GOING TO HOSPITAL

W I T H YO U O N
YO U R J O U R N E Y
Bupa. find a healthier you
A b out Bu pa
Bupa is a healthcare leader, proudly looking after the
needs of more than three million Australians. We have
been around for over 60 years and we’re part of a
global group whose care and expertise now stretches
across 190 countries.
It is our purpose that makes us different. We exist to
help our members live longer, healthier, happier lives.
Which is why our global family reinvests its profits to
provide better services for members and to ensure
quality healthcare remains affordable.
We are dedicated to helping find a healthier you.

C a l l u s f ir s t
Remember, if you’re going to hospital and you’d like to
discuss the information in this guide, give us a call —
we’re here to help.

Call us on 134 135

Visit bupa.com.au

Drop by your local Bupa centre

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 A b out thi s
gui d e

If you haven’t been to hospital very

often, you may not be familiar with how
the hospital system works. So we’ve
created this guide, especially for you.
With this guide, our goal is to help
make your hospital experience as
simple as possible. From discussing
your treatment with your specialist, to
making a successful recovery, there are
many steps to consider before, during
and after your hospital stay.
This guide will hopefully make these
steps easier for you. It includes
information about the hospital process
— from what to pack to how to claim.
If you feel overwhelmed or need more
information, feel free to call us. We’re
here to help you understand and make
the most of your cover.

C ont e nts

B e f o r e h o s p i ta l 4
Preparing for your stay 5
Bupa Medical Gap Scheme 8
Choosing a hospital 10
What to take with you 14
D u r i n g h o s p i ta l 16
What to expect 17
What you’re covered for 18
What’s not covered 19
A f t e r h o s p i ta l 22
Getting back on track 23
How to claim 24
G lo ssa ry 25

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Be f ore
ho s p ita l

4
Pre paring
f or your s tay

In most cases your admission to hospital arises from a visit to your General
Practitioner (GP), who then refers you to a specialist — either a surgeon or physician.
Here’s what we recommend you do before going to hospital:

1 . Tal k to u s
To get the most from your cover, like avoiding unexpected out-of-pocket expenses
and confusion, call us before planning your stay.
You may want to ask us the following questions:

°° Am I covered for my treatment?

°° Are there any waiting periods, exclusions or restricted benefits? (See page 15)
°° Do I need to pay any excess or co-payments? (See page 16)
°°  hich hospital should I go to, and what’s the difference between a ‘Members
W
First’ and a ‘Network’ hospital? (See page 9)

2 . Tal k to yo u r G P
There are several options you can discuss with your GP to ensure you pay minimal
out-of-pocket expenses for your treatment.
Ask your GP questions including:

°° Can you refer me to a specialist who uses the Bupa Medical Gap Scheme
(see page 7)?
°° Can you give me an open referral? This means you can choose from a list
of relevant specialists. You can then call us to find a specialist who uses
our Medical Gap Scheme.
°° Can you refer me to specialists who can treat me in a Members First or
Network hospital?

3 . Tal k to yo u r sp e cialist
The next step will be a consultation with your specialist.
Before agreeing to your hospital treatment, be sure to ask the following:

°° Can you tell me more about my condition?

°° What are my treatment options including non-surgical options, different
types of surgery and the consequences of not having treatment?
°° What are the benefits and risks of each treatment option (eg potential
complications)?

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Other questions to ask include:

°° What hospital/s do you recommend and why?

°° How long will I be in hospital for?
°° Do you use the Bupa Medical Gap Scheme, and if not,
what will my out-of-pocket expenses be?
°° Can you confirm what other specialists will be involved
in my treatment (eg anaesthetist, pathologist, radiologist,
assistant surgeon) and whether they use the Medical
Gap Scheme?
°° Does my treatment involve a prosthesis (eg hip or knee
replacement, cardiac stent) and, if so, will I incur an out-
of-pocket expense?
°° Should I continue taking the medicines I’m on?
°° Can you provide me with a medical certificate (for leave
from work)?
°° How long will it take me to recover and will I need
assistance (eg help at home or in a rehabilitation centre)?

