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Learn how your hospital insurance works, and what your options are if you need treatment.
Planning a hospital stay can be stressful, which is why we want to help you understand what out-of-pocket costs you may face
and provide you with options on how to avoid them and any unexpected bills.
Australian Government bodies (such as Medicare) provide benefits for anyone holding an eligible Medicare card towards out-of-hospital
(or outpatient) services such as visits to the GP, consultations with a specialist, blood tests, medical scans, pharmaceuticals
listed on the PBS, and treatment in a public hospital.
HBF private health insurance provides benefits towards the cost of in-hospital (or inpatient) services in a private hospital
like accommodation and theatre fees, as well as contributing towards specialist and ancillary provider fees such as dental,
optical and physio.
Where it gets complicated is that both Medicare and private health funds will pay a benefit for inpatient treatment and services
in a private hospital. The Medicare Benefits Schedule (MBS) is a list of procedures the Government will pay a benefit
towards. Medicare will pay 75% of the MBS fee for treatment and HBF covers the remaining 25%.
You may have to pay part of a hospital or specialist bill from your own pocket, depending on your doctor’s agreement with
us and your level of cover. This happens when the total cost of your treatment is more than the combined amount Medicare
and HBF will pay, known as out-of-pocket ‘gap’. The gap can happen in two ways: medical gaps and hospital gaps.
Specialists (doctors, surgeons, and anaesthetists) can charge whatever they decide, so there might be a medical gap when
your specialist charges more than the price listed in the Medicare Benefits Schedule. To help manage any out-of-pocket
costs you should understand which of the following categories your specialist falls into:
Medicare Benefits Schedule (MBS) fee
Total medical cost
No agreement / Opt out
A gap will occur if the total cost of your hospital stay (e.g. accommodation and theatre fees) exceeds the amount that HBF
will cover. To help members avoid these gaps, we have arrangements with a large network of Member Plus hospitals across Australia, which means you can minimise or eliminate any out-of-pocket costs. However, you’ll still need to pay
any excess or co-payment on your policy.
Every hospital is different, but there will often be some expenses you will incur during a hospital stay. Be aware that you
may have to pay for the following:
If a particular medical procedure or service is listed as an exclusion on your HBF policy, you will not be able to receive any benefit from us. Alternatively, if a procedure is listed as restricted on your HBF policy, you’ll be covered for it but only to a very limited extent. For example, if you need psychiatric care but it’s listed as a restricted service on your policy, you’ll only receive the minimum default benefit set by the Government and will need to pay the remaining balance yourself.
Find out what your hospital policy covers in myHBF
Prepare for a hospital stay with our preparing for hospital guide
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