To ensure you have a positive and hassle-free experience during your hospital admission, it is important you understand your medical condition, and are fully aware of your treatment options and any costs involved in your health care.
CHECK YOUR LEVEL OF COVER
Before you make any decisions about your hospital stay or procedure, you may want to ask us:
- What is my level of hospital cover?
- Do I have an excess to pay?
- Am I covered for my treatment?
- Will I be covered if I go to a private hospital? If so, does the
- Fund have an agreement with my chosen hospital?
- Have I served my waiting periods?
INFORMED FINANCIAL CONSENT
Prior to a planned admission to hospital, both the Hospital and your Doctor must advise you of any out-of-pocket costs that may be charged.
As a patient you have the right to ask for an estimate of fees before receiving a service or agreeing to a proposed treatment.
There are a range of circumstances where a Doctor may find it difficult to provide full informed financial consent. These include in a medical emergency or if there is an unexpected complication.
Good informed financial consent can help remove any surprises from medical costs, and help you to understand where medical fees come from. Ultimately, informed financial consent outlines what you may have to pay for medical services.
It is a good idea to keep records of your medical invoices. If you feel that the charges were not agreed to, you should contact your Doctor’s office to discuss the reasons for the various charges, and why they are more than expected.
TALK TO YOUR DOCTOR
In most cases, your admission to hospital arises from a visit to your GP who then refers you to a medical specialist. Take the time to discuss and learn about your medical condition, all available treatment options and the recovery. Ensure all your questions are answered so that you are confident to make any treatment decisions.
You can also ask your doctor for an open referral, this will allow you to choose from a number of relevant medical specialists and enable you to choose the one who you feel best understands you and your condition.
If you are unsure what to ask your Doctor, some of the following questions may help:
- What is my condition and why do I require treatment?
- What is the expected outcome of the treatment?
- Are there other treatment options?
- What are the benefits, risks and possible complications associated with my treatment?
- How long should I expect to be in hospital and what will my recovery be like?
- Will I need assistance at home after I am released from hospital?
- Does my treatment, and any associated procedures, need to be performed immediately or can it wait?
- If I need a prosthesis (e.g. hip or knee replacement or a cardiac stent), will there be any additional expenses?
One of the first things you need to do when planning a hospital visit is to decide whether to be admitted as a private patient or a public patient.
You do not need to use your private health insurance cover in a public hospital as you are entitled to free medical care. If you do choose to use your private cover when admitted to a public hospital, keep in mind that it is possible you could still be placed on a waiting list.
The key message is to be informed and know your rights.
You should not feel pressured or coerced about using your private health insurance cover. You can choose to be treated as either a public or a private patient in a public hospital, you have the right to make that choice.
It is important to be informed at every step of the way and you should know exactly what you will be covered for, and be aware of any out of pocket costs you may encounter. If you can make decisions about your care and payments before going to hospital, you can remain focused on your surgery and recovery.
Alternatively, you can choose to access a private agreement hospital as a private patient. We suggest you discuss this with your Doctor.
THE DIFFERENCE BETWEEN BEING A PUBLIC PATIENT AND A PRIVATE PATIENT
All Australians can access inpatient (in-hospital) treatment as a public patient in a public hospital free of charge, as these services are funded by both Australian Government and state and territory governments.
However, public hospital patients are not able to choose the hospital they are admitted to or the Doctors who will treat them. There can also be wait times for non-emergency services.
If there is an outpatient component of the public hospital treatment, you may need to make a payment towards the service.
When a patient has treatment as a private patient, Medicare will pay 75% of the Medicare Benefits Schedule (MBS) fee for the service provided. If they have private health insurance, their insurer must pay at least 25% of the MBS fee, unless they agree to pay more.
PRIVATE PATIENT IN A PUBLIC HOSPITAL
If you elect to be treated as a private patient in a public hospital, Mildura Health Fund will pay the Minimum Benefit Payable (MBP), this is the minimum benefit the Private Health Insurance Act requires health funds to pay for hospital treatment under a hospital cover. Depending on your level of cover, if you choose to stay in a private room, the Fund will pay an additional fixed benefit of $80 above the shared room accommodation rate. If this benefit is less than the hospital charge, the Hospital should advise you of what the out of pocket cost will be.
