This check-list is designed to assist you with planning your hospital stay.
It’s essential that you understand your cover, including any co-payments or excesses, restricted services and waiting periods. Here we provide an overview of co-payments and excesses that you should be aware of, the difference between being treated in a private vs a public hospital, and how waiting periods can be affected by pre-existing conditions.
Understanding what you’re covered for before your stay means you will avoid any surprise out-of-pocket payments. Some of the issues to be clear about include the following.
- Level of cover - Check your level of cover by logging into your Member Service Centre or by contacting us directly.
- Co-Payments & Excesses - You should be aware of any co-payments or excess that you’re required to pay. Daily Co-Payments are available to members who have either Limited or Comprehensive Hospital covers (or any type of package cover). Under this arrangement, you can opt to pay Daily Co-Payments for each day in hospital in return for lower premiums. Your Daily Co-Payment will be either $70 or $100, so you will pay either $70 or $100 for each day you are in hospital (including single days for day surgeries). The maximum you will pay is for 6 days per calendar year for one person or 12 days per calendar year for a family. If you have LiveLife and StepUp package covers, your Daily Co-Payments are waived for each dependent child up to 12 years of age who are included on your membership. Your product may also have an excess of $350 or $500. This means that when you go into hospital you will pay the first $350
/$500 in respect to charges raised by a hospital. This excess is per person up to a maximum of $700/$1000 per family membership per calendar year. You can find out if you have a Daily Co-Payment or Excess by reviewing your last CBHS cover statement or by logging on to your Member Service Centre.
- Waiting periods and pre-existing conditions - Waiting periods and rules relating to pre-existing conditions for benefits apply, so it’s important that you check if you are currently subject to a waiting period for coverage. Find out more by reviewing this page or by calling us directly for more information.
- Understand the Difference between Private vs. Public - If you have hospital cover with CBHS, you can choose to receive treatment in a public or private hospital. The following benefits will vary depending on your choice of hospital, your level of cover, and other factors.
Private hospital - Restricted benefits (including no coverage for theatre or labour ward fees) apply to non-agreement private hospitals. Members with limited and comprehensive cover may access benefits for private rooms, theatre fees and intensive care when admitted to an agreement private hospital. Coverage for private hospital services such as major eye and joint surgeries, colonoscopy and bowel surgery, palliative care programs, and more is available for members with comprehensive cover admitted to an agreement hospital.
Public hospital - Basic, limited and comprehensive hospital members can access benefits for the cost of private rooms, shared rooms, and/or intensive care. However, basic hospital members are subject to restricted benefits for private rooms.
Please note that restricted services can attract different rules. For example, if the service is restricted under your membership and you are staying in a private room in a public hospital, you may need to pay large out-of-pocket costs. However, this may not apply if the services are rendered in public hospitals in shared rooms.
Find out more about CBHS’s hospital cover here or by calling us directly.
- Check for Specialty and Restricted Services - Specialty services can attract benefit restrictions depending on your level of cover, so you might want to clarify with your doctor or hospital about any specialty services you’ll be receiving.
You can contact us if you have any questions about whether your service or product will be covered. Alternatively, you can log into the Member Service Centre to find out if you’re covered for restricted services. Depending on your cover, you may need to pay out-of-pocket expenses for these restricted services.
In most cases you will have spoken to a GP before being referred to a specialist, who then recommends the appropriate hospital treatment. There are several things that you will need to ensure that you ask your specialist before commencing any treatment programs, particularly in regards to out-of-pocket expenses and the Access Gap Cover scheme.
You will probably already have spoken to your GP and specialist before being recommended for treatment in hospital. You should have a discussion with your GP and specialist about minimising your out-of-pocket expenses, and you can ask your GP to participate in CBHS's Access Gap Cover scheme if they don't already.
You can also ask your GP to refer you to a specialist who participates in the Access Gap Cover scheme, or for a list of specialists who may be willing to participate. To prevent from being locked into seeing a specific specialist, you should ask your GP for an open referral so that you can choose from a list of specialists.
