Being admitted to hospital can be a daunting experience and understanding what you are and are not covered for can be confusing. CBHS can help you understand what to expect when you are going to hospital.
step 1 - understand your cover
Before you go in to hospital, the first thing you need to do is make sure you understand what you are covered for with CBHS. Below is a list of considerations that you should follow.
What is your level of cover?
You can find out your level of cover from by logging into the Member Service Centre, or by calling us.
Do you have any waiting periods?
Waiting periods apply to all CBHS covers for new members or members upgrading their cover. To check if any waiting periods apply to your cover, you can call our Member Care Centre. If you have had your current level of cover for over 12 months, it is most likely that waiting periods will not apply. Find out more about waiting periods.
Do you have an Co-Payment on your cover?
On Comprehensive and Limited Hospital covers, you have the option of taking a Daily Co-payment option to reduce your contribution rates. All package covers include a daily Co-payment as standard. Check if you have an Co-payment on your cover by looking at your last CBHS cover statement, or logging on to the Member Service Centre. See Glossary for more information on Daily Co-payment.
Are you going to be staying overnight?
Ask your doctor whether you will be required to stay overnight for the treatment, or whether it will be a day surgery treatment.
What type of service will you be receiving?
Some specialty services have particular restrictions on them. Ask your doctor about the type of service you will be receiving, for example rehabilitation or a new hip.
Does your cover have restricted services?
Check if your level of cover has any restrictions by logging on to the Online Member Service or calling CBHS. See Glossary for more information on restricted services.
step 2 - obtaining a quote
By obtaining a quote from your specialist and other medical service providers involved in your hospitalisation (e.g. anaesthetist, assisting surgeon, pathologist and/or radiologist) you are eliminating any unexpected bills arriving after your hospital stay.
If your specialist agrees to charge you under the Access Gap Scheme you may not even see the bill, as it may be sent directly to CBHS for payment.
Access Gap Cover
Access Gap Cover allows CBHS to pay above the schedule fee for doctors' services provided to you as an admitted patient, covering the entire doctors' fee or leaving you with significantly reduced out-of-pocket expenses.
Doctors can choose to participate in Access Gap Cover on a patient-by-patient basis, so you should discuss Access Gap Cover with your doctor. If your doctor charges the Access Gap fee, you will have nothing to pay. Even if they charge above the Access Gap fee you will be able to establish the 'known gap' you will have to pay before you receive treatment.
Click for more information on Access Gap, including a list of doctors who have previously participated and a checklist of questions to ask your provider.
step 3 - check your hospital has an agreement with CBHS
CBHS has agreements with most Australian private hospitals and day hospitals. Subject to your level of cover, these agreements provide for admitted patient accommodation fees including bed fees, theatre and labour ward, intensive and coronary care fees. To check if your hospital has an agreement with CBHS use the Hospital Search Function.
If your chosen hospital does not have an agreement in place with CBHS, you will be covered up to pre-set limits (set by the Government) and will incur significant out-of-pocket expenses.
step 4 - what are the benefits payable by CBHS?
Below are a number of questions to help you determine what you can expect CBHS to pay for.
1) Do you have an Co-payment on your cover?
Yes - go to question 2
No - go to question 3
2) Have you already been admitted into hospital for 6 or more days this calendar year and paid your Daily Co-payment?
Yes - the maximum Daily Co-payment payable is 6 days per person or 12 days per family per calendar year - you are not required to pay any further Co-payments this calendar year (continue to question 3)
No - you will need to pay the relevant Daily Co-payment each day that you are hospitalised up to a maximum of 6 days per person (continue to question 3)
3) Is the service restricted on my membership?
Yes - go to question 4
No - go to question 5
4) Are you receiving the restricted service in a public hospital in a shared room?
