Hospital Services

When you're admitted to hospital, the type of benefits we may pay includes:

• accommodation
• operating theatre
• intensive care
• doctor and specialist fees
• government-approved prostheses
• PBS medicines.

The level of benefits we pay will depend on whether you go to a hospital participating in the HCF private hospital network.

Public hospital admissions for included services
If you receive treatment as a private patient in a public hospital for services included in your level of cover, the benefits payable are at the Gazetted Rate, which is determined by a state or territory health authority. These benefits are higher than Minimum Benefits but if the hospital charges more than the Gazetted Rate, you'll have an out-of-pocket cost.

Participating private hospital admissions for included services
If you receive treatment at a participating private hospital for services included in your level of cover, the benefits payable are specified in the hospital contract with that hospital.

Non-participating private hospital admissions for included services
If you receive treatment at a non-participating private hospital for services included in your level of cover, the benefits payable are only Minimum Benefits. In some instances, the out-of-pocket costs could be significant and depending on the treatment and length of stay, it could be up to tens or hundreds of thousands of dollars.

No matter which type of hospital you attend, you may need to pay for medical out-of-pocket costs for doctors’ fees, pathology and X-rays. Call our helpline on 13 68 42, then press 2, so we can help you find a hospital and doctor in the HCF network.

Emergency department fees

A maximum of $200 per visit for emergency department fees including administration fees (when a charge is raised by the hospital).

Note: In hospital outpatient clinics (not emergency departments) benefits are only payable for medical fees where the service would be eligible for an MBS benefit if provided to an Australian resident. No other fees or charges are payable for outpatient clinics.

Doctor and specialist services

You're covered for doctors’ services for items listed on the Australian Government Medicare Benefits Schedule (MBS) and where the service would be eligible for an MBS benefit if provided to an Australian resident:

• For regular doctor visits, you'll be covered with nothing to pay when you see a doctor through our GP network.
• For specialists and non-network doctor consultations, we'll cover you for 100% of the MBS fee.
• For pathology and radiology, we'll cover you for 100% of the MBS fee for services such as blood tests, scans and X-rays⁺.

If the provider charges above the MBS fee, you will need to pay an out-of-pocket cost.

Medicine

You're covered for medicines listed on the Australian Government approved pharmacy list (PBS):

• Medicines given to you when you leave hospital (discharged) if they're part of your ongoing treatment. We'll cover up to a maximum of $100 per individual medicine, after you pay an amount equivalent to the current PBS general patient co-payment per medicine.
• The yearly limit for discharge medicines claimable per person is $200.

Ambulance

Emergency transport to the nearest hospital able to provide the treatment required from any location except from a medical facility or a hospital or for on-the-spot treatment.

OTHER THINGS YOU MAY WANT TO KNOW

Excess

An excess is a non-refundable amount of money you agree to pay when you go to hospital. The excess amount you choose affects the cost of your premium. A higher excess will lower the cost and a lower excess will raise the cost.

For Short Stay you can choose a $250, $500 or $750 excess per person per calendar year when hospitalised.

Waiting period

A waiting period is the time you need to wait before a benefit becomes available to you. You’ll be covered immediately for all of your in-hospital and out-of-hospital services. There are no waiting periods under this cover. Pre-existing conditions are not covered after any amount of time.

What's not covered?

Hospital

• Out-of-pocket costs if you go to non-participating hospitals or are treated at a public hospital. This includes if the hospital decides to charge more than the Minimum Benefit or the Gazetted Rate.
• Hospital costs unless you're admitted to hospital, except emergency department fees when not admitted.
• Any costs if you become classified as a nursing home type patient.
• Personal convenience, luxury room and take home items.
• The gap on government-approved prostheses.
• Any excess on your policy.
• Any service that's excluded on your policy.
• Hospital treatment when Medicare pays no benefit for Australian residents e.g. elective cosmetic surgery.

Medical in and out-of-hospital

• Out-of-pocket costs if you go to a non-network doctor or your specialist charges more than the MBS fee.
• Medicines provided on a script from a doctor, specialist or emergency department.
• Non-PBS medicines including high cost and experimental drugs.
• Co-payments on PBS medicines.
• Out-of-pocket costs when your doctor/s charge more than the MBS fee and when any charges aren't covered by our No Gap arrangement.
• Non-emergency ambulance or transfers between hospitals.
• Medical services that are part of any service that's excluded on your policy.
• Out-of-pocket costs for diagnostic services such as X-rays, scans and blood tests if the provider charges more than the MBS fee.
• Medicines prescribed by doctors or emergency department as an outpatient and not part of a hospital admission.
• Medical services for surgical procedures performed by a dentist, podiatrist, podiatric surgeon or any other practitioner or service that's not eligible for a Medicare benefit.
• Costs for medical examinations, X-rays, vaccinations or any treatment required for obtaining a visa to enter Australia, change in visa or application for permanent residency or examination for pre-employment purposes.
• Outpatient medical services provided by an allied health provider (e.g. optometrist, physiotherapist, dentist and psychologist).

Other

• Treatment received outside Australia.
• Costs if compensation, damages or benefits are payable by a third party. e.g. workers compensation or motor vehicle accident.
• Any service that is deemed a pre-existing condition.
• Costs for extras goods and services such as dental, optical, physiotherapy and natural therapies.
• Cost of repatriation.
• Costs of returning mortal remains to home country, or funeral costs.

^{^} A pre-existing condition means an ailment, illness or condition, the signs or symptoms of which in the opinion of a Medical Practitioner appointed by HCF, existed in the period of 6 months ending on the day on which the Policyholder is covered for Hospital Benefits or upgrades to a higher Product or Insured Group. The test applied relies on the presence of signs or symptoms of the illness, ailment or condition; not on a diagnosis.

⁺ This doesn't include costs for medical examinations, X-rays, vaccinations or any treatment required for obtaining a visa to enter Australia, change in visa or application for permanent residency or examination for pre-employment purposes.

^* Excludes emergency ambulance transport from a medical facility or a hospital. Excludes all non-emergency ambulance services.