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Understand your hospital cover

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.

Public system vs. private health funds

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%.

Out-of-pocket costs

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.

Medical 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:

Fully covered
These specialists are fully covered by Medicare and HBF, so you won't have anything to pay (apart from a co-payment or any product exclusions). We call this a Member Plus provider.
Known gap
We will pay a fixed amount above the Medicare Benefits Schedule amount, which means you will have to pay the remaining balance yourself.
Opt out or no agreement
These specialists have opted not to participate in any agreement which means you will pay all costs charged above the amount on the Medicare Benefits Schedule by yourself.

Medicare Benefits Schedule (MBS) fee

Medical Gap

Total medical cost

Fully covered

Known gap

No agreement / Opt out

Paid by HBF
You pay
Paid by HBF
Paid by Medicare


Hospital gaps

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.

Other hospital costs

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:

Your excess:
If you’ve opted to reduce your premiums by adding an excess, you will need to pay this for an inpatient hospital stay.
A private room:
If your policy doesn’t cover a private room but your selected 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.
There is a $100 co-payment and a $1,400 benefit limit towards drugs that are not listed on the government Pharmaceutical Benefits Scheme (PBS).
Pathology and radiology:
If you need diagnostic tests during your hospital stay (for example X-rays and blood tests) you may have to pay for these separately and often a co-payment will need to be made.
Allied health services:
Services like physiotherapy or speech therapy may be included in the hospital charges and therefore covered by your HBF hospital insurance, or you may have to pay for these services out of pocket or with Extras insurance.
Physiotherapy and speech therapy:
If these in-hospital services are not included in your Hospital or Extras insurance you may receive an extra charge for them.
Personal expenses:
You may have to pay for any personal expenses that you use in hospital, such as pay TV, internet and phone calls.
Surgical assistants and anaesthetists:
You may be charged fees by certain specialists that are not fully covered by HBF or eligible for a rebate from Medicare.
Surgically implanted prostheses:
Some are fully covered, while any that are not listed on the Government-approved Prostheses List will attract an out-of-pocket expense. Check with your surgeon and with HBF who can advise you if you’ll be covered for prostheses.
Robotic consumables:
Consumable robotic parts used in hospital surgeries and labs usually aren’t covered.
Recovery aids:
You may be required to pay for items to assist in your recovery such as slings or compression stockings. Check your policy to see if these items are covered under Extras.
Ongoing care needs:
You may have ongoing care needs (for example wound dressing or IV antibiotics) after you are discharged from hospital.

Exclusions and restrictions:

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.

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