When speaking to your specialist, make sure that you ask him or her to explain your condition in plain language. Ask the doctor to outline the different treatment options that are available to you, and ask the doctor to explain the risks and benefits of each option. Make sure they let you know about all the medical professionals who will participate in your treatment so that you understand all the costs that may be applicable.
If you will be using a prosthesis or are being fitted with one, check with your doctor about any out-of-pocket expenses that are payable. You will be covered up to at least the minimum benefit in the prosthesis list under the Government's Private Health Insurance legislation. You may want to discuss other issues such as recovery and continuing current medications while in treatment, and to also have the doctor provide you with a medical certificate for leave from work.
Please note that whether a doctor participates in the Access Gap Cover scheme or not is completely at his or her discretion. Doctors may choose to participate in the scheme on a patient-by-patient basis, and the fact that the doctor has participated in the scheme before doesn't guarantee that he or she will do so again.
Once your specialist has selected a hospital with which to commence your treatment program, you will need to check the hospital has an agreement with CBHS.
Once you and your specialist have agreed upon a treatment plan and you have determined if a hospital stay is necessary, your specialist will nominate the hospital that they prefer to work with. This choice is at the discretion of the specialist but sometimes you will be presented with 2 or 3 hospital choices, so it’s important that once you know the name or names of the hospital that you check if they have an agreement with CBHS. You can find out whether your hospital has an agreement with CBHS by using
this search tool.
If the hospital that your specialist chose does have an agreement with CBHS, as one of our members you will be covered according to your hospital coverage level. This might include accommodation, theatre and labour ward, intensive care and coronary care.
If your specialist has chosen a hospital that does not have an agreement with us, you will still be covered up to pre-set limits - which are set by the government - but you may also incur large out-of-pocket costs.
Identify what will be involved in your hospital stay, including planned treatment program and whether you will be staying overnight.
The next step is to check what will be involved in your stay and treatment. For example, you might be receiving surgery as a day patient (on the basis of a same-day admission). You should also clarify what types of services or treatment you will be receiving. This will make it easier to check if you have services subject to restrictions or exclusions and if you need to pay out-of-pocket cost.
Note that you will be considered an admitted patient if you are receiving chemotherapy on a daily basis, as long as your hospital has an agreement with CBHS and admits you as a day patient. Similarly, you might be able to obtain benefits from your hospital cover with CBHS if you receive home nursing from the hospital after discharge. If not, you might be covered if you have Top Extras or LiveLIfe package cover.
By contrast, in receiving a minor medical procedure that is performed in your doctor’s room, you’re not considered an admitted patient. This attracts a non-admitted theatre fee from your doctor and is therefore covered under Top Extras, Prestige and LiveLife packages. Please note that in this case the bill for doctor services is payable by Medicare only.
Before going into hospital, you should obtain a quote or informed financial consent from all the specialists and medical professionals involved in your hospital treatment. This way you will be aware of all out-of-pocket expenses before your admission. You should also obtain a quote from CBHS to understand your hospital out-of-pocket costs.
The next step is to obtain an informed financial consent or itemised quote from your doctors. These medical professionals may include your anaesthetist, surgeon, radiologist and pathologist. Having access to quotes allows you to plan for the costs of your stay more effectively.
Note that if your doctors participate in CBHS’s Access Gap Cover scheme, you may not receive a bill as the doctor may forward the bill directly to CBHS for payment.
You should also get a quote from CBHS to understand the out-of-pocket payment related to hospital services.
For planning purposes, you will probably also want to be aware of the claiming process before your stay.
Getting to know the claiming process before your stay will allow you to better plan. The two items to be claimed are your hospital fees and your doctor and specialist bills. For your hospital fees, your hospital will bill CBHS directly. If you are required to pay for any part of your admission, you pay this fee directly to the hospital. Ask the hospital about their procedure for payment.
For your doctor and specialist bills, your doctors will bill CBHS directly if they are participating in the Access Gap Cover scheme. If you receive a bill from your doctor, forward it to us for payment rather than to Medicare first. We will process it and forward it to Medicare on your behalf.
If your doctors and specialist are not participating in the Access Gap Cover scheme, take the bill to Medicare and complete a two-way form there to submit the claim. Medicare will process the claim and we can then provide you with your benefits.