Understanding hospital cover

Going to hospital? Knowing how your hospital cover works can help you make choices that may help keep your costs down.

Hospital cover

Procedure costs

Specialists & hospitals

Preparing for hospital

Planning your recovery

At a glance

Hospital cover can help pay towards Included treatment when you’re admitted to hospital as a private patient, once you’ve served your relevant waiting periods.
It doesn’t pay for everything, and you may have to pay some fees yourself (out-of-pocket costs), as well as an excess or per-day payment, if applicable.
You can often reduce out-of-pocket costs by choosing Medibank Members’ Choice hospitals and specialists who choose to participate in GapCover or No Gap¹ arrangements for your procedure.
Contact us as early as possible so we can help you make informed decisions about your cover.

What does hospital cover pay towards?

Hospital cover can help pay towards included treatment when you’re admitted as a private patient, once you’ve served your relevant waiting periods.

Hospital cover can help pay towards:

emergency ambulance transport to hospital
hospital accommodation (overnight or same-day)
operating (theatre) and intensive care unit (ICU) costs
in-hospital specialists’ fees (surgeons, anaesthetists), though you may still have out-of-pocket costs if your specialist/s charges above the Medicare Benefits Schedule (MBS) fee
some in-hospital diagnostic services (scans, blood tests)
some medications used during an admitted hospital stay that are listed on the government’s Pharmaceutical Benefits Scheme (PBS) and are directly related to your treatment
certain prostheses and implanted medical devices.

The amount of benefits you receive depends on:

the treatment you’re having
whether your treatment is Included in your hospital cover
whether you’ve served any waiting periods
the specialists and hospital involved in your care, including whether the hospital is a Members' Choice hospital.

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What doesn’t hospital cover pay towards?

Hospital cover doesn’t pay for everything.

Some common exclusions are:

all appointments and tests outside of hospital or that aren’t part of a hospital admission (even if provided at a hospital), including: GP and specialist appointments, scans, blood tests and x-rays
some medications, including ones prescribed for use outside of hospital
some in-hospital diagnostic and pathology services (scans, blood tests)
some prostheses and implanted medical devices
treatments or services that are Excluded under your cover
treatments or services not listed on the Medicare Benefits Schedule (MBS).

Any amount you pay yourself towards a service or treatment is called an out-of-pocket cost.

Understanding out-of-pocket costs

Whether you’ll pay any out-of-pocket costs and the amount you might need to pay usually depends on:

whether your treatment is Included, Restricted or Excluded under your hospital cover
your choice of hospital
how much each of the specialists (surgeons, anaesthetist) involved in your care decide to charge.

Understanding these costs can help you make choices to keep them down.

Excess and per-day payments

An excess is a set amount you pay towards your hospital accommodation when you’re admitted as a private patient. You usually set your excess amount when you first choose your level of hospital cover. It’s paid once per adult per calendar year (up to the limits on your cover). Knowing your excess can help you plan for any upfront costs; you can check your excess in My Medibank.

A per-day payment is a daily charge you pay towards your hospital accommodation, if applicable - check your cover summary.

Your level of cover

Hospital services are listed on your cover summary as:

Included: We pay benefits for the treatment, but you may still have some out-of-pocket costs.
Restricted: We pay the minimum amount of benefits set by the government, which can mean significant out-of-pocket costs.
Excluded: We don’t pay benefits, so you will likely have significant out-of-pocket costs.

Check your cover summary in My Medibank to see which services are Included, Restricted and Excluded.

Gap payments (specialist fees)

The government sets a standard fee for many medical services, including consultations and procedures performed by specialists in a hospital. These fees are listed in the Medicare Benefits Schedule (MBS).

When you’re admitted as a private patient:

Medicare pays 75% of the MBS fee for medical services provided by your specialists
We pay a minimum of 25% of the MBS fee for medical services provided by your specialists (for Included or Restricted services).

However, specialists can choose to charge more than the MBS fee. If they do, you’ll need to pay the difference (the gap) yourself.

How GapCover can help

The GapCover scheme is designed to help reduce or eliminate gap payments. Each specialist involved in your care (for example, your surgeon and your anaesthetist) can choose whether to use GapCover for your procedure. If they do, they’ll charge you either a Known Gap or No Gap.

Known Gap: your out-of-pocket costs for that specialist are capped at $500 per admission.
No Gap: you pay no out-of-pocket costs for eligible inpatient specialist fees for that specialist.

If you’re planning a hospital treatment, ask each specialist involved in your care whether they’ll use GapCover for your treatment.

Avoid gap payments with the Medibank No Gap program

Waiting periods and pre-existing conditions

A waiting period is the time between when you take out your current level of cover and when we’ll pay benefits towards the treatment or service.

You can still access hospital treatment during your waiting period but we won’t pay benefits towards it, meaning you may have significant out-of-pocket costs.

Similarly, any ailment, illness or conditions with signs or symptoms that existed within the 6 months before you took out hospital cover (pre-existing conditions) usually have a 12-month waiting period before we’ll pay benefits towards their hospital treatment.

Waiting periods are outlined in your cover summary in My Medibank.

How to reduce your out-of-pocket costs

As a Medibank hospital cover member, there may be choices you can make about your hospital care to help keep your costs down.

Choose to contact us early where possible.

If you know or suspect you might need hospital treatment, contact us so we can help you make informed decisions about your hospital cover.

Chat to us online or call 132 331.

Ask if your specialist participates in GapCover or No Gap.

Before you book, ask each specialist involved in your care about their fees. Ask whether they’ll participate in GapCover for your procedure, or if they participate in Medibank’s No Gap¹ programs.

Ask if a Members’ Choice hospital is right for you.

You can generally get better value at a Members’ Choice hospital than a non-Members’ Choice hospital. We have arrangements with most private hospitals and day surgeries in Australia.

Frequently asked questions

What happens if I have to go to hospital in an emergency?

What happens if I’m admitted as a private patient in a public hospital?

If you’re admitted to a public hospital as a private patient, you can still choose to use your Medibank hospital cover to help pay for treatment by paying your excess and any per-day payment (if applicable) directly to the public hospital at the time of your admission. If your admission is unplanned (such as in an emergency), contact us as soon as is feasible so that we can support you during your treatment and progress your claim more quickly.

Now that you’ve covered

☑ How hospital cover works

☑ Excess and per-day payments

☑ How to reduce your out-of-pocket costs

Things you should know

¹Eligible members participating in Medibank’s No Gap program could pay no out-of-pocket costs for your hospital stay, so long as your procedure is included in the program and your procedure is performed by a participating surgeon at a participating hospital. An excess or per-day payment may still be payable, depending on the product a member has chosen and whether they are claiming under their hospital cover for the first time in a calendar year. The Medibank Member Guide and Fund Rules set out hospital benefit exclusions, which apply to all hospital admissions for Medibank members. There may be out-of-pocket expenses associated with outpatient appointments, such as your initial visit with a participating surgeon in their consulting rooms.