I n f o r m e d Financial C ons e nt
If your hospital stay involves any out-of-pocket hospital
charges, the hospital should disclose the cost and obtain
your agreement in writing before your admission.
If your doctors’ fees include any out-of-pocket charges,
your specialist should disclose the cost and obtain your
agreement before your admission to hospital. They
should provide advice on fees charged not only by
themselves but also by other specialists or surgeons as
well as by anaesthetists, assistant surgeons, pathologists
and radiologists.

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7
Bu pa M e d ica l
G a p Scheme

The Medicare Benefit Schedule (MBS) fee is the amount set by the Federal
Government for a medical service. When you receive treatment in hospital as
a private patient, Medicare pays 75 percent of the MBS fee and Bupa pays the
remaining 25 percent.
If your specialist charges more than the MBS fee, there will be an out-of-pocket
expense (also known as a ‘gap amount’ or ‘medical gap’), which you’ll have to pay.
You can reduce or eliminate this gap amount if you choose a specialist who uses
our Medical Gap Scheme — an arrangement designed by us for your benefit.
Whether or not your specialist uses our Medical Gap Scheme, here’s how it works:

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 Scenario 
Your specialist uses our Medical Gap Scheme with no out-of-pocket
expense

°° Your specialist accepts Bupa’s agreed payment and the Medicare

benefit as full payment of their services.
°° Your specialist will send your account directly to Bupa and
Medicare for payment.
°° You won’t receive a bill and won’t have to make a claim.

Scenario 
Your specialist uses our Medical Gap Scheme but also charges
an out-of-pocket expense

°° Your specialist will tell you the gap amount you need to pay
(also called ‘Known Gap’). If not, you should ask.
°° You’ll need to sign a form, acknowledging that you’ve been told
of the gap amount.
°° You’ll receive an invoice from your specialist for the gap amount
either before or after your treatment. An account for the
remainder will go to Bupa and Medicare.

Scenario 
Your specialist doesn’t use our Medical
Gap Scheme

°° You should be told of the expected cost and sign a form

consenting to the expense.
°° Y ou’ll receive an account from your specialist after treatment.
°° You can then claim up to the MBS fee from Bupa and Medicare,
and pay the balance to the specialist.

Prior to your treatment, ask your specialist if they will use our Medical Gap
Scheme. Alternatively, ask us or your GP for the details of specialists who use
our Medical Gap Scheme.

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C hoo s ing
a ho s p ita l

As a Bupa member with private hospital cover, you can choose to be treated in
either a private or public hospital. Your choice will depend on your level of cover
and the type of treatment you‘re having.
Keep in mind that even as a private patient in a public hospital, it’s possible you’ll
be placed on a waiting list.

P r i vat e o r p u b lic pati e nt

Private patient Private patient Public patient

in a private in a public in A public
hospital hospital hospital

Covered for hospital

expenses (ie
accommodation, theatre
and intensive care fees)

Covered for specialist’s

fees, up to the MBS fee Not applicable
or our Medical Gap
Scheme benefit

Your choice of specialist

Your choice of hospital

Ability to access
treatment at your
convenience

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C hoo s ing a
p ri vate ho s p ita l

Get the most from your cover by selecting one of our Members First or Network
hospitals and day facilities — we’ve entered into a special agreement with them to
help reduce or eliminate your out-of-pocket hospital expenses.

