Preparing for hospital

Here’s what you need to know about going to hospital so you can feel more confident about your stay.

Get ready in six easy steps

If you have a hospital treatment coming up, this article breaks down the things you should know like what’s covered and who covers what, plus the important steps to follow before your admission.

1. Know what you’re covered for

Nobody likes surprise bills, especially if you’re experiencing a challenging health event. Understanding what you’re covered for before you head to hospital may help reduce unforeseen costs.

While admitted as a private patient, there are three types of costs you may incur - hospital, specialist and pharmaceuticals.

Cost type
Costs for any services you receive when you are formally admitted to hospital such as accommodation, nursing, theatre costs, food and additional items such as pressure stockings, prostheses and incidentals (e.g. Pay TV, WiFi etc).
Costs associated with the services provided by your specialist and other providers involved in your hospital treatment and stay, such as an anaesthetists, pathologists, radiologists, assistant surgeons and allied health professionals.

Costs for any medications that you may require, such as:

  • Pharmaceutical Beneit Scheme (PBS) and non-PBS co-payments for medications provided to you during your stay
  • Medications provided for use after you’re discharged from hospital

HBF vs Medicare - Who covers what?

What does HBF cover?

If you have eligible HBF hospital cover and are admitted as a private patient, we’ll help cover the costs of your inpatient services included on your cover, as well as the cost of specialist fees, accommodation and other treatments or services provided while you’re in hospital.

If you prefer to be admitted as a private patient in a public hospital, we will pay a benefit towards your treatment. Just keep in mind that you may still need to pay out-of-pocket expenses if you stay in a private room or if your specialist charges more than the HBF benefit.

We won’t pay benefits in these situations:

  • You receive a service or treatment that is excluded on your cover
  • Your treatment or service is provided outside of Australia
  • Your claim is covered by worker’s compensation, third party or other legal right
  • Your premium payments are not up-to-date at the time of treatment or service
  • Your claim is not lodged within two years of the date of service
  • You receive nursing home care and accommodation
  • You have not received your treatment or service at the time you claim
  • You have already claimed and received a benefit
  • Your employer or potential employer is required to provide your treatment or service as a condition of your employment
  • You receive a treatment or service during your service waiting period
  • You receive an outpatient service, such as emergency room care
  • You receive hospital treatment that is not eligible for a Medicare benefit, such as non-medically necessary cosmetic surgery
  • You are not eligible for Medicare. You may like to consider HBF Overseas visitor cover if this is the case
  • You received treatment from a provider who is also a family member on the same policy
  • Your podiatric surgery is provided by a surgeon who is not a registered podiatric surgeon
  • Treatment is rendered by providers who are not approved or recognised by HBF

What does Medicare cover?

Medicare helps cover a portion of your private inpatient medical treatments and services. Medicare will also generally help cover the cost of your outpatient expenses, such as:

  • GP and specialist visits
  • Blood tests
  • Medical scans
  • Pharmaceuticals listed on the PBS
  • Public hospital accommodation, treatment and services when you’re not admitted to hospital

2. Understand Access Gap Cover and HBF Member Plus arrangements

Access Gap Cover 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 Access Gap Cover comes in. To help eliminate or reduce this ‘gap’ for you, we participate in the Australian Health Service Alliance (AHSA) Access Gap Cover (AGC) arrangement for all states outside of Western Australia.

If your specialist participates in the AGC arrangement, they have the option to opt-in or opt-out of the arrangement on a case-by-case basis. Your specialist will choose to bill you in one of two ways – opt in or opt out/no agreement

What it means for you
Known Gap

If your specialist chooses to charge a Known Gap they will charge up to the maximum agreed fee and we will pay an additional amount above the MBS, leaving you with a maximum out-of-pocket expense of $500 for inpatient services (or $800 for obstetric services).

Opt-out (or no agreement)
If your specialist chooses to opt-out of the 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).

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

Medical Gap

Total medical cost

No Gap

Known gap

Opt out/ no agreement

Paid by HBF
You pay
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.

Looking for Member Plus hospitals?

Our HBF Provider Search tool can help you find your nearest Member Plus hospitals to get the most value from your cover.

3. Get a specialist referral

Most hospital treatments begin with a trip to your GP who will discuss your health needs and refer you to a specialist. While your GP may provide you with a recommendation, you’re entitled to choose your own specialist.