Yes - CBHS will pay benefits towards your accommodation (continue to question 6)
No - If you are going into a private room in a public hospital, or going into a private hospital, you will have significant out-of-pocket expenses. Contact CBHS to find out the benefits you will receive (continue to question 6)
5) Does your hospital have an agreement with CBHS?
Yes - You will be covered for accommodation, theatre, labour ward, intensive and coronary care fees. (continue to question 6)
No - you will have significant out-of-pocket expenses. Please contact us for more information (continue to question 6)
6) Are your doctors, and other specialists involved in your treatment charging you under Access Gap Cover?
Yes - Your doctor will have provided you with a written estimate of fees and you should be aware of any out-of-pocket expenses
No - You will be covered for 100% of the schedule fee set by the Department of Health and Aging (Medicare pay 75% of schedule fee and CBHS pay 25%). If your doctor and other specialists charge above the schedule fee, you will have to pay the difference. Ask your doctor and specialists what your expected out-of-pocket expenses will be.
Answering these questions should give you an understanding of the benefits you may receive from CBHS and any expenses that you may have to pay. If you are still not sure please contact the CBHS Member Care Centre for more information.
step 5 - claiming for services received in hospital
Hospitals will bill CBHS directly. If you are required to contribute to your admission (for example you have an co-payment, or have restricted cover) you will be required to pay this directly to the hospital. Please check with the hospital whether you have to pay this upon admission or if they will bill you.
Doctor and Specialist Bills
If your doctor or specialist participated in the Access Gap Cover scheme
Your doctor should bill CBHS directly. If the doctor sent the bill to you, please forward this to CBHS. Do not take it to Medicare first as we will forward it to Medicare on your behalf once we have processed our portion.
If your specialist did not participate in the Access Gap Cover scheme
Please take the bills to Medicare and fill out a Medicare two way form. Medicare must process the claim before CBHS can provide any benefits.
Why won't my doctor participate in the Access Gap Cover scheme?
It is up to your doctor to decide whether they will charge you at the Access Gap Cover rate. Even if the doctor has participated in this scheme before, it does not guarantee that the doctor will participate in Access Gap Cover in for your treatment. Doctors are free to choose whether they will participate in Access Gap Cover on a patient by patient basis. This decision remains solely with the doctor.
Am I classified as an admitted patient when having chemotherapy on a daily basis?
You will be covered for chemotherapy received on a daily basis as long as the hospital you are receiving the treatment from has an agreement with CBHS, and admits you as a day patient.
Am I covered for a minor medical procedure in my doctor's room?
An example of a minor medical procedure could be the removal of a small cancerous spot where the doctor may perform this procedure in a sterile room and raises a specific fee.
Benefits towards this specific fee are available under Top Extras and LiveLife package cover. Benefits are 70% of the cost up to a maximum of $160. This type of service is considered a non-admitted theatre fee.
Can I receive benefits towards home nursing after hospitalisation?
In some instances home nursing is provided by the hospital after you have been discharged and is payable by CBHS under your hospital cover as part of your admission costs.
Alternatively if the above does not apply and you have Top Extras or LiveLife package cover, you will receive benefits towards home nursing by a registered nurse.
What is a Pre-existing Condition?
A Pre-existing Condition is an illness or condition where the signs or symptoms were evident (whether diagnosed by a doctor or not) at any time during a period of 6 months immediately prior to the time of joining CBHS. This is an industry standard rule applied by all health funds for the protection of existing members. The rule applies for 12 months continuous membership from the date of joining or when a member upgrades their cover.
Am I covered for prostheses?
To at least the minimum benefit specified in the prosthesis list issued under Private Health Insurance legislation.
When does CBHS require a medical report for a planned hospitalisation?
If you have joined or upgraded your level of hospital cover within the last 12 months, you may be subject to waiting periods for pre-existing conditions. You need to provide a medical report so our medical advisor can assess whether or not the condition is covered.
The report must be completed by the first doctor consulted for this condition. Download the Certificate for Medical Practitioner form to take to your first consulted doctor.