Call Mildura Health Fund

• Is my treatment covered, and have I served my waiting periods?
• Are my premiums up to date; do I have an excess?
• Am I covered at my chosen private hospital; is it an agreement hospital?
• Do you need any documents from me before my admission?

Ast the hospital

• Arrival time and pre-admission forms?
• How and when do I pay my excess, if applicable?
• Room & costs: private room availability; Informed financial consent for all out-of-pockets, incidentals, boarder fees, other hospital charges?
• Visiting hours and discharge process?

Ask your treating doctor

• Medicare Benefits Schedule items, gap arrangement with Mildura Health Fund, total fees and my expected gap: what if I can't afford it?
• Other providers involved - anaesthetist, assistant surgeon, pathology, and radiology providers, and how they'll bill me?
• Devices/prostheses fully covered or with a gap?
• Recovery plan: instructions, timeline/milestones, red flags, contacts, medications
• Return & rehab: when I can resume activities such as work/driving; physio/rehab needs; follow-up bookings; any dietary restrictions?

Check your cover. Call Mildura Health Fund first

Confirm:

• Your level of hospital cover and whether the treatment is included.
• Any excess and how much.
• Whether you’re covered at your chosen private hospital and if it’s an agreement hospital.
• Whether you’ve served all waiting periods.
• A higher fee does not necessarily mean higher quality — if a quote seems high, ask about no gap options available at Mildura Health Private Hospital, or seek another opinion.

Get Informed Financial Consent (IFC)

Ask your doctor and the hospital for a written estimate of all fees and any out‑of‑pocket costs. Keep copies of all estimates and invoices.

Members won’t need to request an estimate from the hospital unless it’s a non-agreement hospital.

In emergencies or when complications arise, a full estimate may not be possible.

Talk to your doctor

Be clear on your condition, your options, and what recovery will involve.

You are welcome to ask your doctor for an open referral, although the decision to provide one is ultimately up to the doctor. Please be aware that not all specialists accept open referrals, and some may require a referral addressed directly to their practice.

Useful questions to ask include:

• Why do I need this treatment, and what outcome is expected?
• What are the alternatives, benefits, risks, and possible complications?
• How long will I be in hospital, and what will recovery or support at home look like?
• Does the procedure need to be done now, or can it wait?
• Will I need a prostheses (such as a hip, knee, or stent), and could there be additional expenses?

Decide: public or private patient

Public patient in a public hospital: inpatient care is free; no choice of treating doctor or hospital; wait times can apply for non‑urgent care; outpatient components may have a cost.

Private patient: As a private patient, Medicare and Mildura Health Fund each contribute benefits toward services with a recognised item number, subject to your level of cover and any excess. To receive benefits for in‑hospital medical services, the treatment must have an eligible Medicare item number.

Doctors can charge what they believe is fair and reasonable, and if their fee is higher than the combined Medicare and Mildura Health Fund benefits, you may have an out‑of‑pocket cost. Mildura Health Private Hospital is currently the only hospital in Australia with No Gap specialist providers.

Private patient in a public hospital

We pay the legislated Minimum Benefit Payable for hospital treatment.

Private room: we add a fixed $80 above the Minimum Benefit Payable shared‑ward rate. If the hospital charges more, you’ll be advised of any out‑of‑pocket.

Prostheses benefits are payable up to the approved amounts on the Prescribed List of Medical Devices and Human Tissue Products.

Private rooms in public hospitals are allocated by medical need.

You pay personal incidentals such as TV/phone, and any medical/prosthesis gaps above these benefits.

Agreement vs non-agreement hospital

Agreement hospital (445+ nationwide): In most cases you’re fully covered, less any excess for accommodation, theatre and ICU fees.

Non‑agreement hospital: You may incur out‑of‑pocket hospital costs. Always obtain Informed Financial Consent from the hospital.

Emergencies & ambulances

Public hospital emergency: go to the nearest public Emergency Department. Medicare cardholders are treated at no charge in ED. Mildura Health Fund does not cover ED fees. If admitted, you’ll be treated as a public patient at no charge. If you elect private patient status in a public hospital, care is the same, but out‑of‑pockets may apply.

Private hospital emergency: Mildura Health Fund does not pay private ED fees as this is considered an outpatient service.

Ambulance: Mildura Health Fund does not provide ambulance cover or “ambulance‑only” insurance. NSW/ACT residents with hospital cover are automatically covered for emergency transport within their home state and agreement states. Arrangements vary by state, call us for guidance. If you hold Extras and pay an ambulance subscription, you may receive a benefit towards the subscription fee.

Eligibility for Ambulance Victoria Membership is based on a member’s residential town, not their postcode. While Wentworth residents with postcode 2648 are eligible for cover, other towns or localities sharing the same postcode may not be eligible. Members should check directly with Ambulance Victoria to confirm their eligibility.

After an accident requiring admission: if you hold the appropriate level of cover, you will be covered as an inpatient.

What hospital cover helps pay

Accommodation, theatre, labour ward, intensive care unit, and in‑hospital doctors’ fees, as per your level of cover. In the first 12 months of hospital cover, pre‑existing conditions aren’t covered. If you’ve upgraded or transferred your cover in the last 12 months, the conditions of your previous cover may still apply. By law, some costs cannot be covered by private health insurance.