The Fund also pays benefits for prosthesis up to the approved benefits in the Federal Government approved prosthesis list.
This applies for any treatment recognised by Medicare unless it is excluded or is a minimum benefit service under your cover. It is important to note that in public hospitals, private rooms are generally allocated to patients who medically need them.
As a private patient in a public hospital, you will also be responsible for personal expenses such as television hire and telephone calls, together with any medical gaps and prosthesis charges above the minimum benefit as defined on the government approved prosthesis list.
Mildura Health Fund has agreements with over 445 private hospital and day procedure facilities. In most instances you will be fully covered (less any applicable excess) for your hospital costs such as accommodation, theatre and intensive care fees. To find the current list of agreement private hospitals and day procedure facilities visit here.
These are private hospital and day procedure facilities that have not entered into an agreement with the Mildura Health Fund. If you choose a non-agreement private hospital or day procedure facility, you may incur out of pocket costs for hospital related services. It is recommended you contact both the facility to obtain informed financial consent and Mildura Health Fund to determine the benefit payable to you.
GOING TO A PUBLIC HOSPITAL IN AN EMERGENCY
In an emergency you will generally attend the nearest public hospital accident and emergency department.
In hospital emergency departments, Patients are treated as outpatients in hospital emergency departments, where they are diagnosed and cared for without being formally admitted.
All Medicare cardholders will be treated at a public hospital accident and emergency department for no charge. Mildura Health Fund does not cover any accident and emergency treatment costs.
If additional hospital care is needed after the initial assessment, the Doctor will formally admit you as an inpatient. In this situation, all Medicare cardholders will be treated as a public patient in a public hospital at no charge to them or their health insurance fund.
There is no difference in the level of care you receive at a public hospital if you elect to be a private patient, you may however be charged some out-of-pocket costs.
GOING TO A PRIVATE HOSPITAL IN AN EMERGENCY
Mildura Health Fund does not pay a benefit for emergency department fees for private hospitals. If you are admitted to a private hospital as an inpatient, benefits will be payable by the Fund.
NO COVER FOR AMBULANCE TRAVEL
Mildura Health Fund does not provide benefits towards the cost of ambulance travel and does not offer ‘ambulance only’ insurance.
NSW and ACT residents who hold hospital cover, are automatically covered for emergency air and road transport services within their home state and agreement states/territories.
Ambulance cover in Australia varies from state to state. For further, more detailed information, please contact our ambulance cover specialist on 03 5023 0269.
Members who pay an ambulance subscription and hold an extras cover, will receive a benefit towards the cost of their ambulance subscription fees.
COSTS OF GOING TO HOSPITAL AS A PRIVATE PATIENT
Private Health Insurance can help with the cost of hospital accommodation, theatre fees, labor ward fees, intensive care and the fees of the Doctors who treat you in hospital.
Your level of cover determines what treatment you will be covered for. In the first 12 months of holding your hospital cover, you are not covered for the treatment of a pre-existing condition*.
If you have changed your hospital cover in the previous 12 months, upgraded or recently transferred, the conditions of your previous cover may still apply. The Private Health Insurance Act 2007 precludes some hospital and medical costs from being covered by private health insurers.
*A pre-existing health condition is where the signs or symptoms of your ailment, condition or illness existed at any time in the 6 months preceding the day you joined hospital cover or the date you upgraded to a higher level of cover.
There are also certain situations where you might have an out-of-pocket cost including for the following:
- Costs for treatment not covered by Medicare or not covered under your level of cover. Doctor’s fees charged in excess of the Fund Gap Medical benefit.
- Pharmacy not covered under the hospital agreement.
- Items such as high cost disposables associated with certain procedures, and high cost drugs.
- Take home items such as crutches. Some health aids and appliances may be claimable if you hold extras cover. For more information please contact the Fund.
- Personal expenses such as phone calls, daily newspapers, television hire and border fees.
- Hospital stays beyond 35 days that are not supported by an acute care certificate.
- If you are assessed during your hospital stay as no longer needing acute care or are in hospital longer than 35 days, you will be classed as a nursing home type patient. In this case, Mildura Health Fund will pay benefits that are lower than normal hospital benefits and you may be required to make a personal contribution towards the cost of your care.
The excess is payable for all overnight admissions in public and private hospitals. The excess is also payable for same day patients in all public and private hospitals and private day facilities with the exception of the Mildura Health Private Hospital where members do not pay an excess on same day admissions.
