 1300 030 238, Mon-Fri, 9am-5pm AEST.

While every hospital works a little differently, the following may assist you during your stay.

Visitors

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.

Meals

Ask your nurse about mealtimes 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.

Television

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.

Telephone

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.

Internet

Most hospitals offer wireless internet (Wi-Fi) though some may charge you to use it.

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 (e.g. a cardiac stent) up to the approved benefit on 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.

Emergency ambulance

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.

On selected health insurance policies, we offer uncapped emergency ambulance cover.

There are different state ambulance arrangements across Australia.

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. For example:

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.

Pre-existing conditions

A pre-existing condition is any condition, ailment or illness, of which you had signs or symptoms during the six months up to the commencement of your cover, or when you upgraded to a higher level of cover with us.

There is a legislated 12-month waiting period before benefits are payable for pre-existing conditions for most hospital cover products. For some products for overseas visitors, there is lifetime ineligibility for hospital treatment related to a pre-existing condition.

To confirm if your proposed treatment might be related to a pre-existing condition, or if your treatment is eligible for benefits to be paid, we’ll ask you to provide documentation, such as:

• Bupa medical certificates signed by your general practitioner (GP) and any specialists you consulted.
• Referral letters from your GP to specialist/s.

• Emergency department notes if you were treated through a hospital emergency department.
• Doctors’ notes from your medical appointments.
• For injuries resulting from accidents, we will also need a medical certificate or report from the licensed practitioner you saw in the 72 hours following the accident.

As required in the legislation and to ensure a proper assessment in relation to your claim, Bupa will appoint a doctor to assess the information and determine whether, in their opinion, and consistent with normal medical practice, they are satisfied that there would have been signs or symptoms of the condition, ailment or illness in the period before you joined, even if you had not yet had a diagnosed condition or seen a doctor. If the signs or symptoms would have been evident, then this is considered a pre-existing condition under the Private Health Insurance Act (2007).

The outcome is decided by the doctor appointed by Bupa, and not your treating doctor, but any information provided by your doctors will be considered.

What happens when one treatment is covered and the other is excluded under my private hospital cover?

If you’re admitted to hospital for multiple treatments and one or more of those treatments isn’t covered on your policy, Bupa will pay a benefit towards the included treatment (if you have served any applicable waiting periods), but not the excluded treatments. You’ll be responsible for all expenses related to the treatment which is excluded on your policy.

Coverage for your baby

No waiting periods apply to your newborn if they have been added to the appropriate family hospital cover within 90 days 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 accommodation in a public hospital only (minimum benefits) plus a fixed add on benefit for an overnight private room, with your choice of specialist. If you attend a private hospital, you'll incur out-of-pocket expenses, because the amount we pay (the minimum benefit amount set by the Australian 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 dependant children on your membership. Check with us to see what excess and/or co-payment (if any) will apply to your hospital stay.

Fixed fees

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.

Non-emergency ambulance

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 (e.g. chemotherapy, dialysis).

Cosmetic surgery

You're not covered for cosmetic surgery. 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 (e.g. a raised toilet seat or a splint)
• pay TV, internet access, movies and non-local phone calls
• patient-requested non-emergency ambulance transportation.

Out-patient services

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 charged an out-of-pocket. If you have an out-of-pocket expense, 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 (e.g. 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 to the hospital. The hospital will need to inform you of these costs prior to them being raised.

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.

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 (e.g. physiotherapy). By using our Members First network providers you can save money and claim most services on the spot by swiping your membership card.

You can also get in touch the Bupa TeleHealth team, to discuss the range of health and wellbeing programs that are available to support you in your recovery, and into the future. There is often a lot to take in when you have a hospital stay, so having someone support you during this time can be beneficial and may also help prevent a further unplanned hospital admission.

Our telephone-based health coaching programs and services are delivered by health coaches who are specially trained and qualified nurses, dietitians or other health professionals, at no cost to you.

To find out what support you may be eligible for, complete a Bupa TeleHealth Request a call form, or contact us on 1300 030 238, Mon-Fri, 9am-5pm AEST.

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 Australian 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 the Department of Human services website.