M e m b e r s Fi r st hospitals
At Members First hospitals and day facilities, in most instances you’ll be fully
covered for your hospital expenses, such as accommodation, theatre and intensive
care fees. At Members First day facilities there are also no out-of-pocket expenses
for medical treatments (eg your specialist’s fees).
At these hospitals and day facilities, you’ll also have access to special benefits
such as our ‘single room or money back offer’*, a daily newspaper, local phone
calls and free-to-air TV at no additional cost.
We’ve also negotiated maternity care at Members First hospitals that offer
obstetric services. At these hospitals you can benefit from:

°° c hildbirth and parenting education classes prior to and after delivery;

°° postnatal clinics that provide support, advice and education to mothers
and families for up to eight weeks after you leave hospital;
°° a 24-hour postnatal support phone line;
°° parenting support services; and
°° breastfeeding classes for new and experienced mothers.
N e t w o r k hospitals
These are private hospitals and day facilities where, in most instances, you’ll be
fully covered for your hospital expenses such as accommodation, theatre and
intensive care fees. At a Network hospital, you’ll also have access to local phone
calls and free-to-air TV at no additional cost.
To find your nearest Members First or Network hospital, call us or search
 under
 ‘Find a healthcare provider’ at bupa.com.au

* You must book and request a single room in a Members First hospital at least 24 hours before admission. If you don’t get a single room you’ll
receive $50 a day from the hospital for every day you’re not in a single room. Applies to overnight admissions only. Excludes ‘nursing home
type patients’ (see page 17), emergency care, same-day stays or where a single room is medically inappropriate.

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 Fi x e d f e e s
This is a daily charge billed by a small number of Members First and Network
hospitals that you’re responsible for paying. The hospital should inform you
of any fee when you make a booking.
Fixed fees allow us to bring you a greater range of hospitals that provide
certainty around your costs. And if you have Ultimate Health cover, you’re
reimbursed for any fixed fee.

N on - ag r e e m e nt hospitals
These are private hospitals and day facilities that have not entered into an
agreement with Bupa. Because of this, you may incur large out-of-pocket
expenses when attending one of these hospitals.

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 Bringing
you greater
va l ue an d
certainty

°° Members First and Network

hospitals — we’ve entered into
a special agreement with them
to help reduce or eliminate
your out-of-pocket hospital
expenses.
°° ‘Single room or money back
offer’* at Members First
hospitals.
°° Other special benefits at
Members First hospitals#.
°° The Bupa Medical Gap Scheme
is designed to reduce or
eliminate your out-of-pocket
medical expenses.
°° Members First day facilities
extend the no-gap arrangement
to medical treatments
(eg specialist’s fees).

*You must book and request a single room in a Members

First hospital at least 24 hours before admission. If you
don’t get a single room you’ll receive $50 a day from the
hospital for every day you’re not in a single room. Applies
to overnight admissions only. Excludes ‘nursing home type
patients’ (see page 17), emergency care, same-day stays
or where a single room is medically inappropriate.
Includes a daily newspaper, local phone calls and free-to-air
#

TV at no additional cost. We’ve also negotiated maternity

care at Members First hospitals that offer obstetric
services.

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W hat to take
with you

W e s ugge s t your Bupa membership card

you pack :
your Medicare card
 edicines you’re taking, including prescription and
m
non-prescription medicines such as complementary
medicines, vitamins and over-the-counter painkillers
X-rays or medical images
specialist’s letters or referrals
information about your blood type
your hospital bag for labour (if pregnant)
your hospital’s pre-admission pack (if you received one).

If you‘re staying in hospital overnight, don’t forget the

following items (and remember to keep valuable personal
items at home):

C l othing T oi l etrie s other

Sleepwear Hairbrush Books
Underwear  oothbrush
T Magazines
and toothpaste
Slippers Personal
(non-slip)  ntiseptic
A music
soap player
Day clothes
Shampoo
and conditioner
Deodorant

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Be f ore 
Call us first to discuss your cover
ho s p ita l including any waiting periods,
check l i s t exclusions, restricted benefits,
excess or co-payments.
 alk to your GP about selecting
T
an appropriate specialist.
 alk to your specialist about your
T
condition, treatment options and
any out-of-pocket expenses.
Learn about our Medical Gap
Scheme, designed to reduce or
eliminate your out-of-pocket
medical expenses.
 hoose your hospital — select
C
one of our Members First or
Network hospitals or day facilities
to reduce your out-of-pocket
hospital expenses.
Prepare for your stay by deciding
what to take.

