Going to hospital

Being admitted into hospital as a private patient doesn’t have to be a costly experience when you have health cover with GU Health.

GU Health will reimburse you for any item listed on the Medicare Benefit Schedule (MBS), unless there is an exclusion or a restriction on your cover or you are a non-resident.

Here we fill you in on how it all works and your entitlements as a GU Health member.

For more details about what is included under your specific cover, please log in to Online Member Services or refer to Your Plan Information.

Click here to view the Going to Hospital fact sheet.

What's covered
What accommodation and other medical expenses are covered when I go to hospital?
Why should I attend a partner private hospital?
Who pays for things other than hospital accommodation (e.g. medical costs and in-hospital pharmaceuticals)?
How does the Access Gap Cover scheme work?
Why do I pay an excess under my hospital plan?
What is a pre-existing condition?
Exclusions and restrictions explained

It’s important you have the right level of health cover so that there are no exclusions or restrictions on the services you need most. To find out exactly what is provided as part of your GU Health hospital cover, please log in to Online Member Services or refer to Your Plan Information.

Hospital accommodation fees cover many things, including meals and a bed, as well as hospital-provided services such as nursing care. Theatre fees, intensive care, dressings and other items also incur charges when you’re in hospital.

If you attend a public hospital as a public patient, you’ll not be charged for the care, treatment or after-care relating to your public hospital treatment. Please go to What you need to know about private health insurance for more information.

If you have hospital cover with GU Health and you attend a private or public hospital as a private patient, you’ll receive a reimbursement for any item listed on the Medicare Benefit Schedule (MBS), unless it’s excluded on your level of cover.

To make sure you’re getting the best possible deal, we have contracts in place with hospitals that specify how much they can charge for accommodation and other services.

These agreements help to reduce your out-of-pocket expenses.

Our partner (or agreement) private hospitals have an arrangement with us so that you’re fully covered for your accommodation and theatre costs when you go to hospital.

For details about what’s included under your particular cover, please please log in to Online Member Services or refer to Your Plan Information.

QUICK TIP

There are a couple of things that will help you to determine how much you pay for hospital services: the type of cover you purchase and whether GU Health has an agreement in place with the hospital in which you’re treated.

Before going to a private hospital, we recommend you contact us to find out if the hospital you’re choosing to go to has an agreement with us. Also remember to check with us that you've served all your waiting periods and if there's anything else you may need to pay, such as an excess.

The agreements we have with partner private hospitals means that you’re fully covered for your accommodation and theatre fees, less any excess that you may be required to pay based on your level of cover.

Depending on your level of cover, in most cases, you’ll be covered for all in-hospital charges for eligible services provided as part of your in-hospital treatment please refer to the Going to Hospital fact sheet for more information,

To avoid any out-of-pocket expenses, we suggest discussing prosthesis choices with your specialist before going to hospital.

Keep in mind that if you have an excess you'll still be responsible for paying this. Please refer to Your Plan Information or log in to Online Member Services for further details about the excess arrangements that apply to your particular level of cover.

You'll also be responsible for paying for any extras unrelated to your healthcare and that are not included in your level of cover, such as telephone, internet and television access.

At hospitals where no agreement exists (non-partner private hospitals), you’ll only receive restricted benefits for the cost of your hospital services.

On selected plans there will also be a benefit limit of $300 per person per membership year for in-hospital pharmaceutical drugs. Please refer to the section on ‘Restricted benefits’ in Your Membership Guidelines for details.

We recommend that you check to ensure your hospital is listed as a partner private facility before commencing your hospital treatment. We have agreements with most private hospitals throughout Australia. View our partner private hospital list. View our partner private hospital list.

In most cases, Medicare will cover 75 per cent of the Medicare Benefits Schedule (MBS) fee for associated medical costs and in-hospital PBS pharmaceuticals. Provided there are no exclusions or restrictions under your specific cover, we‘ll pay the remaining 25 per cent so you’ll be covered for 100 per cent of the MBS fee.

However, if the practitioner who is treating you charges more than the MBS fee for their services, you may have to pay the difference between the practitioner’s charge for the item number and the scheduled fee.

If your practitioner agrees to participate in GU Health's Access Gap Cover scheme we’ll pay above the MBS fee, up to the Access Gap Cover amount specified in GU Health’s Access Gap Cover benefits schedule.

The result is that your potential expenses could be reduced or, in many cases, eliminated completely. This is because the GU Health Access Gap Cover benefit amount is more than the amount set out in the MBS fee.

If your practitioner chooses not to participate in the Access Gap Cover scheme, we will be unable to cover the higher amount under Access Gap Cover.

Your practitioner has the discretion to choose, on a case-by-case basis, whether they’d like to participate in the scheme, so make sure you ask them about this during your consultation.

Keep in mind that if you have an excess you'll still be responsible for paying this. Please refer to Your Plan Information or log in to Online Member Services for further details about the excess arrangements that apply to your particular level of cover.

You will also be responsible for paying for any extras unrelated to your healthcare and that are not included in your cover, such as telephone and television access.

