Going to hospital

Your guide to making your hospital stay as easy as possible.

Heading to hospital can be a stressful, whether you're going to hospital for the first or 40th time. To help you with your hospital stay we've created the guides below, which deal with every facet of going to hospital. From how to choose the right hospital and what to bring with you, to questions to ask your doctor and how to claim your treatment on private health insurance. So, if you're a little unsure of what's required for your next trip to hospital, read through our going to hospital guides.

What to do before being admitted to hospital

Going to hospital can be a scary and intimidating experience, so here’s everything you need to know to prepare for your stay.

Going to hospital can be a stressful time for you and your entire family.

A hospital stay can be a confusing and intimidating experience for anyone, even if you’re only booked in for a minor procedure, so it’s important to be prepared before you’re admitted.

Read on to find out how to get ready for your hospital visit and what you can expect before being admitted. If you plan ahead, you can ensure that your stay is as stress free and comfortable as possible.

Getting admitted to hospital

Planned hospital admissions usually follow a few simple steps: admitted to hospital

  • Finding out about your condition. You can talk to your GP and specialist about your condition, your treatment options and the pros and cons of each option. This will help you get a better understanding of why you need to go to hospital, what will happen when you get there and how much the procedure will cost.
  • Understanding the costs. Before you go to hospital, it’s important to understand how much your treatment will cost. While Medicare covers public hospital treatment costs and private health insurance covers treatment as a private patient in a public or private hospital, you may still incur out-of-pocket expenses. This occurs when your specialist charges more than the Medicare Benefits Schedule (MBS) fee.However, you can reduce or eliminate these out-of-pocket costs if your specialist participates in your health fund’s gap cover scheme, so contact your insurer to find out if you will have to pay anything from your own pocket. Before you undergo a procedure, your hospital must get your informed financial consent. This means you know how much your treatment will cost.
  • Getting a referral. Most hospital admissions occur after your GP refers you to a specialist. Your specialist will determine whether you need to undergo hospital treatment and the type of treatment you need. Your specialist will then send a letter to the hospital to ask for your admission, including details on the urgency of your situation.
  • Waiting for admission. You will be placed on a waiting time register and the hospital will let you know how long you will have to wait before admission. When the time and date of treatment is set, the hospital will contact you to let you know when you need to go to hospital, where to go when you get there, special instructions for treatment and items you need to bring.
  • Filling out the required forms. You will need to complete hospital forms before your admission. Most hospitals will send an admission pack that will include some questions about your medical history and ask you to provide an emergency contact. You must complete these forms and return them to the hospital before your procedure.

What are your admission choices?

If you hold a Medicare card, you can choose to be treated as a public or private patient. If you’re admitted as a public patient, you will have to accept the following conditions:

  • You cannot choose your own doctor. Instead, you will be treated by a doctor or doctors nominated by the hospital.
  • You will not be charged for the cost of hospital accommodation, medical and diagnostic services or for a range of other in-hospital services.
  • You will receive follow-up care from the hospital’s outpatient clinic once you have been discharged.

If you are treated as a private patient, you will get the following benefits:

  • You can choose your own doctor.
  • You can get a single room (if a room is available and if it is included in your health insurance cover).
  • You can get cover for the cost of hospital accommodation and theatre fees as well as for medical and diagnostic services and more.
  • After you leave hospital, you will receive follow-up care from your specialist doctor in their private room.

Choosing your hospital

Several factors will influence your choice of hospital. One of the most important factors is whether you have hospital cover from a private health insurer. If you do, you can choose to be treated in a private or public hospital. However, in some cases your choice of hospitals may vary depending on where your specialist works.

If you do have hospital cover, your insurer will also affect your choice of hospital. Health funds have agreements in place with private hospitals around Australia to ensure that most or all of your hospital fees are covered. But if you choose a hospital that doesn’t have an agreement with your health fund, there’s no guarantee that your fund will foot the full bill for all of your treatment costs.

You will need to contact your health fund for a list of agreement or contracted hospitals.

What are gap cover schemes and how do they work?

Even if you have comprehensive hospital cover in place, you could still incur out-of-pocket expenses when you go to hospital. Out-of-pocket expenses arise when there is a difference between what your health fund and Medicare cover and how much the hospital and the treating specialists charge. This amount is the gap.

