Going to hospital?

You can avoid any unexpected out-of-pocket expenses by understanding what you’re covered for before you go into hospital.

• Check your level of cover - Log into your Member Centre or mobile app, or contact us and we’ll check your level of cover.
• Do you have a co-payment or excess?  -  Members on some covers opt to pay daily co-payments in return for lower premiums. Daily co-payments are either $70 or $100 for each day you are in hospital (including single days for day surgeries). The maximum you pay is six days per calendar year for one person or 12 days per calendar year for a family. If you have LiveLife (Gold) and StepUp (Bronze Plus) package covers, your daily co-payments are waived for each dependent child on your membership. Your cover may also have an excess of $500 or $750, so when you go into hospital you pay the first $500 or $750 of the hospital charges. This excess is per person up to a maximum of $1,000/$1,500 per family membership per calendar year. Find out if you have a daily co-payment or excess by checking your last CBHS cover statement or log into the Member Centre or app.
• Waiting periods and pre-existing conditions - Waiting periods and pre-existing conditions can impact what benefits you get back, so it’s important that you check them both. Find out more here or call us and we’ll check for you.
• Understand the difference between private and public - If you have hospital cover with CBHS, you can choose to receive treatment in a public or private hospital. Benefits vary depending on your choice of hospital, your level of cover and other factors, such as whether the hospital is a CBHS-agreement hospital.

Private hospital - Restricted benefits (including no coverage for theatre or labour ward fees) apply to non-agreement private hospitals. Members with Limited (Bronze Plus) and Comprehensive (Gold) 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 (Gold) cover admitted to an agreement hospital.

Public hospital - Basic Plus, Limited (Bronze Plus) and Comprehensive (Gold) Hospital members can access benefits for the cost of private rooms, shared rooms, and/or intensive care. However, Basic Plus 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 call us on 1300 654 123.

• Check for specialty and restricted services - specialty services can have 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.

Contact us if you have any questions about whether your service or product will be covered. You can also log into the Member 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 restricted services.

You can ask your GP to refer you to a specialist who participates in the Access Gap Cover (AGC) scheme, or give you a list of specialists who might be willing to participate. AGC is designed to reduce or eliminate the medical ‘gap’. The aim is for you to end up with less or, in some cases, no out-of-pocket medical expenses when you receive treatment at a private hospital as an inpatient.

TOP TIP: Ask your GP for an open referral so you can choose from a list of specialists, that way you’re not locked into seeing one person.

There are several things you need to ask your specialist before you start treatment.

• Ask him or her to explain your condition in plain language and outline the different treatment options.
• Ask them to explain the risks and benefits of each option.
• Make sure they tell you about all the medical professionals who will participate in your treatment so you understand the costs that might apply.

If a prosthesis (an artificial part to replace something in the body) is involved, check with your doctor about any out-of-pocket expenses. 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 can choose to participate in the scheme on a patient-by-patient basis, so 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 determined that you will need a hospital stay, they will nominate the hospital they prefer to work with. This is at their discretion. Sometimes they’ll give you a choice of two or three hospitals. Once you know your options, check if they have an agreement with CBHS by using this search tool.

If the hospital has an agreement with us, 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 doesn’t have an agreement with us, you will be covered up to pre-set limits – set by the Government – which may mean you incur large out-of-pocket costs.

Clarify what types of services or treatment you will receive. This makes it easier to check if your services are subject to restrictions or exclusions, and if you need to pay any out-of-pocket costs.

You’ll be considered an admitted patient if you receive chemotherapy daily, so long as your hospital has an agreement with CBHS and admits you as a day patient. Similarly, you might be able to claim benefits from your Hospital cover if you receive home nursing from the hospital after discharge.

By contrast, you’re not considered an admitted patient for minor medical procedures received in your doctor’s rooms. This attracts a non-admitted theatre fee from your doctor and is covered under Top Extras and Prestige (Gold) packages. Please note that in this case the bill for doctor services is payable by Medicare only.

Before you go into hospital, get a written quote from all the specialists and medical professionals who will be involved in your treatment. This may include your anaesthetist, surgeon, radiologist and pathologist. An itemised quote is known as informed financial consent, and you are legally entitled to request it.

You should also get a quote from us to understand any hospital out-of-pocket costs.  That way, you’ll be aware of all your out-of-pocket expenses before your admission.

The two items you’ll be claiming for are your hospital fees and your doctor and specialist bills.

Your hospital will bill us directly for any hospital fees. If you’re required to pay any part of your admission for example your co-payment or excess, you pay this fee directly to the hospital. Ask the hospital about their procedure for payment.

If your doctors and specialists participate in the Access Gap Cover scheme, they should bill us directly. If you receive a bill from an Access Gap doctor, forward it to us for payment, not Medicare. We’ll process it and forward it to Medicare on your behalf.

If your doctors and specialist don’t participate in the Access Gap Cover scheme, submit the bill to Medicare and complete a two-way form to claim your benefits. Medicare will process the claim and we can then provide you with your benefits.