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During
ho s p ita l

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W hat to ex p ect

While every hospital works a little differently, the following

may assist you during your stay.

Visito r s
Ask your hospital about their visiting hours and
arrangements for your family and friends. Find out who is
considered ‘family’, arrangements for parents or guardians
(if the patient is a child), and when your friends can visit.
M e als
Ask your nurse about meal times and how to order, and
let the nurses know if you have any dietary restrictions.
Information about meals is often included on the hospital’s
television information channel.
T e l e v ision
Some hospitals charge for television use and some have their
own information channel explaining their services, such as a
chaplain. Note that you’re covered for free-to-air TV at our
Members First and Network hospitals.
T e l e phon e
Some hospitals will charge you to make local, interstate and
international calls. Others restrict the use of mobile phones
within the hospital. Note that you’ll be able to make local
telephone calls for no additional cost at our Members First
and Network hospitals.
I nt e r n e t
Most hospitals now offer wireless internet (Wi-Fi) though
some may charge you to use it.

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W hat you ’ re
co v ere d f or

Your ho s p ita l co s t s
If you’re admitted to hospital as a private patient you’re covered for the hospital’s
service charges, which typically include:

°° accommodation for overnight or same-day stays

°° operating theatre, intensive care and labour ward fees
°° medicines approved by the Pharmaceutical Benefits Scheme (PBS) and
provided as part of your in-hospital treatment
°° a llied services including physiotherapy, occupational therapy and dietetics
°° dressings and other consumables
°° surgically implanted prostheses up to the Government-approved benefit
published in the Government’s Prostheses List.
Your me d ica l co s t s
These are the fees charged by specialists involved in your hospital treatment.
As a private patient, you’re covered for the cost of medical treatment up to the
MBS fee. Medicare pays 75 percent of the MBS fee and Bupa pays the remaining
25 percent. If your specialist charges more than the MBS fee, there will be a ‘gap’
for you to pay.
However, if your specialist uses it, our Medical Gap Scheme can help eliminate
or reduce the gap for you (see page 7).
Pro s the s e s
If your hospital treatment includes a surgically implanted prosthesis (eg
a cardiac stent), you’ll be covered up to the Government-approved benefit
published in the Government’s Prostheses List.
To avoid any out-of-pocket expense, we suggest discussing prosthesis choices
with your specialist before going to hospital.
E mergency am b u l ance
In most circumstances, we’ll cover you for emergency ambulance transport and
on-the-spot treatment. These services are capped per calendar year at one service
a year for single memberships and two services a year for family and single parent
memberships.
There are different state ambulance arrangements across Australia — learn more
about these by contacting your state’s ambulance service.

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W hat ’ s not
co v ere d

While your hospital cover helps pay for a wide range of services you may receive
as a private patient, there are occasions when you won’t be fully covered and may
experience out-of-pocket expenses.
For example:
At a non - agreement ho s p ita l
A small number of hospitals in Australia are not part of Bupa’s network. If you
choose to be treated at a non-agreement hospital (see page 9), you may face
large out-of-pocket expenses.
During a waiting p erio d
A waiting period starts from the date you take out your health insurance
or upgrade your cover. If a treatment has a waiting period, you won’t be covered
during that time.
2 months ° Initial waiting period, palliative care, psychiatric and
rehabilitation services.
12 months ° Pregnancy-related services (including childbirth) and
assisted reproductive services (ie IVF).
° Pre-existing ailments, illnesses or conditions (anything you
had signs or symptoms of in the six months before you
joined or upgraded your cover is regarded as ‘pre-existing’).
If you visit hospital during this time, you may need to provide
documentation that shows your treatment isn’t related to
a pre-existing ailment, illness or condition.
3 years ° Laser eye correction surgery (only available on Ultimate
Health Cover and Ultimate Corporate Health Cover).
C o v erage f or your b a b y
No waiting periods apply to your newborn if they have been added to the
appropriate family hospital cover within two months of their birth.
E xc l u s ion s an d re s tricte d b ene f it s
Sometimes specific services or treatments are excluded or restricted under your
level of cover.
If your treatment is an exclusion, you’ll be responsible for all expenses related
to your hospital admission for that procedure or service.
If restricted benefits apply to your cover, you’re covered for shared-room
accommodation in a public hospital only, with your choice of specialist. If you
attend a private hospital or request a private room in a public hospital it’s likely
you’ll incur out-of-pocket expenses, and the restricted benefit amount set by
the Government won’t be enough to cover your costs.

