2. Understand HBF Member Plus arrangements
HBF Member Plus specialists
In general, if you choose to be treated as a private patient in a private hospital, Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee, and we pay the remaining 25%. But many specialists (doctors, surgeons, anaesthetists) choose to charge more than the MBS fee. If this happens, there may be a ‘gap’ (the difference between the MBS fee and the specialist’s fee).
That’s where Member Plus comes in. We have agreements in place with specialists across Australia to help minimise or eliminate Member out-of-pocket costs. In WA, there are two different types of agreements a specialist can participate in – Full Cover and Provider Choice Opt-in/Opt-out. Alternatively, the specialist can choose to have no agreement with HBF.
What it means for you
If your specialist participates in a Full Cover agreement, they will only charge up to an agreed fee and we will pay an additional amount above the MBS, leaving you with no out-of-pocket cost for your inpatient services.
Provider Choice Opt-in
If your specialist participates in Provider Choice, they have the option to opt in or opt out on a case by case basis. If they choose to opt in, your specialist will only charge up to an agreed fee and we will pay an additional amount above the MBS, eliminating your out-of-pocket cost.
No Agreement/Provider Choice Opt-Out
If your specialist chooses to opt-out of Provider Choice or has not registered to participate in any agreement, their in-patient services will be covered up to the MBS fee. You will need to pay the difference between the MBS fee and the specialist’s fees (this is your out-of-pocket cost).
Remember: No matter what category of agreement your specialist falls under, you may still need to pay an agreed hospital excess on your policy and other out of pocket costs. We also can’t pay benefits for specialists’ fees if the treatment category is excluded on your level of cover.
Medicare Benefits Schedule (MBS) fee
No Agreement / Provider Choice Opt-Out
Paid by Medicare
Paid by HBF
Paid by HBF
HBF Member Plus hospitals
When choosing your specialist, consider whether they will treat you at a Member Plus hospital. Member Plus hospitals offer members a range of great benefits, including fully covered accommodation and theatre fees.
Before you arrange a hospital stay, call us on 133 423 to confirm that you are being admitted to a Member Plus hospital and, if you have the MBS item numbers for your treatment, we’ll tell you what you’re covered for and any out-of-pockets you may incur.
What about other private hospitals?
You can choose to be treated at non-Member Plus private hospitals, but you may incur significant out-of-pocket costs. Chat to us on 133 423 for more information.