To help reduce or eliminate these out-of-pocket expenses, health funds run gap cover schemes. If a specialist participates in your health fund’s gap scheme, you either will not have to pay any gap at all or your out-of-pocket costs will be capped at a certain level.

When meeting with your specialist and discussing the costs of treatment, ask whether they participate in your health fund’s gap scheme.

Preparing for your stay

Before you go to hospital, there are a few important things you can do to prepare for your stay:

  1. Talk to your GP. Discuss your referral with your GP. You have the right to ask for another referral if you’re not happy with the specialist they’ve suggested. For example, you may wish to ask for an open referral, which allows you to choose from a list of specialists with the appropriate qualifications or for a referral to a specialist who participates in your health fund’s gap cover scheme.
  2. Talk to your specialist. If you have any questions about your medical condition or the treatment you need to undergo, ask your specialist. He or she can offer expert advice about the benefits and risks of treatment as well as help relieve any anxiety or confusion you may have. Discussions with specialists can sometimes be overwhelming as there is a lot of information to take in, so you may wish to take a friend or loved one with you.
  3. Talk to your health fund. Contact your health insurer to find out exactly what is covered by your policy. Will you have any out-of-pocket expenses? Can you reduce or eliminate those out-of-pocket expenses by choosing specific specialists or a certain hospital? You can also find out about any waiting periods, exclusions or excesses that apply to cover.

Waiting for treatment

Hospitals book patients in for treatment based on the urgency of their condition, with the sickest patients receiving treatment first. This means that you could wait for a few days before your admission or you could wait for several months.

If your health changes while you are waiting to be admitted to hospital, see your GP as soon as possible. Depending on the circumstances, they may need to notify the specialist or the hospital if the changes affect your treatment needs. Your GP can also offer advice on how to better manage your condition while you wait to undergo treatment.

Checklist of what to bring to hospital

Make sure to bring the following items with you when you go to hospital:

  • Your Medicare card
  • Your private health insurance details
  • Your admission letter from the hospital
  • Important everyday items, such as glasses, dentures and mobility aids
  • Regular medications
  • X-rays, ultrasounds and other scans relating to your hospital treatment
  • Toiletries and pyjamas
  • A change of clothes for when you return home
  • Books, magazines and other items to prevent boredom

Knowing your rights and responsibilities

You need to know your rights and responsibilities before you are admitted to hospital for treatment.

Your rights:

From your doctors, you have the right to the following:

  • A detailed explanation from your doctors about treatment options, their benefits, their risks and any potential alternatives
  • Advice on what to do and what to expect before and after treatment
  • An outline of their fees (including your out-of-pocket costs) before admission
  • The names and contact details of other specialists involved in your treatment
  • Confidentiality and the right to be treated with respect and dignity

From your hospital, you have the right to the following:

  • An outline of any out-of-pocket expenses prior to admission
  • Confidentiality and the right to be treated with respect and dignity

Your responsibilities:

As a patient, you will need to do the following:

  • Follow all the pre-surgery instructions given to you by your specialist to ensure your safety and to make treatment as effective as possible
  • Understand what your health insurance policy does and does not cover
  • Make sure your health insurance premiums are up to date
  • Advise your specialist of any allergies, current medications and medical history that may affect your treatment

Getting to hospital

The final thing you need to consider is how you will physically get to the hospital on the day of your admission. You could organise a lift to the hospital with a friend or loved one, or you may wish to arrange a taxi ahead of time.

Remember to allow time for traffic on the day. This will take any extra stress out of the situation and, along with the other tips in this guide, will hopefully ensure that your hospital stay goes as smoothly as possible.

Choosing a hospital

Choose the right hospital to receive the best-quality treatment you can afford.

If you’ve been told by your doctor or specialist that you need to go to hospital for a procedure, one of the key decisions facing you is the choice of hospital.

There are several important factors you need to consider when deciding on a hospital, so let’s take a closer look at how you can choose the right hospital and receive the best possible care.

Private vs public

One of the most important decisions you need to make, is whether to go to a public or private hospital. hospital emergency

If you have a Medicare card and private hospital cover with an Australian health fund, you have the freedom to choose whether you would like to be treated in a public or private hospital. However, if you don’t have private health cover you will need to undergo treatment in a public hospital.

