Being admitted into hospital as a private patient doesn’t have to be a costly experience when you have health cover with GU Health.
GU Health will reimburse you for any item listed on the Medicare Benefit Schedule (MBS), unless there is an exclusion or a restriction on your healthcare policy or you are a non-resident.
Here we fill you in on how it all works and your entitlements as a GU Health member.
For more details about what is included under your specific cover, please head to Online Member Services or refer to your member booklet.
Click here to view Going to Hopsital fact sheet
It’s important you have the right level of health cover so that there are no exclusions or restrictions on the services you need most. To find out exactly what is provided as part of your GU Health hospital cover, please read your GU Health member booklet or go to Online Member Services.
Hospital accommodation fees cover many things, including meals and a bed, as well as hospital-provided services such as nursing care. Theatre fees, intensive care, dressings and other items also incur charges when you’re in hospital.
If you attend a public hospital as a public patient, you’ll not be charged for the care, treatment or after-care relating to your public hospital treatment. Please go to What you need to know about private health insurance for more information.
If you have hospital cover with GU Health and you attend a private or public hospital as a private patient, you’ll receive a reimbursement for any item listed on the Medicare Benefit Schedule (MBS), unless it’s excluded on your level of cover.
We have contracts with private hospitals that specify how much these hospitals can charge for accommodation and other services. These are known as partner or agreement private hospitals. The contracts that GU Health has in place with these hospitals will help you to avoid paying extra out-of-pocket costs when you’re admitted.
For details about what’s included under your particular cover, please head to Online Member Services or refer to your member booklet.
Partner or agreement private hospitals are hospitals that have an arrangement with GU Health. This agreement guarantees you’ll be covered for 100 per cent of your accommodation and other services, such as theatre fees.
The agreements with these hospitals help to reduce your out-of-pocket expenses. For example, if you’re planning to give birth in a particular hospital, and that hospital has an agreement with GU Health, you'll pay less than you would if you were to attend a non-partner private hospital.
Keep in mind that if you have an excess you'll still be responsible for paying this, as outlined in your policy. You'll be responsible for any extras unrelated to your healthcare and that your policy doesn’t cover, such as telephone and television access.
If you do decide to go to a non-agreement private hospital to receive treatment, and your cover doesn’t specify otherwise, GU Health will only pay up to the basic default benefit rate for that treatment set by the Department of Health and Ageing. This means you will have to pay any outstanding amounts. Make sure you’re choosing the right hospital for your treatment by using our partner private hospital list.
In most cases, Medicare will cover 75 per cent of the Medicare Benefits Schedule (MBS) fee for associated medical costs and in-hospital PBS pharmaceuticals. And provided you have the appropriate private hospital cover, we‘ll cover the remaining 25 per cent so you’ll be covered for 100 per cent of the MBS fee.
However, if your doctor, surgeon, anaesthetist, obstetrician or any other health professional involved in your treatment charges above the MBS fee for their services, you'll incur an out-of-pocket expense. If they agree to participate in the Access Gap Cover scheme we'll pay above the MBS fee, up to the Access Gap Cover amount specified in the Access Gap Cover benefits schedule.
If your doctor chooses not to participate in the Access Gap Cover scheme, we will be unable to cover the higher amount under Access Gap Cover. Speak to your doctor, surgeon or anaesthetist about any out-of-pocket charges you may incur for using their services.
Even with the most comprehensive hospital cover, you could still incur expenses when it comes to your in-hospital medical bills. This is where GU Health’s Access Gap Cover scheme can save you money.
Normally, any remaining amount above the MBS fee is charged to you. For example, if your surgeon or anaesthetist chooses to bill $50 above the MBS fee for a service, Medicare and GU Health will be unable to cover that extra cost.
However, if your doctor is involved in the scheme it could mean that your potential expenses will be reduced or, in many cases, eliminated completely. This is because the Access Gap Cover benefit amount is, in most cases, more than the amount set out in the MBS. Therefore, if your doctor chooses to participate in Access Gap Cover, depending on the rate specified in the schedule, we could cover part or all of the $50 mentioned in the example above. The only requirement is that your health provider is registered with the Australian Health Services Alliance (AHSA).
If you have experienced out-of-pocket expenses in the past, it's likely that the practitioner did not participate in the Access Gap Cover scheme. Keep in mind that doctors do have the discretion to choose, on a case-by-case basis, whether or not they would like to participate in the scheme, so please confirm the specifics with your doctor during your consultation.
If there’s still an outstanding amount even after Access Gap Cover, your doctor should make sure you receive informed financial consent, in writing, prior to your procedure.
We’ve made it easy for you to choose a doctor. Find a doctor that’s participated in our Access Gap Cover scheme in the past through our provider search tool.
To reduce the cost of hospital cover contributions, an excess amount is often decided by you or your employer. This amount is only paid upon your admission to hospital as a private patient.
Generally, an excess is paid once in an excess year. Your hospital will normally ask you to pay the excess before or on your admission day. Then this amount is removed for the bill before it’s sent to us for processing. However, depending on your level of cover, an excess might be applied to the first two hospitalisations in the excess year before it’s capped.
Refer to your GU Health member booklet or go to Online Member Services for details specific to your membership.
A pre-existing condition is an ailment, illness or condition of which the signs or symptoms existed at any time in the six months before you joined us, upgraded or changed your level of cover. This is irrespective of whether you were diagnosed or aware of the pre-existing condition, and includes all proposed elective or cosmetic procedures.
We may request further medical evidence when trying to determine your eligibility for benefits. Where required, the determination of whether a condition is pre-existing will be made by a medical practitioner appointed by GU Health. To enable us to make an assessment, you’ll need to provide us with all the information we request from you and/or your treating medical practitioner(s). Please consider this when you agree to a hospital admission date so we have sufficient time to review your individual situation.
If you’re admitted into hospital without confirming your benefit entitlements and we later determine your condition is pre-existing, you’ll need to pay any hospital and medical charges not covered by Medicare – no benefits will be paid by GU Health. If you’re an overseas visitor and not eligible for Medicare, you’ll be liable for the full cost of your treatment/admission.
In some cases where you’re admitted to hospital for an emergency, we may not have time to assess if the pre-existing condition applies. As a result you may have to pay for all or some of the hospital and medical charges. This is especially the case if:
If you policy has restrictions for some conditions, you’ll be covered for those conditions to a very limited extent. GU Health will only pay up to the basic default benefit rate for that treatment, as set out by the Department of Health and Ageing. This means you’ll have to pay any outstanding amounts.
To understand your membership exclusions and restrictions, please read your member booklet.
Our Hospital Care at Home program provides you with healthcare services in the privacy, safety and comfort of your home. Having access to this program means that you don’t have to remain in hospital longer than necessary, or that you can avoid hospital admission altogether.
You may be able to access Hospital Care at Home if you:
You will need a referral from your doctor or hospital to be considered for the program. Provided you meet the criteria, we will provide services to you at no cost. Programs are usually between one and four weeks in duration.