3 Going to hospital We understand that going to hospital can be a stressful time. If you re feeling nervous or don t quite know what to expect don t worry, this is completely normal. At Medibank, we re not just here to pay the bills. We re here to help you stay informed and feel supported during this important event and to make sure your hospital experience is stress-free, so you can focus on what s important getting better. To help you prepare for your hospital visit and make the most of your cover, we ve put together this step-by-step guide. Need more help? Don t worry. We re here with you all the way. With you all the way Before going into hospital, we recommend you give us a call. That way you can find out exactly what you re covered for, what out-of-pocket costs you might have to pay, and how we can help you make the most of your cover. You can call us for advice and support on at any stage of your treatment before, during and after because we really are with you every step of the way. Better health isn t just about going into hospital. It s a lifestyle. To help you achieve your optimum health and wellbeing, Mi Health is included as part of your hospital cover. Mi Health is your personal suite of health support services available 24 /7. Find out more about Mi Health on page 17. This brochure is relevant to Australian residents with Medibank hospital cover. If you have Visitors Health Insurance, Working Visa Health Insurance or Overseas Student Health Cover, call us on for advice and information about going to hospital. The information in this brochure is current at the date of issue, 1 September, and only applies to Medibank branded products. The information provided is for general information purposes only and is not a substitute for medical advice. Medibank does not recommend or endorse any advice, specialists, other healthcare providers, products, tests, procedures or other general information mentioned in this booklet. Reliance on any information provided by Medibank is done so at your own risk and Medibank takes no responsibility for any injury, loss, damage or other consequences that may result from the use of this information. As a member of Medibank, your entitlement to benefits will depend on your level of cover and is subject to our Fund rules and policies. Premium rates, benefits and the Fund Rules and policies are subject to change from time to time. 3
4 Contents Step-by-step: before, during and after 5 Choosing your hospital 6 Understanding your costs 8 Making a claim 12 Your right to know 13 Questions to ask your specialist 14 Questions to ask Medibank 15 Going home 16 Better health support with Mi Health 17 Better care 18 Useful resources 18 4
5 Step-by-step: before, during and after Before you go to hospital 1. Find out about your condition Understanding your condition and treatment alternatives is the best way to ensure you get the right care. Talk to your GP and specialist about your options, and make the most of our 24/7 Health Advice Line to get advice and support from a Medibank nurse. For online information and health tools, visit the Medibank Health Hub or check out 2. Get a referral from your GP To receive treatment in a hospital from a specialist you ll need to get a referral from your GP. 3. Talk to your specialist Once your GP has given you a referral, talk to your specialist about your treatment. Your specialist will give you information about your condition, your treatment and any pre-admission assessments or tests you might need. You can also find out about any other specialists involved, their fees and any additional expenses. Ask if your specialist will participate in GapCover to reduce and even eliminate your out-of-pocket costs. See page 9 for more about GapCover and questions you should ask your specialist. 4. Understand your rights You re entitled to know how much your treatment will cost before you go into hospital. Find out how to take control of your healthcare and make smart, informed choices on page Contact us Once you ve spoken with your specialist, get in touch with us to make sure your cover includes the treatment and to find out how to reduce your out-of-pocket costs. We re also here to help out with any other questions you might have about your treatment. For advice and support, call us on or drop into your local Medibank store. 6. Complete your hospital forms Your hospital will need you to complete an admission form before you go in for treatment. Make sure to complete these and return them before your admission date. During your hospital stay 7. Know your rights and responsibilities As a patient in a hospital or day surgery, you re entitled to a certain standard of treatment and care. Find out about your rights and responsibilities on page Take care of yourself Before you re discharged from hospital, ask your specialist or nurse for written instructions on how to care for yourself after treatment. After you leave 9. Lodge your claim(s) Find out how to lodge your claim on page 12 or call us for help on Embrace better health We re committed to better health. Take advantage of our GP-supported online tools, programs and videos on our Health Hub to manage and maintain your health now and in the future. Find out more on page 17. 5
6 Choosing your hospital When you have hospital cover, you can choose to be treated at either a private hospital or a public hospital, although this might depend on your specialist and where they work. Check with your specialist to see if they ll treat you at a Members Choice hospital. This could help limit your out-of-pocket costs. You should also check with the hospital directly to find out what you might be charged for. Better value with Members Choice We have special arrangements with hundreds of private hospitals around the country to help limit your fees and reduce your out-of-pocket costs. To find a Members Choice hospital near you, search our online directory at With our network covering a large group of private hospitals in Australia, your treatment just got a whole lot more affordable. 6