If you choose to be admitted as a public patient, you’ll be treated by specialists nominated by the hospital and Medicare will cover your hospital accommodation and specialist fees.

On the other hand, if you’re a private patient you can choose your own doctor and potentially access a private room, while your theatre fees, hospital accommodation and more are covered by your health fund.

However, it’s worth pointing out that if the specialist you want to provide your treatment only works at specific hospitals, this may influence your decision. In some cases you may want to receive treatment at a specific hospital simply because it has the best facilities for someone with your medical condition.

Private vs public: A closer look at what’s covered

Should you choose to be treated as a private patient in a private hospital, or as a private or public patient in a public hospital? The table below outlines how your choice will affect the treatment you receive.

Private patient in a private hospital Private patient in a public hospital Public patient in a public hospital
Can I choose my specialist? Yes, provided you are not admitted as an emergency patient. Yes, provided you are not admitted as an emergency patient. No. You will be treated by a specialist or specialists appointed by the hospital.
Can I choose my hospital? Yes, depending on the specialists you choose and where they work. Yes, depending on the specialists you choose and where they work. In some cases. Choice is dependent on where your specialist works and when a place becomes available on the public hospital waiting list.
Can I choose when I will be treated? Yes, you will be treated as soon as you and your specialist are ready. Yes, you will be treated as soon as you and your specialist are ready. No. The time you will have to wait for treatment depends on how long it takes for a place to become available on the public hospital waiting list.
Can I access a private room? Yes, if available and covered by your health fund. Yes, if available and covered by your health fund, and depending on your clinical needs. Maybe, but this depends on the hospital where you undergo treatment – private rooms are allocated to patients who need them the most.
Will I need to pay hospital accommodation costs? No, you will typically not have to pay any accommodation costs if you visit a hospital with which your health fund has an agreement. However, an excess may apply to your policy. While some or all of your costs will be covered by your health fund, you may need to pay extra to secure a private room. A hospital excess may also apply to your policy. No, these are covered by Medicare.
Will I need to pay specialist fees? Maybe. While Medicare and your health fund cover these costs, you may incur out-of-pocket expenses if your specialist charges more than the MBS fee. However, this gap may be covered if your specialist participates in your health fund’s gap cover scheme. Maybe. While Medicare and your health fund cover these costs, you may incur out-of-pocket expenses if your specialist charges more than the MBS fee. However, this gap may be covered if your specialist participates in your health fund’s gap cover scheme. No, these are covered by Medicare.

Gaps and out-of-pocket expenses

Another important point to consider when choosing a hospital is whether or not you will need to pay any out-of-pocket expenses. These expenses arise if your specialist charges more than the Medicare Benefits Schedule (MBS) fee for your procedure.

The difference between the MBS fee and your specialist’s fee is known as the gap, and paying this amount could cost you a significant amount of money.

However, to help reduce or eliminate this out-of-pocket cost, your health fund may run what is known as a gap cover scheme. If doctors participate in your fund’s gap cover scheme, they agree to charge a set fee for their services, which means you won’t be left with any bills to pay yourself.

With this in mind, it’s important to be aware of how much your specialists charge for a procedure, as well as whether or not they participate in your health fund’s gap cover scheme, before starting treatment.

Contract and agreement hospitals

Australia’s health funds have contracts in place with private hospitals located all around Australia.

Under these agreements, insurers have special arrangements in place to help limit the out-of-pocket expenses their members have to pay when they undergo treatment.

By choosing a hospital that your fund has a contract, you could potentially save yourself thousands of dollars by reducing your additional expenses, or even eliminating them altogether.

Contact your health fund for a full list of its local, contract/agreement hospitals, but remember that this is far from the only factor you should consider when choosing a hospital.

Questions to ask the hospital

Before deciding on the right hospital for your treatment needs, make sure to ask the following:

  • Will I have any out-of-pocket costs during my time in hospital?
  • How much will those costs be?
  • When will I need to pay the excess or co-payment that applies to my hospital cover health insurance, if applicable?
  • What payment methods are available?
  • Will I receive a private room for the duration of my stay?
  • Can I choose my own doctor?
  • Are there any appointments I need to attend before my admission?
  • Can you give me any information on what I need to do to prepare for my hospital visit, or what I need to bring with me when I’m admitted?

