Using Your Cover

How you could influence your hospital costs

When it comes to hospital admissions, knowing your entitlements with private hospital cover is a key factor to getting the best outcomes for your health and your hip pocket.

Written by Medibank

A hospital admission might not be the best thing to ever happen to you; but when you hold private hospital cover, there are a few ways you could take control of your situation and lessen the stress:

You have a choice of specialist

With private hospital cover, you can choose the surgeon or specialist who treats you. If you know which surgeon or specialist you would like to see, you can ask your GP to write a referral to them – otherwise, your GP will be able to help you choose a surgeon or specialist.

If your GP recommends a particular specialist, ask them why they’ve recommended them over others. You can always ask for an open referral - this provides you with the choice on where you present the referral or which specialist you want to visit.

Ask for a quote

It’s your right to know the full cost of your in-hospital treatment and how much your out-of-pocket expenses could be. Knowing about potential costs not only saves you worrying – it can also save you money.

Before going to hospital, ask each of your specialists and your hospital for a breakdown of all the costs in writing. This is known as Informed Financial Consent. It should list the fees for each specialist involved in your treatment – your surgeon, assistant surgeon, and anaesthetist – and any other related costs.

Tell your specialists if you’re worried about cost – there may be ways to cut down on expenses without compromising your care.

There are times when it isn’t possible for your specialists to give you an estimate of the cost before you’re treated, like in an emergency. In these situations, you’re entitled to find out about your medical expenses as soon as possible after receiving treatment.

Out-of-pocket expenses

If your specialist decides to charge more than the Medicare Benefits Schedule fee (the set government fee), you will likely be left with an out-of-pocket expense, commonly referred to as the ‘gap’.

This means that in the private hospital system, the out-of-pocket expense you pay is the difference between what Medibank and Medicare contributes towards the total cost of your medical treatment and the specialist fees associated with that treatment.

There are a few different reasons a medical out-of-pocket expense can arise as a result of your hospital admission. Be sure to familiarise yourself with these in our Going to Hospital guide.

Ask about specialists that participate in GapCover

GapCover is a scheme designed to help eliminate or reduce your out-of-pocket expenses for in-hospital specialists’ charges.

With access to the digital health platform ‘Healthshare’, GPs and their patients are able to look up specialists who have participated in Medibank’s GapCover arrangements. You can also find the same list of specialists on Medibank’s Find a Health Care Provider page.

GapCover doesn’t cover all medical services, and specialists can choose whether or not to participate in GapCover for part, or all of your treatment. So, check upfront with each specialist involved if they’ll participate in GapCover for all claims as part of your treatment to help reduce your out-of-pocket expenses. And remember, there will be other charges aside from your specialist’s fees that can add to your total costs.*

*Excludes public hospital covers and overseas visitor covers. Out-of-pocket expenses may still apply. GapCover does not apply to diagnostic services.

Remember the excess

An excess is the amount you pay towards your hospital admission (same-day or overnight), before we pay any benefits. You only pay this once a year and you would have chosen the amount (usually $250 or $500) when you chose your cover. Excess does not apply to dependants on our family covers.

Ask what else is involved

When a hospital stay is on the cards, there’s a lot to think about so it might be good to go in with a list of questions. Ask things like whether you’ll need to stay in hospital and for how long? Will you need to take time off from work? Are you likely to need any post-surgery rehab or follow-up treatment?

Choose a Members’ Choice Hospital

At hospitals in Medibank’s Members’ Choice Network, we have agreements in place to limit your out-of-pocket expenses – meaning you’ll generally get better value at one of these hospitals.

You may still have to pay for some treatments that we don’t pay benefits towards under your policy, out of pocket expenses for medical treatment and any excess that applies. Remember to check the Going to Hospital guide for a detailed view what you can expect from your hospital admission.

Call us before your procedure

Before you commit to a specialist or procedure, it’s always a good idea to call us on 132 331. We can help you understand what out-of-pocket costs you are likely to encounter, and what you can expect from your hospital stay.

Just remember to ask your specialist for the specific Medicare Benefits Schedule (MBS) item number/s that relate to your treatment. They might forget to offer, so remember to ask!

For more information on what you need to know before a hospital admission, refer to our Going to hospital guide.

Written by Medibank

Previous article

How to get more from your Extras

Next article

How to prepare for your hospital stay

Related articles

Subscribe to receive the best from Live Better every week. Healthy recipes, exercise tips and activities, offers and promotions – everything to help you eat, move and feel better.

By clicking sign up I understand and agree to Medibank's privacy policy

Thanks for subscribing. You’re on the road to a better, healthier version of you!