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1 Going into hospital?

2 Going into hospital? Being admitted into hospital can be an anxious time for you and your family. Having hospital cover can give you peace of mind, but may also raise many questions about what you re entitled to. Following is a summary of common questions. What am I covered for? Hospital - You re fully covered for theatre and accommodation charges for most hospitalisations at our contracted hospitals or in public hospitals (restrictions and exclusions may apply to some covers, please refer to the relevant product brochure). Inpatient medical services These include services provided by your specialist, anaesthetist, pathologist, radiologist etc. while you re admitted into hospital. Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee and we pay the remaining 25%. Should your specialists charge over the schedule fee for inpatient services, you ll be out-of-pocket for this additional amount unless the practitioner bills you under Access Gap Cover to reduce this amount (see page 6). Services provided in hospital by other professionals such as physiotherapists may be covered in the hospital contract. If these services aren t covered in the contract, benefits may be claimable if you have the appropriate extras cover. How do I know if the hospital I am going to is a contracted hospital? We have an extensive network of contracted hospitals throughout Australia and a search facility is available on our website. Remember to check this information each time you need to go into hospital, as the status of hospitals can change. Are there types of hospitalisation services that I m NOT fully covered for? Most levels of cover include plastic and reconstructive or elective surgery. If you do have cover for this, we will only pay if your doctor and Medicare deem this as medically 2

3 3

4 necessary. You also may not be fully covered for hospital stays in private hospitals which aren t contracted to TUH. Some incidental services, such as medications not directly related to the reason for your hospitalisation, may also not be covered. You re also not covered for consultations with doctors or specialists prior to or following any hospitalisation Medicare will pay a percentage of the schedule fee in these cases. What if I m still serving waiting periods? You re covered immediately if you need to be hospitalised due to an accident that occurs after you have joined TUH unless this is claimable from a third party. For all other hospitalisations you ll need to serve the full waiting period for the condition before any benefit is paid. If it s a preexisting condition, the waiting period is 12 months. Waiting periods also apply to upgrades of cover or transfers from another health fund, if you weren t previously covered for that condition. Benefits for hospitalisations which take place in the first two months after the upgrade or transfer are paid at the previous rate of hospital cover. Am I covered for day surgery? Yes. Many of the services which once required an overnight or extended stay can now be performed in a day. You re fully covered for theatre or accommodation relating to day stays in contracted hospitals or public hospitals, providing Medicare is paying benefits towards the associated doctor s bills. The excess for day surgery is the same as an overnight hospitalisation. Am I covered for medical services provided in the doctor s rooms or clinic? No. Some simple procedures which were formerly carried out in hospital can now be carried out in the doctor s surgery. As you are not an inpatient when undergoing these procedures, TUH is unable to pay any benefits towards the doctor s fees. Medicare will pay a percentage of the schedule fee in these cases. Do I need to advise TUH that I m going into hospital? 4 We recommend that you do, as we ll be able to advise you of the status of the hospital you are going to, your

5 entitlements under your level of cover and register you for our Home Care Programs where relevant. Are there any questions I should ask my doctor before admission? Yes. Firstly, ask what hospital you ll be treated in and ensure, where possible, that the hospital is contracted to TUH. Secondly, ask your doctor if he/she participates in Access Gap Cover. If the answer is yes, you should request to be treated under this scheme. For major treatment, this information should be provided in writing. It is your right to ask for this information before you agree and give your informed financial consent to a proposed treatment (see page 6). How do I pay my doctor s bills? Bills from doctors, anaesthetists, pathologists and other medical practitioners which relate to inpatient services should be submitted to Medicare before being sent to TUH. The only exception to this is where the doctor has billed you through the Access Gap Scheme. These accounts should be sent to TUH directly and would have a notice on them advising you to do so. Does TUH pay my doctor directly? If your doctor has charged you under Access Gap Cover, we ll pay him/her directly. In all other cases, we ll send the benefit cheque to you to pass to your doctor. How do I pay my excess? If your cover has an excess, this will be paid direct to the hospital, rather than to TUH. Many hospitals require you to pay the excess prior to your admission. When will I receive my hospital and doctor s bills? In most cases, the hospital will bill TUH directly so you won t see their account. We ll send you an advice that the hospital bill has been paid on your behalf. Practitioners participating in Access Gap Cover will usually send their accounts directly to TUH. Other medical practitioners accounts are normally sent to you personally. 5

6 What is Access Gap Cover? Access Gap Cover is designed to cut down the out-ofpocket expenses you may incur on services you receive while you re admitted as an inpatient into hospital. All health fund members who have hospital insurance are eligible for Access Gap Cover providing their doctor is willing to participate. Access Gap Checklist Before you receive your treatment as a private patient, you have the right to know what you re required to pay up front and to receive this information in writing. This is called Informed Financial Consent. You should ask your doctor, TUH and your hospital about any out-of-pocket expenses you may have to pay. This checklist provides you with the questions you need to ask before you go into hospital as a private patient. Ask your treating doctor or specialist: How much is your fee? Do you participate in Access Gap under Australian Health Service Alliance (AHSA)? If I have to pay a gap, how much will that be? What if I can t afford to pay this gap? Which other doctors and medical staff will be involved in my treatment, eg. radiologist, anaesthetist, assistant, etc? How can I get information about their fees and if they participate in Access Gap under AHSA? Will I receive just one bill? Am I having a surgically implanted device or prosthesis? Will the cost of this be covered by TUH or will I have to pay a gap? What is the Medicare Benefits Schedule item number for the procedure I am to have? (see Ask TUH section) 6

7 Ask TUH: Does my policy cover me for this procedure or service (based on the Medicare Benefits Schedule item numbers provided by your treating doctor)? Under my policy, do I have to pay an excess or any other charges? If so, how much? Will I have to pay extra for my hospital accommodation, my doctor s fees and those of anyone else involved with my treatment, or is it all covered under my policy? If I have to pay extra, when and to whom do I pay it? Ask your hospital: Does this hospital have any agreement with TUH? Will I have a gap to pay for my hospital accommodation? What else do I have to pay for out of my own pocket during my time in hospital? This information is a summary of the most common questions our members ask us. Please read this flyer in conjunction with the product brochure that applies to your cover and the Important Information Guide both are available on tuh.com.au or by contacting us. 7

8 Contact us to find out more about how you can make the most of your membership. Phone: tuh.com.au 07/2015

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