You may also have specific questions regarding your care. For example, if you’re going to hospital to have a baby:

  • Does the hospital have birth pools and other facilities that match your birth plan?
  • What is the hospital’s intervention rate and Caesarian section rate?
  • Will you have the same carers during labour?
  • How long do new mothers usually stay in hospital after giving birth?

The answers to these questions will help you make an informed choice about where best to deliver your baby.

Your rights and responsibilities

When choosing a hospital you have a right to:

  • Receive a detailed outline of any out-of-pocket expenses you may have to pay prior to your admission.
  • Expect that if your medical condition changes during treatment and it’s not possible for the resulting effect on potential costs to be discussed with you, the hospital will inform you of these costs as soon as possible after the procedure.
  • Confidentiality and privacy.
  • Be treated with dignity and respect.

However, you also have a few important responsibilities. You must:

  • Understand what is involved in your treatment, including the potential benefits and risks.
  • Understand the costs involved in treatment and what is and isn’t covered by your private health fund.
  • Follow any pre- and post-surgery instructions from your specialist.
  • Complete and return any hospital admission forms as soon as possible.
  • Pay any excess or co-payment required under your private health insurance cover.

If you’re aware of your rights and you fulfil all your obligations, you will probably be able to choose the right hospital and receive successful and stress-free treatment for your condition.

Questions to ask your doctor

All the questions you should ask before a stay in hospital

Going to hospital can be a confusing and daunting time.Whether you’re having major surgery or just a minor operation, it’s important that you’re fully informed before going under the knife.

By asking your doctor or specialist all the right questions, you’ll be as prepared as possible for a smooth and hopefully hassle-free hospital stay.

So, what questions should you ask your doctor? Read on to find out.

What to ask your GP

With the exception of emergency situations, most hospital admissions occur after you are referred to a specialist by your GP. If your GP indicates that they will refer you questions to ask to a specialist who can assess and treat your condition, here are a few questions you might like to ask:

  • Why do I need to see a specialist?
  • Why are you referring me to this particular specialist?
  • How much experience do they have treating this particular condition?
  • If the waiting time for treatment by one specialist is lengthy, can you recommend another specialist?
  • Does the specialist work at public and private hospitals?
  • How can I make an appointment with the specialist?
  • How can I find out how much it will cost me to see the specialist?

What to ask your specialist

Seeing a specialist about your condition can be a stressful and anxiety-filled time. And if you’re worried about your health, it’s sometimes easy to get a little overwhelmed and forget to focus on the information the specialist is providing.

Your specialist will probably answer most or all of the questions below during your consultation, but it’s worth using them as a handy checklist to make sure all of your concerns are covered during your appointment.

What to remember when talking to your doctor or specialist

Keep these tips in mind to ensure that you stay informed about treatment:

  • Make a list. Put together a list of important questions before meeting your specialist so that you remember everything you want to ask.
  • Consider a longer appointment. If you have a long list of questions, you might want to consider booking a longer appointment so you have enough time to cover everything.
  • Take a friend. Ask a friend or loved one to accompany you to your specialist appointment. They will be able to help you understand the specialist’s answers and make sure you ask all the necessary questions.
  • Ask again. If you don’t understand an answer, don’t be afraid to ask for it to be explained again.
  • Get a summary. Ask your specialist to provide a written outline of your treatment plan so you can take it away to study in your own time.
  • Ask for an interpreter. If you have trouble communicating in English, you can access an interpreter by phoning the Translating and Interpreting Service on 13 14 50.

Asking questions is an essential part of ensuring that you get the right care for your condition. Once you have all the answers to your questions about your treatment options, the benefits and risks, the costs involved and the ins and outs of a visit to hospital, you can make an informed decision about health care.

Hospital checklist

Your comprehensive checklist of what to pack and the questions to ask before being admitted to hospital.

Hospital stays can be a daunting experience.

While wrapping your head around treatment options, medical jargon and health insurance cover, it can be difficult to focus on the nitty-gritty of a hospital trip.

What do you need to pack? Where should you go when you arrive? How will you get to and from the hospital?

For answers to these questions and more, check out our comprehensive checklist on how to prepare for a trip to hospital.

