You’ll need to ask them some questions about your condition and treatment.
Download our handy checklist that you can print and take with you to your appointment.Download PDF
It’s really important that you choose the right doctor and the right hospital. If you choose an access gap doctor, it’ll help reduce or eliminate any out of pocket expenses when going to hospital. And make sure you choose a hospital contracted with us.
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Active kids are happy kids! And whilst being active is great for our kids health sometimes accidents happen – which is why you’ll pay no excess if any one of your kids ever needs to go to hospital.
What is it?
You may need to pay an ‘excess’ when you’re admitted to hospital.
An ‘excess’ is a fee paid in return for lower health cover premiums. This cost will apply for each hospital admission, but there is an annual cap to limit your costs incurred to you.
Will I need to pay an excess fee? How much will it be?
Your excess fee depends the type of coverage you have.
Log in to view your cover and level of excess.
Do I pay excess for day stay or smaller procedures?
Despite only being in hospital for a few hours, excess still applies to your stay if you choose to be admitted as a private patient. Whether you are admitted as a private patient in a public or a private hospital, as there will be a bill for the sterile facilities that in the hospital needed to be booked and used for your treatment and we will be contributing to this, as well as the 25% of the scheduled fee.
Sometimes for day stays, your excess will be more than the cost of the hospital bill – if this happens, the hospital will only charge you the cost of the facilities, and will send us a bill with nothing to pay. This is so that we can minus this from your excess balance for any other admissions you have in the year.
What are they?
If your doctor chooses not to participate in our Access Gap Scheme then, by law, we are only required to pay 25% of the Medicare Benefits Schedule (MBS) fee. Medicare pays 75% of the MBS fee.
However, medical practitioners are able to set their own fees. If your bill is more than the MBS fee you’ll have to pay the difference. This difference is known as the ‘gap fee’ or out-of-pocket expense.
What’s the Access Gap Cover Scheme?
To help reduce or eliminate your out of pocket hospital expenses, we participate in the Access Gap Cover Scheme.
The scheme is administered by the Australian Health Services Alliance to help reduce or eliminate your out of pocket hospital expenses. Almost 9 out of 10 medical services under the Access Gap Cover Scheme have no out of pocket expenses.
However, medical practitioners can decide on a case-by-case basis whether or not they choose to participate in the scheme.
What if my medical practitioner decides to not participate in the Scheme?
Medicare will pay 75% of the cost under the Medicare Benefits Scheme (MBS). By law, health.com.au is only able to pay 25% of the cost. But because medical practitioners can set their own fees, if your invoice is more than the MBS feeyou will need to pay the difference.
What it is it?
Before you receive your treatment you are entitled to ask your doctor, your hospital and health.com.au about any extra fees you may have to pay out of your own pocket.
These extra fees are commonly known as ‘gap’ payments.
Knowing how much your overall treatment will cost is called ‘informed financial consent’.
How do I get informed financial consent?
Ask, ask, ask!
Speak to your doctor, your hospital and health.com.au before you receive any treatment.
Ask your treating doctor specialist how much their fee will be and if you will need to pay a gap. For major treatment this information should be provided in writing.
You may have lower or no out-of-pocket costs if your treating doctors elect to use our Access Gap Scheme. You are entitled to ask your doctors if they will use it.
You may have more than one doctor involved in your treatment, e.g. a surgeon and anaesthetist. Your surgeon will be able to advise who else will be treating you and how you can contact them.
Ask your health fund (that’s us!) whether your insurance will cover the procedure, and whether you will need to pay an excess, or any other fees associated with your treatment.
We may ask you to obtain the Medicare item numbers your doctor will be using to provide you with a quote.
If you are within waiting periods, you will also need to ask your doctors to provide medical certificates for assessment of whether benefits will be paid.
Ask your hospital if they are one of our contract hospitals and whether you will have to pay any gaps or extra costs.
Your hospital should perform a membership eligibility check with us before you’re admitted. They’ll also and seek your informed consent about any extra fees you may have to pay out of your own pocket.
This information should be provided in writing.
Will I have any? And what will they be?
Switching from another health insurer?
When switching from another insurer, any waiting periods you have already served will be recognised so that you don’t have to serve them again. If your new health.com.au policy is an upgrade from your previous cover then you may have to wait before you can claim, but only for the services you didn’t have on your previous policy.
New to private health insurance?
If you have never had private health insurance before you will need to serve some waiting periods before you can make a claim.
Learn more here
A pre-existing condition is an ailment, illness or condition where, in the opinion of an independent medical referee appointed by health.com.au (not your own doctor), the signs or symptoms of a condition existed and would have been evident to you or a medical practitioner during the six months before you first signed up for hospital cover or upgraded to a higher level of hospital cover.
Pre-existing Conditions have a 12 month waiting period. The Australian Government have published this PDF, which you can download for more information.
Please note that psychiatric, rehabilitation, and palliative care are not subject to pre-exisiting waiting periods.
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