When you need to go to hospital, your first priority should be to get better, so we’ve broken down everything you might need
to know and do before your hospital stay. At any time, please feel free to contact us – from hospital costs to claims
and recovery, we’re always here to help.
Understand your cover in advance
Avoid surprise bills by understanding what you’ll be covered for before you head to hospital. Depending on your hospital
policy, you might have a number of excluded treatments (things you won’t be covered for), so check that the procedure
you’re going to have is included in your policy before you’re admitted by logging into myHBF and checking your product sheet.
It’s also good to be aware of what your health fund covers vs. what Medicare covers. Your hospital insurance will only cover
inpatient services, which are any services or procedures that happen once you’re formally admitted to hospital (when
you officially ‘check-in’ as an in-patient). Sometimes you can go to hospital for an appointment or treatment (things
like blood tests or scans), but not be admitted; this is considered an outpatient service, which your health fund will
not cover. Don’t worry - Medicare generally helps cover these costs so you shouldn’t have to pay all outpatient expenses.
Visit your GP
Most hospital treatments begin with a trip to your GP, who’ll discuss your treatment with you and refer you to a specialist
if necessary. We can’t choose your specialist for you, but we can make the process easier and less daunting. When you’re
selecting a healthcare provider;
- Talk to your GP about your condition. If they refer you to a specialist, ask for a few recommendations - you’re entitled
to choose the specialist you feel is right for you
- Ask for specialist recommendations from family and friends who have experienced similar procedures themselves
- Visit Whitecoat to read unbiased customer reviews about providers
- Use our Find a provider tool to search through HBF Member Plus specialists
in your area, which are fully covered by HBF.
Understand Member Plus Agreements
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 HBF pays the remaining 25%. Some specialists (doctors, surgeons, anaesthetists) can choose to
charge more than the MBS fee. If this happens, there may be a ‘gap’, which is the difference between the MBS and the
To help manage your out-of-pocket costs for inpatient hospital services, it’s important to understand that your specialist’s
fee will fall into one of three categories:
- Fully covered: These specialists are fully covered by Medicare and HBF, which means you won't have anything
to pay (apart from an excess 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
Paid by HBF
Paid by HBF
Paid by Medicare
Member Plus hospitals
HBF has a large network of Member Plus hospitals across Australia, which help keep your out-of-pocket costs to a minimum.
In Member Plus hospitals you’ll be fully covered for shared room accommodation and theatre fees for all agreed services
on your policy, less any co-payment or policy excess.
Most hospital-stay services are covered in Member Plus hospitals, but there may be some that are not, called ‘non-agreed’
services. Before you arrange a hospital stay call us on 133 423 to confirm you are being admitted to a Member Plus hospital
and what you are covered for. Remember that all benefits are subject to any restrictions or inclusions on your cover.
Member Plus hospitals also cover:
- If you need a parent, partner or carer to stay overnight with you in hospital, HBF will fully cover costs where it is
an agreed service, and their presence is integral for the management of your condition. Costs covered include accommodation
and meals in your room.
- While you’re staying in hospital as a private patient, you’re covered for all medically necessary inter-hospital ambulance
transfers, to or from a private hospital.
Non Member Plus private hospitals
You can still choose to be treated here, but you may incur significant out-of-pocket costs, so check with us before you
HBF will pay a benefit towards your treatment if you choose to be admitted as a private patient in a public hospital,
but there may also be out-of-pocket expenses if you have an excess, stay in a private room or your doctor charges
more than the MBS fee.. You may not avoid public hospital waiting lists, get a private room or have continuity of
care with the same doctor.
If you choose to be a public patient in a public hospital, you’ll be fully covered by Medicare for your hospital stay,
including free accommodation, doctors’ services, diagnostic tests and medications (but excluding personal expenses
such as television hire or telephone calls).
As a public patient you won’t be able to choose your doctor or room type, and you may be put on a long waiting list for
non-emergency surgery. Doctors will be appointed by the hospital to treat you and private rooms will only be allocated
according to clinical need.
Visit your specialist
At your specialist consultation, he or she will assess your condition and if necessary discuss your hospital treatment
options. Remember to;
- Ask your specialist for a written cost estimate for your procedure, including specialist and additional fees (e.g.
anaesthetist or assistant surgeon costs)
- Ask your specialist which hospital they will treat you at.
Get an HBF quote
The amount you’ll pay out of your own pocket for your hospital procedure will depend on your level of cover, the specialists
you’re seeing and the hospital you’re attending.
We’ll check all details including any waiting periods, restrictions, minimum benefits, whether excess co-payments apply
and how to minimise any out-of-pocket expenses.
So we can give you accurate advice, please call us with your written cost estimate. We’ll ask you questions about your:
You’re legally entitled to know what your costs might be before going into hospital. If your hospital stay involves any
out-of-pocket hospital charges, for example assistant surgeon or pathologist fees, the hospital (whether public or
private) and your specialist must disclose the cost and obtain your agreement in writing before admission - this
is called informed financial consent. The only time informed financial consent is not required is in an emergency
where you are unconscious or otherwise unable to give consent. In these circumstances consent is deemed to have been
Be aware of unavoidable out-of-pocket costs
Every hospital works a little differently, but there will often be some expenses you will incur that you should prepare
- Your excess:
- If you’ve opted to reduce your premiums by adding an excess, you will need to pay this for an inpatient hospital
- 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 may be 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
- Plastic and reconstructive procedures:
- There may be restrictions on how much of these procedures can be covered.
- 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.
These will be billed to you directly.
- 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.
What's not covered
If you receive treatment as an outpatient (i.e. you are not admitted), in most instances you will not be covered by private
health insurance. If eligible, these services may be claimed from Medicare.
Costs for treatments not recognised by Medicare
There are some hospital procedures, such as cosmetic surgery, that are not eligible for a Medicare rebate or covered
by private health insurance.
Treatment before your waiting periods are served
Be aware of any waiting periods on your policy as you will not be covered for treatment you have before this time has
elapsed. HBF can advise you on your personal waiting periods, but in general, a waiting period of 12 months applies
to pre-existing conditions, maternity and IVF, and a 2 month waiting period exists for general hospital treatments/palliative
care, psychiatric and rehabilitation services.
Restricted or excluded treatment
If you receive treatment that is specifically restricted or excluded on your policy as a private patient, you will incur
significant out-of-pocket expenses.
If your claim is over two years old
We can only process claims and provide benefits to you if your treatment happened less than two years ago.
If you are not eligible for full Medicare benefits
You may be hit with significant out-of-pocket medical and hospital costs if you are not eligible for full Medicare benefits
and don’t have eligible Overseas health cover either.