7 Private patient in a private hospital Private patient in a public hospital Public patient in a public hospital How quickly will I be treated? As soon as you and your specialist are ready.* As soon as you and your specialist are ready.* When a time becomes available on the public waiting list. This could be weeks, months or years depending on your treatment. Can I choose my own specialist(s)? Yes (unless you re admitted as an emergency patient, whereby choice of specialist is not always possible). Yes (unless you re admitted as an emergency patient, whereby choice of specialist is not always possible). No. Can I choose which hospital I ll be treated at? Yes, but this will depend on your specialist and where they work. Yes, but this will depend on your specialist and where they work. Possibly, but this will depend on where your specialist works and when a place becomes available on the public waiting list. Can I get a private room? Yes, subject to availability. Yes, depending on availability and your clinical needs. Possibly, depending on the hospital you re being treated at. Will I have to pay for my hospital accommodation? Possibly, part or all of your hospital accommodation fees will be covered, but you may have to pay an excess. Possibly, part or all of your hospital accommodation fees will be covered, but you may be charged extra for a private room and you may have to pay an excess. No, Medicare will cover all of your hospital accommodation fees. Will I have to pay any specialist(s) fees? Possibly. Medicare and Medibank will cover part or all of your specialist(s) fees. Possibly. Medicare and Medibank will cover part or all of your specialist(s) fees. No, Medicare will cover all of your specialist(s) fees. *Subject to your policy s included services and waiting periods 7
8 Understanding your costs Understanding your costs and knowing what you could be up for is the best way to avoid surprises and get the best value for your treatment. You re also legally entitled to know what your costs might be before going into hospital. This right is called Informed Financial Consent. To find out more about Informed Financial Consent, see page 13. How your fees are calculated When you go into hospital, there are often a number of specialists involved in your treatment. For example, your treatment might require the services of a surgeon, an anaesthetist and a pathologist. Your fees will include charges from each specialist involved, plus charges from your hospital to cover things like your accommodation and other services. The amount of these fees will depend on your specialist(s) and hospital. When your specialists choose to participate in GapCover and treat you at a Members Choice hospital, your out-of-pocket costs are reduced and sometimes even eliminated. That s why it s important to ask your specialist up front if they ll participate in GapCover for your particular treatment. Will you have to pay an excess? Depending on your level of cover, you might need to pay an excess for your hospital stay when you re admitted. For most covers with an excess, you only need to pay this once per policy holder (or partner) per calendar year. You won t need to pay an excess for any dependent adults or children. Call us to check if there s an excess for your policy on or drop into one of our stores. Understanding out-of-pocket costs Although private cover helps reduce your hospital fees, you may still need to pay some expenses out of your own pocket. Depending on your level of hospital cover, you might need to pay for things like the following out of your own pocket: Hospital excess Costs for pharmaceuticals or services not covered (either fully or partially) by our agreement with your hospital Gap fee: the difference between what your specialists charge and the benefit you receive from Medibank (us) and Medicare Prosthesis, x-ray (radiology) or pathology (laboratory) expenses (determined by your hospital) Costs for treatments not recognised by Medicare. To keep track of what you can expect to pay, use the out-of-pocket expenses table on page 11 when you visit your specialist. 8
9 Why is there a gap for specialist(s) fees? When you re treated by a specialist Medicare pays for 75% of a pre-determined standard fee known as the Medicare Benefits Schedule (MBS) fee and we pay the remaining 25%. Because specialists can choose their own service fees, they sometimes charge more than the MBS fee, leaving you to make up the difference. This is what s referred to as the gap. By choosing a specialist who will participate in GapCover, we pay some or all of the gap for you, so you can reduce or even avoid these out-of-pocket costs. Closing the Gap GapCover is an agreement we make with participating specialists to limit your medical out-of-pocket costs. When your specialists participate in GapCover, you either pay no gap at all or your out-ofpockets are capped at $500 per specialist. Ask if your specialist will participate in GapCover. If they choose not to participate then you have the option of looking for one that does. You can find a list of previous GapCover participants at medibank.com.au. How specialist(s) bills work But remember, a specialist can opt in and out of GapCover, so make sure to ask if they are willing to participate for your particular treatment. To find out more about GapCover, visit our website, drop into a Medibank store or give us a call on We re always here to help. About GapCover It s important to know that specialists can choose to participate in GapCover on a claim-by-claim basis. This means you should always ask about GapCover before you start treatment. If a specialist charges more than the maximum $500 gap, this indicates they re not participating in GapCover and means you ll need to pay the difference between the MBS fee and the specialist s total fee. This can be expensive, so it s important to find out what you might be up for before you go to hospital. GapCover doesn t apply to pathology and radiology services (although these might be covered by a Members Choice hospital), nor does it apply to your excess payments or any services not included under your cover. Total fee charged by your specialist(s) Medicare Benefits Scheme (MBS) fee The standard fee for your procedure set by Medicare Gap The difference between what your specialist charges and the MBS 75% Medicare pays for 75% of the MBS fee 25% Medibank pays the remaining 25% of the MBS fee Medibank GapCover Helping you minimise or even avoid the gap Note: Specialists can choose to participate in GapCover on a claim-by-claim basis. 9