What to pack when going to hospital

Be sure to pack the following items in your hospital bag: what to pack

  • Medicare card
  • Private health insurance details
  • Any other concession or health care cards you hold
  • Any pre-admission paperwork or letters from your doctor
  • Any relevant X-rays or scans
  • All current medications you’re taking
  • Health or mobility aids if needed, such as walking frames or hearing aids
  • Sleepwear and comfortable clothing, plus clothes to wear home
  • Toiletries including a toothbrush, toothpaste, soap and deodorant
  • Eye mask and ear plugs
  • Books, magazines or other items to keep you entertained
  • Mobile phone (if permitted) and charger

What to pack when pregnant

If you’re pregnant and packing a bag for the maternity ward, as well as the items above you’ll need to consider a few extras:

  • Your birth plan and hospital notes
  • Massage oil or lotion
  • Lip balm
  • Hair bands
  • Snacks and drinks during labour
  • Pillows for additional comfort
  • Heat packs
  • A TENS pain relief machine (if you want to use one)
  • Nursing bras
  • Breastfeeding tops
  • Breast pads and nipple cream
  • Clothing and nappies for the newborn to wear
  • Baby wipes and nappy bag

Arranging transport to and from the hospital

It’s essential to plan how you’re going to get to the hospital for your treatment. Ask a friend or family member for a lift or pre-book a taxi to get you there on time. Leave plenty of time for traffic delays so you’re not running late, make arrangements for your pets and organise time off work if required.

Finally, organise how you’ll get home after your procedure by teeing up a friend or loved one to transport you or be prepared to cover the cost of a taxi. If you’re going into hospital to give birth ensure your vehicle is installed with a baby car seat before the big day arrives.

What happens once you're admitted

Going to hospital? Here’s what you can expect during your stay.

Going to hospital can be a stressful and worrying time for anyone, even if you’re only booked in for a minor procedure. Read on for details of what you can expect during your time in hospital, as well as what you can do to ensure that your stay runs as smoothly as possible.

Getting to hospital

hospital bed
The first thing to consider is actually getting to hospital on time. You can ask a friend or family member to give you a lift, you may be able to drive yourself, you could catch public transport or you might want to pre-book a taxi.

Just make sure you leave enough time to allow for any unexpected traffic delays, and check ahead to find information about parking and public transport timetables to avoid any unnecessary stress on the day.

In most cases, you will be required to attend a pre-admission clinic before you are admitted to hospital.

As well as providing information about your treatment, this clinic will also help you understand where you need to go when you get to hospital, and what you can expect during your stay.

What do you need to bring?

You’ll need to remember to take a wide range of important items and documents with you when you go to hospital, including:

  • Your Medicare card
  • Your private health insurance details
  • Any other health care or concession cards
  • Any scans, X-rays and other test results relating to your admission
  • Your driver’s licence or other proof of ID
  • Your admission letter from the hospital and any other admission forms you were required to complete
  • Clothes, pyjamas and toiletries
  • Any medications you are currently taking or any medical or mobility aids you require
  • Pregnant women being admitted to the maternity ward will need a range of extra items, including nappies, baby wipes, baby clothes, nursing bras and more
  • A book to read or some other acceptable form of entertainment

During your stay

You’re entitled to receive a certain standard of treatment and care from your doctors and the hospital. Not only do you have a right to be treated with respect and dignity, but you also have a right to Informed Financial Consent, which means you must be kept informed of how much treatment will cost and whether any changes to your condition will affect this.

Your specialist will provide you with instructions on what you need to do after you have been discharged, to provide the best possible recovery. Listen to this advice and, if needed, ask for a written copy so that you can do everything possible to get back on your feet.

You could also ask a range of questions about how you can best manage your health once you’re out of hospital, such as:

  • Are there any signs and symptoms I should watch out for?
  • When do I need to make a follow-up appointment?
  • When can I return to work / other normal activities?
  • Will I need to take any medication?
  • What else can I do to help with my recovery?

During your stay in hospital you may also be referred to an allied health professional who can provide follow-up treatment and help you enjoy a quicker recovery. Allied health professionals include physiotherapists, occupational and speech therapists, social workers, podiatrists and more.

