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 arrangements in place with specialists across Australia to help members minimise or eliminate out-of-pocket expenses. In WA, there are three different types of agreements a specialist can participate in - Full Cover, Known Gap and Opt-out (or no agreement).
What it means for you
If your specialist participates in a Full Cover arrangement, 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 expense for your inpatient services.
If your specialist participates in a Known Gap arrangement, they have the option to opt-in or opt-out of the arrangement 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, minimising or eliminating your out-of-pocket expense.
Opt-out (or no agreement)
If your specialist chooses to opt-out of the Known Gap arrangement or are not registered to participate in an arrangement, 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 expense).
*HBF has a “HBF Limited Surgical Items List” (HBF List), which is subject to change from time to time. Where your treatment involves an item on the HBF List, HBF will not pay a benefit greater than the Medicare Benefit Schedule (MBS) fee for that item and any services you receive from an anaesthetist associated with that item. As such, out-of-pocket costs may apply. This applies regardless of whether your chosen provider is a Full Cover or Known Gap provider.
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.
Medical cost breakdown
Medicare Benefits Schedule (MBS) fee
Paid by HBF
Paid by HBF
Paid by Medicare
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.