UNDERSTANDING THE MEDICAL GAP
Doctors are not required to charge fees that are equal to the MBS fee, and many don’t.
Doctors should have a billing policy for their practice, which includes:
- when payment is required;
- any discounts available for early payment or charges
- for late payment;
- acceptable forms of payment; and
- the name and contact details of a nominated person to discuss payment issues and problems
Doctors should have a cancellation policy, which is clearly communicated to patients before or at the time of booking an appointment.
For services provided in hospital, the benefit amount payable will depend on the arrangements in place between the Fund and your Doctor, as well as the Fund and the hospital you are being treated in. The law requires that private health insurers must pay 25% of the MBS fee outside of a no or known-gap agreement.
A common misunderstanding about private health insurance and private hospital treatment is that if you have private insurance, you don’t have to pay anything else – there will sometimes be out-of-pocket cost, even if your policy includes the medical treatment you need.
For services delivered in a hospital, the amount that the Fund will refund is based on our own medical benefits schedule and may not represent the amount the Doctor may believe is appropriate to charge as a fee.
The Fund has No Gap agreements in place with the majority of providers that treat you at the Mildura Health Private Hospital. View our no gap providers here
An out-of-pocket cost can arise when the amount covered by Medicare and the Fund does not cover the full fee that has been charged for a service.
MEDICAL FEES CAN CHANGE
Sometimes a treatment plan needs to change, either during the operation, or over the course of treatment. Unexpected changes in treatment may change the services delivered and therefore the amount the patient is required to pay. Any changes to the treatment plan should be discussed in advance, if possible.
It is important to remember you may have more than one Doctor involved in treating you – such as a surgeon, an assistant surgeon, an anaesthetist, plus any Doctors handling any pathology or diagnostic imaging.
For a complete picture of your out-of-pocket costs, you should ensure that every doctor or health professional involved in your care provides you with an estimate of their fees.
It is important to remember that a Doctor charging high medical fees is not necessarily providing a higher quality of health care than that provided by other Doctors.
The MBS Online contains a full listing of the Medicare services, by item that are subsidised by the Australian Government. You can search the MBS for all the latest fees and service descriptions at http://www.mbsonline.gov.au
WHAT ELSE IS COVERED?
A prosthesis is a surgically implanted medical device or artificial body part, such as a hip or knee joints or a cardiac pacemaker.
If you are having a procedure that involves implantation of a prosthesis, there is always one that your surgeon can use that is on the government approved listing, meaning that you will not have an additional amount to pay.
Other costs you may incur
Depending on the procedure you are having whilst an inpatient in hospital, your Doctor may need to use high cost items that are not normally covered.
When this occurs, long term Mildura Health Fund members may qualify for an ex-gratia benefit to be paid to the Hospital, on their behalf, towards the cost.
This can include items such as high cost consumables associated with certain procedures, and high cost drugs.
What is not covered?
Private hospital cover with Mildura Health Fund does not include the following:
- Treatment received whilst serving a waiting period
- Treatment that relates to a pre-existing condition whilst serving a waiting period
- Treatment provided at the emergency department of a public or a private hospital.
- Treatment for which Medicare does not pay a benefit e.g. cosmetic surgery and procedures not included in the Medicare Benefits Schedule.
Before you leave hospital, your Doctor will determine that you are well enough to leave and that you have all the necessary information to ensure a smooth recovery at home.
When you are discharged, check that your Doctor or the Hospital has provided you with the following information;
- How do I know if my recovery is on track?
- How long should my recovery take?
- What should I look out for if I think there is a problem?
- Who should I contact if I need help?
- When can I return to regular activities?
- Are there any specific instructions for my recovery?
- Will I need physiotherapy or other rehabilitation services?
- When should I make a follow up appointment with my Doctor?
- Is there anything I should avoid eating or drinking?
- Your Doctor may recommend that you see additional healthcare providers to assist in your recovery, such as a physiotherapist or exercise physiologist. To check if these services are claimable under your level of extras cover, please contact us.
If you want to be covered for obstetrics, both pregnancy and birth related services with a private obstetrician it is important to take out private hospital cover well before you are thinking about becoming pregnant. Your choice of private care will depend on what options are available to you, what services are available at your local public and private hospital and at which hospital your private obstetrician can treat you.