Other factors to consider during your stay

  • Visiting hours. Ask the hospital for details on visiting hours and regulations. Find out who is considered “family” and when people are allowed to visit you following surgery.
  • Television. Many hospitals will charge you for the use of a TV.
  • Telephone. Most hospitals restrict the use of mobile phones, while you may also be charged for the cost of making calls from your hospital room landline.
  • Internet. Many hospitals offer access to Wi-Fi, but this usually comes with a fee attached.
  • Meals. Ask hospital staff for details on when meals are served and how you can place your order. You should also inform the staff of any dietary restrictions and allergies.
  • Further assistance. If you are vision impaired, ask the hospital to provide all forms in large print or Braille format. If you have a hearing impairment, you can request an Auslan interpreter for all communication with hospital staff. Finally, if you’re in a wheelchair, hospital staff can provide any assistance you need to ensure accessibility to facilities.

Leaving the hospital

Everything you need to know about getting home safely and ensuring a speedy recovery.

The operation or treatment is over and you’re now preparing to be discharged from hospital. However, there’s still plenty you can do to ensure a smooth trip home and an even smoother recovery.

Being discharged

Once your doctor has approved your discharge from hospital, it’s time to start preparing for your return home. leaving hospital

Day-stay patients will usually remain in a recovery area until being told they can go home, while most hospitals aim to discharge inpatients by 9am or 10am.

You will need to fill out any relevant discharge forms provided by hospital staff and settle any outstanding accounts.

You may be given copies of X-rays or other medical records to take with you, while new mothers will receive a personal health record for their baby.

Your doctor or specialist will also advise you on the medications you will need to take when you return home – these may be provided by the hospital or you may be given a prescription to fill when you return home.

Discharge against advice

Except in specific high-risk cases, for example, if you’re suffering from an infectious disease, you have the right to leave hospital whenever you choose. However, be aware that choosing to discharge yourself against the advice of your doctor is potentially a very dangerous decision. You will need to sign a disclaimer accepting full responsibility for this decision before you can be discharged.

Making a claim

In many cases, you won’t need to submit a claim to your health fund at all. The cost of hospital accommodation and specialist services will hopefully already have been taken care of by your insurer.

However, if you do receive a bill for in-hospital expenses, contact your insurer to find out whether this will be covered by your policy. Your insurer will be able to advise how you can make a claim under your policy. For example, if you receive a bill from your doctor or specialist you may have to claim from Medicare first before you can claim from your health fund.

Transport and assistance

Don’t forget about transport arrangements when leaving hospital. Chances are you won’t be able to drive yourself, so ask a friend or family member to pick you up or book a taxi to get you home on your expected day of discharge.

You may also need to give some thought to how you will manage your daily living activities once you arrive home. For example, will you need any assistance with shopping or meal preparation? Will you need help with personal care or to get to any follow-up appointments with your GP or specialist?

Older Australians are able to access government-subsidised after-hospital care, known as transition care, to help with their recovery. This can provide access to low-intensity therapy, a social worker, nursing care and support with personal care. More information on transition care and whether it’s right for you is available through the Australian government’s My Aged Care website.

Going home

To ensure a fast and successful recovery, it’s crucial that you continue looking after yourself once you leave hospital and return home. Ask your specialist for instructions on what you can expect during the recovery process, as well as what you can do to increase the speed of recovery. Some of the questions you might like to ask include:

  • Are there any signs and symptoms I can expect during recovery?
  • Should I be concerned about any of these symptoms?
  • Who should I contact if I need help?
  • Will I need to continue taking any medication?
  • When do I need to attend a follow-up appointment?
  • Will I require physiotherapy or any other form of rehabilitation?
  • When can I resume my normal leisure activities?
  • When can I go back to work?
  • Will my hospital discharge information be forwarded to my GP?

Once at home, follow all the instructions given to you by your specialist and stick to your recovery plan as closely as possible. By staying committed to improving your health and wellbeing, you’ll be back on your feet sooner than you think.

Hospital glossary

All the important terms and definitions you need to know before going to hospital.

