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I’m going to hospital. What do I need to know?

Your Going to Hospital Checklist

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

Avoid out of pocket expenses!

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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Kids pay $0 excess going to hospital

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.

Other Important Information

Do I have an excess?

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.

Out-of-Pocket Expenses

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, 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.

Waiting Periods

Will I have any? And what will they be?

View your waiting periods

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 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 

Pre-Existing Conditions

A pre-existing condition is an ailment, illness or condition where, in the opinion of an independent medical referee appointed by (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.

Common One Day Procedures


How does billing work?

  • The consultations prior to the procedure in hospital are outpatient. Take these bills to Medicare to claim any rebates you are entitled to.
  • There will be a hospital bill – if you are an adult, the hospital will charge you an excess at the time you are admitted (or earlier). The rest of the bill will get sent to us.
  • There will be at least two medical bills claimable: the bill for the specialist performing the scope and an anesthetist.
  • Just like any other medical practitioner, your specialist and anesthetist may go under access gap >link to Access Gap section< if you ask.
  • It is very common to require follow-up colonoscopies procedures.

Wisdom Teeth Removal 

How does billing work? 

  • There will be two bills a dental bill, and if you have extras you can claim this claimable under your major dental extras.
  • However, you will need to pay for the dental procedures in full and claim at a later date (there will not be a Hicaps machine available at the hospital).
  • Just like any other medical practitioner, your specialist and anaesthetist may go under Access Gap if you ask.

Knee and shoulder scopes and reconstructions

How does billing work?

  • Consultations prior to the procedure are outpatient. Claims these via Medicare.
  • Just like any other medical practitioner, your specialist and anaesthetist may go under Access Gap if you ask.
  • You will very likely require physio or gym after the procedure. This is claimable under your Extras.