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The information provided below applies to members covered by the Fund's Ultimate Choice, Easy Choice, and Total Care Hospital tables. This information should be read in conjunction with the information contained in the Fund's latest brochure.
Quick links
- What am I covered for?
- Are there hospitalisations that I'm NOT fully covered for?
- How do I know if the hospital I am going to is a contracted hospital?
- Are there any questions I should ask my doctor before admission?
- Do I need to contact the Fund to advise that I'm going to hospital?
- How do I pay my excess?
- When will I receive my hospital and doctor bills?
- How do I pay my doctor's bills?
- Does the Fund pay my doctor directly?
- What if I'm still in my waiting periods?
- Am I covered for day surgery?
- Am I covered for medical services provided in the doctor's rooms or clinic?
What am I covered for?
You are fully covered for theatre and accommodation charges for most hospitalisations provided in the Fund's contracted hospitals or in public hospitals. If you are covered on a hospital table which incorporates an excess, you may be required to pay this excess if it has not been paid by you on another service during that Calendar Year. These benefits do not apply to Restricted or Excluded items. For more information on excluded or restricted services see Active Choice or Young Choice.
The Fund is also able to supplement Medicare benefits for inpatient services so that you are covered right up to the schedule fee. These services include those provided by such practitioners as your specialist, anaesthetist, pathologist, radiologist etc. If you are charged over the schedule fee for inpatient services, you will be out of pocket for this additional amount unless the practitioner concerned is billing you under the Access Gap Cover.
Services provided in hospital by other professionals such as physiotherapists are generally not paid through your hospital cover but benefits can be claimed on these services if you have appropriate extras cover.
You may also be out of pocket for some incidental services such as drugs not directly related to the reason for your hospitalisation.
Are there hospitalisations that I'm NOT fully covered for?
Yes. The Fund is unable to pay full benefits for hospitalisations where Medicare is NOT paying the associated doctors' bills. Examples of such services include cosmetic, elective and laser eye surgery. If you are in doubt about the status of your hospitalisation, your doctor or Medicare will be able to advise you.
You also may not be fully covered for hospital stays in private hospitals which are not contracted to the Fund.
How do I know if the hospital I am going to is a contracted hospital?
The Fund has an extensive network of contracted hospitals throughout Australia and a list of contracted hospitals in your state can be obtained by clicking here.
It is important that you check this information each time you are going to hospital, as the status of hospitals can change. Don't rely on information you received in relation to a previous hospitalisation.
Are there any questions I should ask my doctor before admission?
Yes. Firstly you should ask what hospital you will be treated in and ensure, where possible, that you will be attending a hospital which is contracted to the Fund. Secondly, you should ask your doctor if he participates in the Fund's Access Gap Cover. This also applies to your anaesthetist, pathologist and other medical practitioners who will provide services to you while you are an inpatient. If the answer is 'yes', you should also ask if you will be treated under this scheme.
It is important you obtain this assurance as doctors are allowed to exercise their own discretion in choosing who they will bill under this system. If the doctor bills you under the Access Gap Cover, he will provide you with a written advice of costs involved and how much you will be out of pocket, if at all. If your doctor does not participate in Access Gap Cover, you should ask if he charges over Medicare's schedule fee. Any amount charged over the schedule fee is not claimable through Medicare or the Fund and is paid by you.
Do I need to contact the Fund to advise that I'm going to hospital?
This is not compulsory but it is usually to your benefit to do so. By contacting the Fund, we will be able to advise you of the status of the hospital you are going to, any potential problems with your table of cover and register you for our Member Support Program where relevant.
How do I pay my excess?
If you are required to pay an excess on your hospitalisation, many hospitals will require you to pay this amount prior to your admission. If the hospital does not request you to pay your excess prior to admission, they will send you a bill for this amount at a later date. You do not pay this amount directly to the Health Fund.
When will I receive my hospital and doctor bills?
In most cases, the hospital will bill the Fund directly so you will not see their account. You will receive an advice from the Fund to advise you that the hospital bill has been paid on your behalf. Practitioners participating in Access Gap Cover will usually send their accounts directly to the Fund. Other medical practitioners' accounts are normally sent to you personally.
How do I pay my doctor's bills?
Bills from doctors, anaesthetists, pathologists and other medical professionals which relate to inpatient services should be submitted to Medicare before being sent to the Fund. The only exception to this is where the doctor has billed you through the Access Gap Scheme. These accounts should be sent to the Fund directly and should have a warning on them advising you to do so.
When you submit accounts for inpatient services to Medicare, you will have two options available to you. Firstly, you can fill in a standard Medicare claim form. If you choose this method, Medicare will pay your benefit over the counter or post you a cheque, depending on the amount involved. Medicare will also issue you with a Statement of Benefit.
To claim any additional benefits that may be available through the Fund, attach this Statement of Benefit to a Health Fund claim form and submit it to the Fund. Alternatively, in addition to the standard Medicare claim form, you may also fill in a 'two way' claim form. If you fill in this form, Medicare will pay their benefit and then submit the claim to the Fund on your behalf. The only drawback with the two way system is that it is not usually as quick as the traditional method so, if the doctor is offering you a discount for paying by a certain date, it may be to your advantage to pay the account before submitting it to Medicare.
Does the Fund pay my doctor directly?
If your doctor has charged you under Access Gap Cover, the Fund's payments to him are normally paid directly to him. In all other cases, the Fund will send the benefit cheque to you.
What if I'm still in my waiting periods?
No benefits are payable for hospitalisations incurred in the first two months of a new membership even if it does not relate to a pre-existing condition. For members who have upgraded their hospital cover or have transferred from another Fund with continuity, hospitalisations which take place in the first two months after the upgrade or transfer are paid at the previous rate of hospital cover.
If you have joined the Fund or upgraded your hospital cover in the 12 months prior to your hospitalisation, it is normal practice for the Fund to seek further advice regarding your hospitalisation. In this case, the Fund will forward you documents to be completed by your GP and the specialist you have consulted. On receipt of this information by the fund the documents from these doctors are forwarded to an independent medical referee who will advise the Fund further. The Fund is guided by the advice of these medical professionals.
If the medical referee advises the Fund that the hospitalisation does not relate to a pre-existing condition, then normal benefits are payable. If the advice is that the hospitalisation does relate to a pre-existing condition then no benefits are paid or benefits are paid at the level of hospital cover held prior to any upgrade.
Am I covered for day surgery?
Yes. These days many of the services which once required an overnight or extended stay, can be performed in a day stay in hospital. You are fully covered for theatre or accommodation relating to day stays in contracted hospitals or public hospitals, providing Medicare is paying benefits towards the associated doctors' bills. Excesses are payable on same day stays in hospital.
Am I covered for medical services provided in the doctor's rooms or clinic?
No. These days, some simple procedures which were formerly carried out in hospital can be carried out in the doctor's surgery. As you are not an inpatient when undergoing these procedures, the Fund is unable to pay any benefits towards the doctor's fees. Medicare will pay a percentage of the schedule fee in these cases.
You are also not covered for consultations with medical practitioners prior to or following any hospitalisation.
