Going to hospital

Going to hospital can be stressful, and the last thing you need is to worry about how much it’s going to cost.

Hospital Cover

We’re here to help.

We’re here to support you and your family before, during and after your hospital stay. It’s part of our commitment to outstanding value and exceptional member care. If you have any questions, you can contact us any time before, during or after your admission.

Before you go into hospital

Use this checklist to help you plan your stay in hospital (click the expandable titles for more details).

Understand your cover

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 Service Centre 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 product may also have an excess of $500 or $750, so when you go into hospital you pay the first $500 or $750 of charges raised by the hospital. 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 your Member Service Centre.
  • Waiting periods and pre-existing conditions - Waiting periods and pre-existing conditions can impact benefits, 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 agreement versus non agreement hospitals.

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.

  • 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 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 restricted services.

Contact your GP and find the right specialist

You can ask your GP to refer you to a specialist who participates in the scheme, or give you a list of specialists who might be willing to participate. 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 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.

Agreement versus non-agreement hospitals

Once your specialist has determined that a hospital stay is necessary, 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, so once you know the names of the hospital, 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.

Define your hospital stay and treatment

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 obtain 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.

Informed financial consent

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.

Understand the claiming process

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

Your hospital will bill us for any hospital fees. If you’re required to pay any part of your admission, 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. 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, take the bill to Medicare and complete a two-way form to submit the claim. Medicare will process the claim and we can then provide you with your benefits.

During your hospital stay
  • Packing - Pack essential items such as your CBHS membership card, Medicare card, any medications you’re taking, medical reports or scans and images, referral letters, pre-admissions pack if you have one, and other clothing and toiletries for a comfortable stay.
  • What to expect - Every hospital has its own routines and procedures. If you received a pre-admissions pack from your chosen hospital, it will contain useful information about the admissions process, visitors and visiting hours, meals and amenities such as TV and phones. Your hospital may charge you for extra items such as internet access, pay TV, non-emergency transportation that you request and other items. Contact your hospital direct if you’d like more details.

After your hospital stay

Your rehabilitation and recovery are just as important as your operation. We’re here to support you in any way we can, so please don’t hesitate to call us on 1300 654 123.

Generally, your hospital will bill us upfront. You’ll need to pay any daily co-payment and any other out-of-pocket expenses directly to the hospital.

Consult your specialist

Before you leave hospital find out if you need to take any medications and obtain clear instructions on how many and how long to take these for.

It’s a good idea to ask your specialist about your daily routine or work during recovery and rehabilitation. You are likely to have other questions, such as, do they recommend you go back to work or take time off during your recovery? Are they able to complete a sick certificate for your leave period from work?

Your specialist will probably arrange a follow-up appointment to take place some days or weeks after you’re discharged from hospital. He or she will usually take time to discuss the risk of complications or issues (if any) that might arise after your operation or treatment. You might also discuss at-home nursing or help at home, if you require it.


Your rehabilitation program might be as simple as resting at home for a few days, or it could be more complicated and require ongoing treatment such as physiotherapy or nursing. Your specialist will discuss with you any rehabilitation services you might need. In many cases these services will be covered up to applicable limits under your Extras or Package cover

At home care

If you need at-home nursing care after discharge and the hospital provides this, CBHS will cover the costs of this service as part of your hospital admission costs. 

Hospital substitute treatment

In some cases, you may continue to receive hospital treatment after being discharged. This home-based service will be fully covered by CBHS if you have hospital or package cover, but your doctor must first approve your hospital substitute treatment program as clinically appropriate for your circumstances.

For example, you can receive wound management, nursing services, physiotherapy, or occupational therapy in your own home. Support services such as meal and domestic help may be included. These services must be an appropriate substitute for treatment that you would be fully covered for if received in hospital.


Your doctor and hospital will usually bill us directly. If your doctor does not participate in our Access Gap Cover scheme, he or she will bill you. You should submit your claim to Medicare using a two-way claim form. After Medicare has processed the claim, we will reimburse you with any payable benefits.

Contact us

Your health and happiness are at the heart of everything we do, so please call us on 1300 654 123 if you have any questions. If you’d like to find out more about the Hospital Substitute Treatment program, call our Health and Wellness team on 02 9843 7616 or email wellness@cbhs.com.au.