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A

  • Accommodation: This refers to the cost of a hospital bed, meals and nursing care. It does not include fees charged by doctors and other specialists.
  • Acute: A medical condition that comes on suddenly and for a relatively short period of time.
  • Admission: The administrative process by which you become a patient in a hospital and can receive treatment. Receiving treatment in a hospital’s emergency department does not constitute an admission
  • Admitted patient: A patient who is admitted to hospital to receive treatment and care.
  • Agreement hospital: Also referred to as a contract hospital, this is a private hospital or day surgery with which your health fund has an agreement. Under this arrangement, health fund members can access treatment with little or no out-of-pocket costs.
  • Allied health professional: A health professional other than a doctor, nurse or dentist. For example, a physiotherapist or a dietitian may be referred to as an allied health professional.
  • Ambulance cover: A health insurance product that provides benefits for ambulance transport and treatment.
  • Ancillary cover: Ancillary cover is another name for extras cover.
  • Annual limit: This is the maximum amount your health fund will pay per year for a particular service or treatment.

B

  • Benefit: The amount your insurer will pay for a specific service
  • Benefit limitation period: A period of time during which you are only entitled to receive restricted benefits from your health insurer for a specific condition or treatment

C

  • Co-payment: Applies to hospital cover and is a set amount you agree to pay for each day you are in hospital. In return for accepting a co-payment, you will receive lower premiums

D

  • Day surgery: A private hospital where patients are admitted, treated and then discharged on the same day. Sometimes also referred to as a day facility
  • Dependant child: An unmarried child under 18 years of age. Some health insurers will continue to cover your children as dependants until they reach 25 years of age when certain conditions are met, for example if your child is a full-time student
  • Diagnostic tests: Tests to diagnose your condition, for example X-rays and blood tests

E

  • Elective surgery: Surgery for a condition that does not require immediate medical attention
  • Emergency treatment: Emergency treatment is given when a patient is treated within 30 minutes of presentation and if they are in danger of suffering loss of life, limb, bodily function or mental stability, if they are in severe pain or if they are bleeding
  • Excess: A set amount that you agree to pay upfront as a contribution towards the cost of hospital treatment. By agreeing to pay an excess when you are hospitalised, you can access lower premiums
  • Exclusions: Conditions or services that are not covered by your health insurance policy
  • Extras cover: Health insurance that covers out-of-hospital health services that are not covered by Medicare, including optical, dental, physiotherapy and natural therapies. Also referred to as ancillary cover or general treatment cover

F

  • Fund: A private health insurance organisation registered under the Private Health Insurance Act 2007 in Australia.
  • Fixed fee: A daily fee charged by some hospitals in addition to a co-payment or excess.

G

  • The gap: The difference between what you are charged for medical or hospital services and the amount covered by Medicare or your private health insurance. You will need to pay this “gap” out of your own pocket (unless your health insurer has a gap cover arrangement)
  • Gap cover scheme/arrangement: An arrangement your health fund has with your doctor to limit your out-of-pocket costs when receiving treatment
  • General treatment cover: See extras cover

H

  • Health fund: Private health insurance organisation
  • HICAPS: Health Industry Claims and Payment Service. This allows you to electronically claim a private health insurance benefit at the point of service by swiping your health fund membership card
  • Hospital cover: Health insurance that covers the cost of receiving hospital treatment as a private patient, including accommodation, medical treatment and ambulance (in some states and territories)

I

  • Informed financial consent: The provision of information about the cost of treatment, including any out-of-pocket expenses you will have to pay. This information must be provided to you by all service providers before you are admitted to hospital
  • Inpatient: A patient who has been formally admitted to hospital or a day surgery
  • Insurer: Private health insurance organisation
  • Intensive care: Hospital treatment for a life-threatening condition

J

K

  • Kinesiology: An alternative therapy employing muscle monitoring to identify imbalances in the body. It is used to treat stress, muscular, nervous and nutritional issues and emotional and learning and behavioural problems.
  • Knee replacements: See joint replacement

L

  • Labour ward fees: These fees cover the cost of delivering a baby in a hospital maternity ward
  • Lifetime limit: The maximum benefit a health fund will pay for a specific service during a member’s lifetime

M

  • Medical expenses: Fees and charges for medical procedures performed while you are in hospital
  • Medicare Benefits Schedule (MBS): The schedule of fees for standard medical services set by the Australian Government. Based on this schedule, Medicare pays 75% of the scheduled fee for in-hospital medical services and 85% for out-of-hospital specialist medical fees
  • Minimum benefit: The minimum amount an insurer is allowed to pay for a hospital service included in your policy. Sometimes also referred to as a default benefit

