Going to hospital?

You can avoid any unexpected out-of-pocket expenses by understanding what you’re covered for before you go into hospital.

• Check your level of cover - Log into your  Member Centre or mobile app, or contact us and we’ll check your level of cover.

Do you have an excess?  -  Members on some covers opt to pay an excess in return for lower premiums. An excess is the amount you pay towards the cost of your hospital admission before any benefit is payable. If you choose an excess, it means that when you go into hospital (same-day or overnight) you will pay the chosen excess amount directly to the hospital. The excess is only payable once per person up to a maximum of twice per couple/family membership per calendar year. Excesses do not apply to any dependant child insured on selected Hospital policies. Find out if you have an excess by checking your last CBHS Corporate cover statement or log into the  Member Centre or app.

• Waiting periods and pre-existing conditions - Waiting periods and pre-existing conditions can impact what benefits you get back, so it’s important that you check them both. Find out more here or call us and we’ll check for you.
• Understand the difference between private and public - If you have hospital cover with CBHS Corporate, you can choose to receive treatment in a public or private hospital. Benefits vary depending on your choice of hospital, your level of cover and other factors, such as whether the hospital is a  CBHS Corporate-agreement hospital.

Private hospital –  CBHS Corporate holds agreements with an extensive range of Australian private hospitals and day surgeries. These agreements ensure hospital fees including bed, theatre, labour ward and intensive and coronary care fees are covered when admitted as a patient to hospital (subject to your level of cover). For charges incurred in a non-agreement hospital, you may only receive benefits similar to a public hospital shared room rate.

If you choose a non-agreement hospital you may incur out-of-pocket expenses for hospital related services, regardless of your level of cover.

Public hospital  All CBHS Corporate Hospital covers provide benefits for certain treatments with your choice of doctor in a public hospital. No benefits are payable if the service or treatment is an exclusion.

Important note: Members should be aware that it is possible you will be placed on a public hospital waiting list even if you are admitted as a private patient in a public hospital.

Please note that restricted services can attract different rules. For example, if the service is restricted under your membership and you are staying in a private room in a public hospital, you may need to pay large out-of-pocket costs. However, this may not apply if the services are rendered in public hospitals in shared rooms. Find out more about CBHS Corporate’s hospital cover  here or call us on 1300 586 462.

• Check for specialty and restricted services - specialty services can have benefit restrictions depending on your level of cover, so you might want to clarify with your doctor or hospital about any specialty services you’ll be receiving.

Contact us if you have any questions about whether your service or product will be covered. You can also log into the  Member Centre to find out if you’re covered for restricted services. Depending on your cover, you may need to pay out-of-pocket expenses for restricted services.

You can ask your GP to refer you to a specialist who participates in the  Access Gap Cover  (AGC) scheme, or give you a list of specialists who might be willing to participate. AGC is designed to reduce or eliminate the medical ‘gap’. The aim is for you to end up with less or, in some cases, no out-of-pocket medical expenses when you receive treatment at a private hospital as an inpatient.

TOP TIP: Ask your GP for an open referral so you can choose from a list of specialists, that way you’re not locked into seeing one person.

There are several things you need to ask your specialist before you start treatment.

• Ask him or her to explain your condition in plain language and outline the different treatment options.
• Ask them to explain the risks and benefits of each option.
• Make sure they tell you about all the medical professionals who will participate in your treatment so you understand the costs that might apply.

If a prosthesis (an artificial part to replace something in the body) is involved, check with your doctor about any out-of-pocket expenses. You will be covered up to at least the minimum benefit in the prosthesis list under the Government's Private Health Insurance legislation. You may want to discuss other issues such as recovery and continuing current medications while in treatment, and to also have the doctor provide you with a medical certificate for leave from work.

Please note that whether a doctor participates in the Access Gap Cover scheme or not is completely at his or her discretion. Doctors can choose to participate in the scheme on a patient-by-patient basis, so the fact that the doctor has participated in the scheme before doesn't guarantee that he or she will do so again.

Once your specialist has determined that you will need a hospital stay, they will nominate the hospital they prefer to work with. This is at their discretion. Sometimes they’ll give you a choice of two or three hospitals. Once you know your options, check if they have an agreement with CBHS Corporate by using  this search tool.

If the hospital has an agreement with us, you will be covered according to your Hospital coverage level. This might include accommodation, theatre and labour ward, intensive care and coronary care.

If your specialist has chosen a hospital that doesn’t have an agreement with us, you will be covered up to pre-set limits – set by the Government – which may mean you incur large out-of-pocket costs. Restricted benefits (including no coverage for theatre or labour ward fees) apply to non-agreement private hospitals.

Clarify what types of services or treatment you will receive. This makes it easier to check if your services are subject to restrictions or exclusions, and if you need to pay any out-of-pocket costs.

You’ll be considered an admitted patient if you receive chemotherapy daily, so long as your hospital has an agreement with CBHS Corporate and admits you as a day patient. Similarly, you might be able to claim benefits from your Hospital cover if you receive  home nursing from the hospital after discharge.

By contrast, you’re not considered an admitted patient for minor medical procedures received in your doctor’s rooms. This attracts a non-admitted theatre fee from your doctor and is partially covered under Premium Package (Gold) and Advanced Extras. Please note that in this case the bill for doctor services is payable by Medicare only.

Before you go into hospital, get a written quote from all the specialists and medical professionals who will be involved in your treatment. This may include your anaesthetist, surgeon, radiologist and pathologist. An itemised quote is known as informed financial consent, and you are legally entitled to request it.

The two items you’ll be claiming for are your hospital fees and your doctor and specialist bills.

Your hospital will bill us directly for any hospital fees. If you’re required to pay any part of your admission for example your excess, you pay this fee directly to the hospital. Ask the hospital about their procedure for payment.

If your doctors and specialists participate in the Access Gap Cover scheme, they should bill us directly. If you receive a bill from an Access Gap doctor, forward it to us for payment, not Medicare. We’ll process it and forward it to Medicare on your behalf.

If your doctors and specialist don’t participate in the Access Gap Cover scheme, submit the bill to Medicare and complete a two-way form to claim your benefits. Medicare will process the claim and we can then provide you with your benefits.