When you’re selecting your specialist:

  • Consider choosing an AGC specialist
  • Ask your GP for a few recommendations
  • If available, read online reviews from previous patients

4. Visit your specialist

At your specialist consultation, they will assess your condition and, if necessary, discuss your hospital treatment options. You should always ask your specialist for a written cost estimate for your procedure, including specialist and additional fees (e.g. anaesthetist or assistant surgeon costs).

Remember to ask your specialist:

  • To provide a written cost estimate for your procedure, including specialist and additional fees (e.g. anaesthetist or assistant surgeon costs) with relevant MBS item numbers
  • Which hospital they will treat you at (you’ll get the most value at a Member Plus hospital)

5. Get an HBF quote

We know your cover inside out. Call us on 133 423 before you book a hospital stay or receive medical treatment and we’ll do everything we can to help you understand and manage your medical bills.

We’ll check:

  • If you need to serve any waiting periods
  • If you have any restricted services on your cover
  • Minimum benefits
  • Costs associated with your treatment
  • Whether excess or co-payments apply to your cover
  • How to get the most value from your cover

To help us give you accurate advice, please have your written cost estimate on hand.

We’ll ask you questions about:

  • Your specialist’s name and provider number
  • Whether you’ll be admitted as a day or overnight patient
  • Your anaesthetist’s name and provider number
  • MBS item numbers for your treatment
  • Your hospital and admission date
  • Any other fees that may apply

6. Be aware of common out-of-pocket costs

Every hospital works a little differently, but there will often be some expenses you will incur that you should prepare for.

Hospital insurance excess
If you’ve opted to reduce your premiums by adding an excess to your cover, you may need to pay this for an inpatient hospital stay.
A private room
If you stay at a non-Member Plus hospital and your hospital only has private rooms available (or you choose to stay in a private room), you may need to pay the difference between a shared room rate and a private room rate.

The Pharmeuticals Benefit Scheme (PBS) provides Australians who are eligible for Medicare with access to subsidised medications. You may be charged a co-payment for any PBS medications during your hospital stay. If your hospital’s agreement doesn’t specify benefits for non-PBS pharmacy items, a $100 co-payment per hospital episode and $1,400 benefit limit per continuous hospital episode will apply.

If you are admitted to a Member Plus hospital, we’ll pay a benefit for any prescribed non-PBS pharmacy items used for your hospital treatment, as long as it’s specified in your hospital’s Provider Agreement. This means you may have limited or no out-of-pocket costs to pay.

Allied health services

If you require allied health services such as physiotherapy and speech therapy during your stay, you may be need to pay a portion of the bill.

Remember: If you have an appropriate level of extras cover, this may help cover these costs.

Pathology and radiology
You may need to pay a co-payment if you need diagnostic tests during your hospital stay (e.g. x-rays and blood tests).
Personal expenses
You may have to pay for any personal expenses that you use in hospital, such as TV, internet and phone calls.
Surgical assistants and anaesthetists
Certain specialists may charge fees if they’re not fully covered by HBF or eligible for a Medicare rebate.
Robotic consumables
We don’t cover consumable robotic parts used in hospital surgeries.
Recovery aids
You may need to pay for recovery aids such as slings and compression stockings.
Ongoing care needs
You may receive a bill if you have ongoing care needs (e.g. wound dressing or intravenous (IV) antibiotics) after you are discharged from hospital.
Exclusions and restrictions

We can’t pay benefits for any treatments or services that are listed as an exclusion on your policy. If a service is listed as ‘restricted’ on your policy, this means only the government-required minimum amount of benefits will be provided and you could face large out-of-pocket costs if you choose to be treated for a restricted service at a private hospital.

Surgically implanted protheses

While some surgically implanted protheses are fully covered, you will need to pay an out-of-pocket for any that are not listed on the Government-approved Prostheses List. Chat to your surgeon to see what type of protheses will be used, and then call us on 133 423 to see if you’re covered.


You’re legally entitled to know what your costs might be before going to hospital.

If your stay involves any out-of-pocket charges, like assistant surgeon or pathologist fees, the hospital (public or private) and your specialist must disclose the cost and get your agreement in writing before admission - this is called ‘informed consent’. The only time this is not required is in an emergency where you are unconscious or unable to consent.

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