N

  • National Private Patient Claim Form: A form you sign to acknowledge that you have obtained informed financial consent for your procedure and that you agree to pay any out-of-pocket expenses that have been outlined to you before admission. This form must be completed before you can be admitted as a private patient
  • Non-PBS pharmaceuticals: Prescription pharmaceuticals that are not listed on the Australian Government’s Pharmaceutical Benefits Scheme (PBS). When non-PBS pharmaceuticals are covered by your health insurance, you will usually need to make a co-payment (equivalent to the normal PBS payment) before your health fund will pay a benefit

O

  • Out-of-pocket expenses: Fees and charges that aren’t covered by Medicare or your private health insurer and that will need to be paid by you
  • Outpatient: Patients that do not require admission to hospital

P

  • Palliative care: The care of patients with a serious illness for which there is little or no prospect of cure

Pharmaceutical Benefits Scheme (PBS)

  • Pharmaceutical Benefits Scheme (PBS): A government subsidy designed to reduce the cost of a wide range of prescription medications
  • PHIO: The Private Health Insurance Ombudsman. The Ombudsman is an independent service to help Australian consumers who have questions about or problems with their health insurance
  • Pre-existing condition: An ailment, illness or condition which, in the opinion of a medical practitioner chosen by your health fund, existed at any time in the six months prior to you taking out hospital cover or upgrading your level of cover
  • Preferred provider: An extras or general treatment service provider with which your health fund has an arrangement allowing members to receive higher benefits
  • Premium: This is the amount you pay for health cover
  • Private hospital: A hospital run for commercial and/or charitable purposes
  • Private patient in a private hospital: If you’re treated as a private patient in a private hospital, you can choose your doctor and receive treatment at a time that suits you
  • Private patient in a public hospital: As a private patient in a public hospital, you get to choose your doctor but the time you will have to wait for treatment will depend on public hospital waiting lists
  • Prostheses: Prostheses are surgically implanted items, for example artificial knee joints. Some surgically implanted prostheses are included on The Prostheses List, which features items that private health insurers must pay benefits for when they are provided to someone with an appropriate level of hospital cover
  • Public hospital: A hospital funded by the government
  • Public hospital policy: Hospital cover health insurance that provides restricted benefits for all conditions. If you have this type of cover, you will be able to access treatment as a private patient in a public hospital but you may incur significant out-of-pocket costs if treated in a private hospital

Q

  • Qualifying event: An insured event that triggers a member’s protection under their policy (eg loss of employment, divorce or death).
  • Quit Smoking: Some quit smoking programs are claimable on your extras cover.

R

  • Restricted membership insurer: A health fund that provides health insurance for people within a specific industry or group, for example the education sector. These insurers typically offer insurance on a not-for-profit basis, but you must be a member of the industry or group (or potentially a family member of someone in the industry or group) to join a fund
  • Restrictions: Also known as restricted benefits, restrictions are conditions or services that are covered by your health insurance policy but only to a limited extent. If you receive treatment in a private hospital for a condition that is restricted under your policy, you will need to pay significant out-of-pocket expenses

S

  • Same-day patient: A patient who is admitted, treated and discharged on the same day
  • State of the Health Funds Report: Annual report on the performance and service delivery of health insurers, prepared by the Private Health Insurance Ombudsman

T

  • Theatre fees: Fees for procedures performed in a hospital operating room

U

  • Underwriting: The process by which an insurer determines the level of risk of an applicant and the associated cost of the monthly premium.

V

  • Valid from date: This is the date a new health insurance policy is available for purchase.

W

  • Waiting period: This is the period of time which you must be a member of a health fund before you are eligible to make a claim for a particular service

X

  • X-ray/lab: Any diagnostic lab test or x-ray performed in support of basic health services. Lab tests include services like blood work and urinalysis and X-ray services include basic skeletal x-rays, ultrasounds, MRIs, and CT scans.

Y

  • Yearly limit: This is the maximum amount you are able to claim in a calendar year.

Z

  • Zero gap: A scheme in which participating doctors affiliated with a health fund charge a set fee, with the result that there is no gap between the Medicare benefit and health insurance benefit and therefore zero for the member to pay.

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