Even with the most comprehensive hospital cover, you could still incur expenses when it comes to your in-hospital medical bills. This is where GU Health’s Access Gap Cover scheme can save you money.

Normally, any remaining amount above the MBS fee is charged to you. For example, if your surgeon or anaesthetist chooses to bill $50 above the MBS fee for a service, Medicare and GU Health will be unable to cover that extra cost.

However, if your doctor is involved in the scheme it could mean that your potential expenses will be reduced or, in many cases, eliminated completely. This is because the Access Gap Cover benefit amount is, in most cases, more than the amount set out in the MBS. Therefore, if your doctor chooses to participate in Access Gap Cover, depending on the rate specified in the schedule, we could cover part or all of the $50 mentioned in the example above. The only requirement is that your health provider is registered with the Australian Health Services Alliance (AHSA).

If you have experienced out-of-pocket expenses in the past, it's likely that the practitioner did not participate in the Access Gap Cover scheme. Keep in mind that doctors do have the discretion to choose, on a case-by-case basis, whether or not they would like to participate in the scheme, so please confirm the specifics with your doctor during your consultation.

If there’s still an outstanding amount even after Access Gap Cover, your doctor should make sure you receive informed financial consent, in writing, prior to your procedure.

We’ve made it easy for you to choose a doctor. Find a doctor that’s participated in our Access Gap Cover scheme in the past through our provider search tool.

Where your cover has an excess it is only paid if you or anyone on your membership is admitted into hospital as a private patient. Generally, an excess is paid once in an excess year for each person on the membership. Alternatively it might be applied to the first two hospitalisations on your family membership before it’s capped. This will depend on your individual cover.

Selected hospital plans waive the excess for same-day admissions or for children or student dependants.

It’s worthwhile finding out if you have a ‘hospital excess’. Please refer to Your Plan Information or log in to Online Member Services for further details about the excess arrangements that apply to your particular level of cover.

A hospital excess is payable on the hospital component but not the medical component of your cover. If you do have an excess, and you have not already paid it in your current membership year, you may be required to pay this amount to the hospital prior to your admission. GU Health will then cover the remaining cost of your accommodation directly with the hospital.

A pre-existing condition is one which is considered to have shown signs or symptoms up to six months prior to joining or increasing your level of hospital cover, irrespective of diagnosis. Pre-existing conditions are subject to a 12-month waiting period, meaning benefits may not be paid for these conditions until the appropriate level of cover has been held for 12 months.

We may request further medical evidence when trying to determine your eligibility for benefits. Where required, the determination of whether a condition is pre-existing will be made by a medical practitioner appointed by GU Health. To enable us to make an assessment, you’ll need to provide us with all the information we request from you and/or your treating medical practitioner(s). Please consider this when you agree to a hospital admission date so we have sufficient time to review your individual situation.

If you’re admitted into hospital without confirming your benefit entitlements and we later determine your condition is pre-existing, you’ll need to pay any hospital and medical charges not covered by Medicare – no benefits will be paid by GU Health. If you’re an overseas visitor and not eligible for Medicare, you’ll be liable for the full cost of your treatment/admission.

In an emergency

In some cases where you’re admitted to hospital for an emergency, we may not have time to assess if your condition is pre-existing prior to your admission. As a result you may have to pay for all or some of the hospital and medical charges. This is especially the case if:

  • you have less than 12 months membership on your current cover
  • you’re admitted to a public or partner private hospital and choose to be treated as a private patient and we later determine that your condition was pre-existing.

    Once the emergency treatment is carried out you may then choose to be re-admitted as a private patient (if required). In such instances we strongly recommend that you:

  • ensure the hospital is a partner private hospital

  • obtain Informed Financial Consent so you understand any potential out-of-pocket expenses
  • contact your Member Relations Team to ensure your level of cover is sufficient for the service/treatment you require. Private hospital emergency room fees are not covered under any resident cover options. If you’re a non-resident and are covered for outpatient services, please refer to the outpatient services section of Your Plan Information.

Exclusions are procedures or services that are not covered under your level of cover which we’re unable to pay any benefits for.

If you choose a product with restricted benefits (also called default or minimum benefits), you’ll only be covered for admission into a shared room in a public hospital for those services.

If you’re admitted into a private facility, the benefit we will pay is equal to the lowest cost of a shared room in a public hospital. This means you could face significant out-of-pocket expenses if you are admitted to a private hospital.

We won’t pay a benefit for intensive or coronary care, labour ward, or theatre fees in a private hospital or private day centre. If you wish to be covered in a private hospital, we recommend you consider purchasing a more comprehensive level of cover.

Restricted benefits may also apply in instances where you’re undergoing a treatment which isn’t listed under the MBS. This may include plastic and cosmetic surgery and surgery by an accredited podiatrist. Please refer to Your Plan Information for details of benefits included under your level of cover.

Grand United Corporate Health Limited (GU Health) ABN 99 002 985 033 is a registered health insurer. A subsidiary of nib holdings limited ABN 51 125 633 856. © Grand United Corporate Health Limited 2018.