11 Reducing your out-of-pocket costs Reducing your out-of-pocket expenses is easier with Members Choice hospitals and GapCover. To reduce what you need to pay, make sure you: Contact us to check what you re covered for Choose a Members Choice hospital whenever possible Ask your specialist for the contact details of all specialists involved in your treatment Ask each specialist if they participate in GapCover Ask each specialist for a written estimate of out-of-pocket costs or to confirm their GapCover participation. How much will my prostheses cost? Under hospital cover, we pay an agreed amount towards the cost of surgically implanted prostheses and other items on the Federal Government s Prostheses Schedule*. While this cover applies to most types of prostheses, there are some that you may need to financially contribute to. To make sure you re getting the right prosthesis for your needs, discuss your options with your specialist and ask for a written estimate of any out-of-pocket costs. If you re concerned about what you re covered for, give us a call on to discuss your options. * Visit to view the full Federal Government Prostheses Schedule. My potential out-of-pocket costs Item Amount Hospital excess $ Hospital out-of-pocket expenses (e.g. phone calls, Foxtel, parking etc.) $ Specialist(s) gap fees $ Specialist(s) booking fee (typically pregnancy and delivery) $ Anaesthetist gap fee $ Assistant surgeon or other specialist gap fee $ Prosthesis expenses $ Other possible expenses (e.g. x-rays or pathology) $ Total $ 11
12 Making a claim At Medibank, we re here to help make your hospital treatment as stress-free as possible. We re here to help out with the bills and provide advice and support before, during and after you go to hospital. If you re unsure about how to claim, or need help with understanding your medical bills, call us on We re always here to help. Taking care of your bills In a lot of cases, you won t need to submit a claim to us at all. This is because we take care of as much as possible behind the scenes. This applies to: Your hospital accommodation bills these are sent directly to us by the hospital. Any excess or fees for items not covered under your policy will be billed directly to you. Specialist services from GapCover participants your specialists will bill us directly. Any gap amount will be billed directly to you. If a specialist charges you more than $500, this indicates they re not participating in GapCover. How to claim for medical expenses If you do need to make a claim, it s important to remember that you don t need to pay your specialist(s) bill first. Thanks to two-way-claiming, you re no longer out-of-pocket while you re waiting to be reimbursed. As soon as you receive your bill for a service that s covered under your policy, contact Medicare to find out about two-way claiming. Medicare will process their portion of your claim and forward the rest to us. Things you should know If you ve paid for services out of your own pocket before claiming, you ll be reimbursed for your eligible amount via EFTPOS or cheque. If a GapCover specialist bills you directly, it s important that you do not pay this bill. If you do, you cannot claim under GapCover and will not receive your full GapCover benefit. Call us on for advice on what to do if this happens. When to submit a claim If you re billed for in-hospital expenses or by a specialist not participating in GapCover, you may be able to claim back a portion of these. To find out what you re covered for, call us on or drop into a Medibank store near you. 12
13 Your right to know As a private patient, you re entitled to know who will be treating you, how much each specialist will charge, and if you need to pay any fees out of your own pocket. This right to know is called Informed Financial Consent. You can ask for this information from your specialist(s), your hospital and your health fund (that s us). We ve compiled a list of questions you might want to ask on pages Most importantly, it s a good idea to get as much information as you can in writing (don t forget to save it!) It could come in handy later, and it ll help you remember what you ve agreed to. In an emergency Sometimes it just isn t possible for your specialist to give you an estimate before you re treated, like in an emergency. In these situations, you re entitled to find out about your medical costs as soon as possible after receiving treatment. Emergency situations could include being admitted to the Emergency Ward or unplanned events during a procedure. Either way, you should be informed of any costs as soon as possible. If for any reason your specialist(s) can t provide you with this information personally, they have a responsibility to inform your relatives or someone who can act on your behalf. Your right to know As a private patient you are entitled to: Know the full cost of your hospital treatment Know about any out-of-pocket costs you could be up for Ask for this information in writing from your specialist, hospital or Medibank Make a complaint if your rights aren t upheld. If you re concerned or unsure at any stage, you can always call us on We re here to help you stay informed and feel supported during this important time. 13