Where out-of-pocket costs can still arise

• Treatment not covered by Medicare or by your Mildura Health Fund policy.
• Doctor’s fees charged above the Fund Gap Medical benefit.
• Discharge pharmacy take‑home medicines not under the hospital agreement.
• Specialised consumables, e.g., robotic/high‑cost items, or high‑cost drugs outside the agreement.
• Take‑home items, e.g., crutches, some aids may be claimable via Extras cover.
• Personal incidentals such as phone, TV, newspapers.
• Hospital stays over 35 days without an acute‑care certificate. You may become a “nursing home type patient”; a personal contribution may apply.
• Partner boarding: a boarder fee, including meals during the admission, may apply and is not claimable.

Excess, when it applies

An excess applies to all overnight admissions in public and private hospitals and to same‑day admissions in public or private hospitals and private day facilities, except at Mildura Health Private Hospital, where no excess is charged for same‑day admissions.

OTHER POSSIBLE COSTS & WHAT ISN’T COVERED

• High‑cost items, e.g., specialised consumables or certain medicines, may be used for some procedures and aren’t generally covered. Long‑term members may be eligible for an ex‑gratia payment, paid directly to the hospital, to help reduce these costs.

Not covered under Mildura Health Fund private hospital cover:

• Treatment during a waiting period, including treatment related to a pre‑existing condition while serving waiting periods.
• Emergency department services, public or private.
• Services with no Medicare benefit, e.g., cosmetic procedures or items not on the Medicare Benefits Schedule.

Doctor’s fees

• Doctors set their own fees; they don’t have to charge the Medicare Benefits Schedule fee.
• Doctors can charge what they believe is fair and reasonable for their services. When a doctor charges above the standard Medicare and Fund benefits, a gap may be created.
• Where possible, ask each provider involved in your care such as your surgeon, assistant surgeon, anaesthetist, pathology and radiology providers for Informed Financial Consent. Some providers may not be able to supply Informed Financial Consent in advance.
• If your procedure plan changes during treatment, services and costs may change. This should be explained in advance where possible.
• Prostheses: where a device is needed, e.g., joint replacement or cardiac device, there is always at least one option on the government’s approved list for which no additional amount should be payable beyond your cover.
• Mildura Health Fund offers No Gap arrangements that some doctors elect to participate in. Mildura Health Private Hospital is currently the only hospital in Australia with No Gap specialist providers.

Understanding your fees

After seeing your doctor and receiving an itemised quote, you may contact Mildura Health Fund to better understand what’s covered under your policy.

To help us give you the right information, please have the relevant Medicare Benefits Schedule item numbers ready. Without these, we may not be able to confirm your cover or your gap, if any.

You can contact our team by phone or email at medical@mildurahealthfund.com.au. We’re here to support you with any questions about your policy and benefits.

For medical advice or treatment details, your doctor is the best person to guide you.

• If you’ve served the required waiting periods, Mildura Health Fund covers your admission, less any excess that applies.
• For inpatient medical services, you receive 100% of the Medicare Benefits Schedule fee, Medicare and Fund benefits combined.
• If your doctor charges above the Medicare Benefits Schedule fee, Mildura Health Fund pays an additional gap benefit. You may still have an out‑of‑pocket depending on the doctor’s charge.
• Before your stay, please provide Medicare Benefits Schedule item numbers and fees so we can confirm cover and any out‑of‑pocket.
• If a partner or support person stays overnight as a boarder, a boarder fee may apply. This fee is not claimable through private health insurance and will be payable by the boarder.

After your hospital stay

Before you leave, make sure you know your:

• Timeline and milestones.
• Warning signs and who to contact.
• When to resume activities, for example, work and driving.
• Any rehab or therapy instructions.
• Follow‑up appointments.
• Follow‑up appointment dates.

Your doctor may refer you to physiotherapy or exercise physiology, contact Mildura Health Fund to check if these are claimable under your Extras cover.

• On discharge, we generally settle the hospital account directly.
• Ask your doctor to bill Mildura Health Fund.
• If you’ve already paid a doctor, claim with Medicare first. When you receive your Medicare Statement (through your MyGov inbox), send it to us so we can process any Gap Medical benefit.
• Being prepared helps you focus on what matters most ‑ your recovery.

Planning for private obstetric care

• Take out private hospital cover well before planning a pregnancy as a 12-month waiting period applies to pregnancy and birth.
• Your options depend on local hospitals and where your obstetrician can treat.
• If you are expecting multiples (twins, triplets or more), only one baby may be admitted as a patient under the birth admission. Additional babies requiring admission, treatment or special care may be admitted separately and may incur additional costs.

Assisted reproductive services (IVF)

• Only the in-hospital component is covered by private hospital insurance. Out-of-hospital steps including consultations and tests may be claimable via Medicare.
• Before proceeding, contact Mildura Health Fund to confirm waiting periods have been served and benefits are payable.

Pre-admission pregnancy care (Medicare Only)

• Most pre-admission costs are Medicare-claimable: GP visits at 100% of the Medicare Benefits Schedule fee, specialist/diagnostics at 85%.
• If your doctor bulk bills, there's nothing to pay.
• The Medicare Safety Net may further reduce out-of-pockets for out-of-hospital services.

Once you're admitted to deliver

• If you've served your waiting periods, Mildura Health Fund covers your admission, less any excess.
• For inpatient services you receive 100% of the Medicare Benefits Schedule fee, Medicare and Fund benefits combined. If your doctor charges above the Medicare Benefits Schedule fee, we pay a gap benefit, a residual gap may remain.
• If a partner or support person stays overnight as a boarder, a boarder fee may apply. This fee is not claimable through private health insurance and will be payable by the boarder.

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