Pregnancy and birth related services are covered after a 12 month waiting period has been served.
Assisted reproductive services, or IVF, is a process to treat infertility and has several steps. Only the component that involves an admission to hospital is covered by your private health insurance. Services that occur outside of a hospital admission, including consultations and tests may be claimable through Medicare. Before proceeding with IVF or similar check with Mildura Health Fund to confirm all waiting periods have been served and that benefits are payable.
WHAT IS COVERED PRIOR TO MY HOSPITAL ADMISSION TO DELIVER THE BABY?
Most medical expenses that arise prior to hospital admission are claimable through Medicare. Medicare will reimburse 100% of the MBS fee for doctor’s services, and 85% of the MBS fee for specialist services and all other medical treatments such as ultrasounds and blood tests. If your doctor or obstetrician bulk bills Medicare, you will have nothing to pay. The Medicare Safety Net may also help to minimise any out of pocket costs you may have for medical services prior to your delivery.
WHAT FEES AND CHARGES APPLY TO MY BABY?
If your baby is healthy, he or she will not be formally admitted to hospital. This means the hospital will not raise a charge for the care of your baby. If your baby needs to be admitted as an inpatient, the hospital will raise a charge to cover the cost of the care of your baby. This means that any excess that is payable on your hospital cover will also apply to your baby.
If your baby is not admitted but is seen by a paediatrician and has pathology or radiology tests these costs can be claimed through Medicare only.
If you are expecting twins or any multiple birth, at least one baby will be formally admitted to hospital even if they are both healthy. This means that any excess that is payable on your hospital cover will also apply to your baby.
If you are not insured you will be responsible for the full hospital costs.
WHAT IS COVERED ONCE I AM ADMITTED TO HOSPITAL TO DELIVER THE BABY?
Once you are admitted to hospital, the Mildura Health Fund will cover the cost of your admission less any applicable excess, provided you have served your 12 month waiting period.
You will receive 100% of the MBS, the Medicare benefit plus the Fund benefit for inpatient services. If your Doctor chooses to charge above the MBS fee, we will pay a further benefit towards this amount, known as the gap. This may result in a gap payment or out of pocket cost to you, depending on the Doctor’s charge. If your Doctor has an agreement in place with us, they will bill us direct. Otherwise you can submit your unpaid account to us for claiming
Medicare benefits are payable for antenatal, intra-partum and postnatal services (up to 6 weeks post-delivery), provided by eligible privately practicing midwives working in collaboration with a specified medical practitioner. Fund benefits will only be payable for inpatient services provided by a midwife.
To provide services under Medicare, midwives must meet the eligibility requirements for the MBS items, and be registered with Medicare Australia.
Please contact the Fund prior to any planned hospitalisation with the MBS item numbers, and fees the Doctor will be charging, so that we can ensure that you will be covered and advise you of any out of pocket amounts you may need to pay.
ADDING YOUR NEWBORN BABY TO YOUR MEMBERSHIP
You do not have to wait until you receive a birth certificate or a new Medicare card before adding your newborn to your Mildura Health Fund membership.
If you have a singles membership, to cover your newborn, you will need to change from a single to a single parent family or a family policy depending upon your circumstances. The single parent or family premium will be payable from the date of your baby’s birth.
If you currently hold a single parent or family type membership, your newborn simply needs to be added within two months of his/her birth.
Provided your membership has served all waiting periods, your newborn will be covered immediately. Any unserved waiting periods will apply to your newborn.
If your partner chooses and is able to stay in hospital with you, there may be a border fee that will be at your cost and not claimable.
When you are discharged from hospital, the Mildura Health Fund will generally settle your invoice directly with the Hospital on your behalf.
Ask your doctor to send their itemised invoice directly to Mildura Health Fund. You should already know if there are any out-of-pocket costs. If your doctor does send the invoice to you, just forward it, unpaid to the Mildura Health Fund.
If you have paid the Doctors invoice in full, your claim should first be submitted to Medicare who will issue a Medicare Statement. This can then be forwarded to us for processing of the Gap Medical benefit you are entitled to.
Remember, being fully aware of your hospital choice and associated costs will have you prepared for your hospital visit and will allow you to focus on what is most important - your health and recovery.