14 Questions to ask your specialist About your condition and treatment Can you explain my condition to me? Do you have any information I can take away with me? Where can I find out more? What are my treatment alternatives and what do they involve? Is my treatment necessary? How will the suggested treatment help me? What could happen if I don t have this treatment? What are the risks of this treatment? How soon do I need this treatment? What do I need to do to prepare myself before admission? Do I need to stop or start any medication? Do I need to have any special tests or go to a pre-admission clinic? How long will I be in hospital? Who will be doing the surgery/procedure? Will anyone else be involved in the surgery/procedure and can I have their contact details? Will I need to have an anaesthetic? If so, what will it involve? How quickly will I recover after my procedure? How can I expect to feel during recovery? About your fees Will you participate in Medibank s GapCover network? Will your fees be fully covered under GapCover or will I need to pay a gap? Will there be charges from other specialists involved in my treatment? What might my out-of-pocket costs be? Can you provide me with a written estimate of these? Can you provide me with all of the relevant MBS item numbers? If I need a prosthesis, what out-of-pocket expenses could there be? 14
15 Questions to ask us Am I covered for this procedure or treatment? Will I need to pay an excess? Have I served all my relevant waiting periods? Has my specialist previously participated in GapCover? Is my hospital part of the Members Choice scheme? If not, how will this affect my hospital bills? What out-of-pocket costs might there be? Does my hospital cover help me with after-hospital care like physiotherapy? How does GapCover work? 15
16 Going home Going into hospital for treatment can be a stressful time, and it s important to take care of yourself after you ve been discharged to allow for a full and speedy recovery. Make sure you get written instructions from your specialist about how to manage your health post-hospital. You might want to ask the following questions before you leave: What signs and symptoms should I be aware of? Who should I contact if I need help? When should I make a follow-up appointment with my GP? When should I make a follow-up appointment with my specialist? Will I need physiotherapy or other rehabilitation services? Are there any specific instructions to help with my recovery? Will I need to take any medication? If so, for how long? When can I return to work? When can I resume all my usual activities like driving and exercise? Will my discharge information be passed on to my GP? Can you supply me with a medical certificate for my employer? Getting back on track There are lots of things you can do to get your health back on track after your hospital treatment. Your specialist might recommend services like physiotherapy, and you may be given an after-care plan to follow. Whatever is right for you, we re here to support your recovery with a range of health support services and programs through Mi Health and betterhealth apps. 16
17 Better health support with Mi Health Feel supported and get professional medical advice after your time in hospital with Mi Health a range of health support services to help you manage and maintain your health. Under your hospital cover you have access to: Medibank Nurse 24/7 Health Hub Mobile Health Apps. You can also call us at any time for general support on Medibank Nurse 24/7 If you ve got a question about you or your family s health, medications or treatment, our Medibank nurses are on call around the clock to help. Designed to complement the care you receive from your GPs and specialists, Medibank Nurse 24/7 is there for you as part of your Medibank hospital cover. Call 1800 Mi Health ( ) to speak to a Medibank nurse 24 hours, 7 days a week. Health Hub Health Hub is your reliable online health resource, overseen and maintained by GPs. Health Hub is a virtual library and toolkit in one, with a range of videos, coaching programs, recipes and more to help you achieve better health. Health Hub can help you manage your health, weight loss, stress and medical conditions from the comfort of your own home. Check it out online when you log into Online Member Services at Better health on the go Keep track of your health while you re out and about with our free Mobile Health Apps. Download Symptom Checker (for iphone*) for a quick diagnosis on the run (we recommend you always seek out a professional opinion as well) and keep track of your food and exercise with Energy Balancer (for iphone and Android). iphone is a trademark of Apple Inc. Android is a trademark of Google Inc. 17
18 Better care At Medibank we re all about better care. We re committed to a better healthcare experience for you and better health for everyone. For friendly and informed healthcare help and advice, call us on Your rights and responsibilities Understanding your rights is the best way to make sure you get the best care possible. On top of your right to Informed Financial Consent (see page 13), you have a number of other rights included in the Patients Hospital Charter and Public Patients Hospital Charter. These charters outline your rights, your responsibilities and what to do if your hospital experience doesn t meet your expectations. Ask for a copy of your relevant charter from your hospital, or find it online at Concerns with your healthcare If you re concerned about your healthcare, you should always talk to your healthcare professional first. For more information, seek a second professional opinion or contact the patient advocate or resolutions representative at your hospital. To make a complaint, contact the independent healthcare complaints department in your State or Territory. Useful resources Medicines Get information and find tips for managing your medicines at To report any side-effects or errors, or for advice on medicines, call the Adverse Medicine Events Line on General health information For general health information visit a Commonwealth Government initiative to improve the health of Australians through better access to quality information. Medicare Safety Net The Medicare Safety Net is there to help you with your medical expenses. If you need to see a GP or specialist often or require multiple tests, your medical costs can add up quickly. This is where the Safety Net could kick in. Once you reach a certain threshold, your medical care could start costing you less. Find out more about the Medicare Safety Net at Call us on Find us online at medibank.com.au Drop in for a chat at a Medibank store near you 18
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