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E xce s s an d co - payment s
Depending on your level of cover, you may need to
pay an excess and/or co-payment for your hospital
admission. Some levels of cover, including Ultimate
Health Cover, Top Hospital Cover and some corporate
covers are excess and co-payment free. For dependent
children on your membership, there’s no excess or co-
payments with Advantage Hospital Cover and no excess
with Standard Hospital Cover and some corporate
covers. Check with us to see what excess and/or
co-payment (if any) will apply to your hospital stay.
FIXED FEES
This is a daily charge billed by a small number of
Members First and Network hospitals that you’re
responsible for paying. The hospital should inform
you of any fee when you make a booking.
N on - emergency am b u l ance
While in most cases you’ll be covered for emergency
ambulance services, some ambulance services won’t
be covered. These include:

°° transport from a hospital to your home, a nursing

home or another hospital where you’ve been
admitted to the transferring (first) hospital; and
°° transport from your home, a nursing home or
a hospital for ongoing medical treatment (eg
chemotherapy, dialysis).

C o s metic s urgery
You’re not covered for cosmetic surgery which isn’t
clinically required.

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W hen l eav ing ho s p ita l
You may need to pay for certain services or products when you are discharged
from hospital. Depending on your level of cover and the hospital you attend, these
may include:

°° pharmacy items not opened at the point of leaving hospital

°° aids supplied for use at home (eg a raised toilet seat or a splint)
°° pay TV, movies and non-local phone calls
°° patient-requested non-emergency ambulance transportation.
O ut- patient s er v ice s
With the exception of a limited range of specific programs, your hospital cover only
applies when you’re admitted to hospital as an ‘in-patient’. Your hospital can tell you
if you’re covered by a specified out-patient program but if you’re unsure, contact us.
Sometimes people visit an emergency department in a private hospital but are not
admitted after being assessed. If you‘re not admitted you’re considered an ‘out-
patient’ and won’t be covered by Bupa. In this case, you may be out-of-pocket.
If out-of-pocket, check whether you’re eligible for a rebate under the Medicare
Safety Net (see page 20).
W here you recei v e b ene f it s f rom another s ource
Your health insurance doesn’t apply where compensation, damages or benefits
may be claimed from another source in relation to a condition, injury or ailment
(eg workers’ compensation, travel insurance).
A s a nur s ing home ty p e patient
If you’re assessed during your hospital stay as no longer needing acute care or are
in hospital for more than 35 days, you’ll be classed as a nursing home type patient.
In this case, Bupa will pay benefits that are much lower than normal hospital benefits
and you’ll be required to make a personal contribution towards the cost of your care.
W here M e d icare pay s no b ene f it
There are certain hospital procedures performed by a dentist, surgical podiatrist
or other practitioner that are not eligible for a Medicare rebate and which are not
covered by your hospital cover. Contact us for further information.

During Learn more about your hospital including visiting hours

ho s p ita l and how to order meals.
check l i s t
Take note of what you’re covered for in hospital.
Be aware of which costs you may not be covered for.

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A f ter
ho s p ita l

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G etting b ack
on track

You may not feel 100 percent well when you leave hospital and it’s possible you
might need further treatment. Most of all, you’ll probably need to take time out
to rest and recover. We’re here to help you get back on your feet and stay well
once you’ve recovered.
Before leaving hospital, ask your specialist the following questions:

°° What medicines will I need during my recovery?

°° When can I resume day-to-day activities?
°° When is my next appointment?
°° What complications might arise and what should I do if this happens?
°° Will I need help at home, and how can I organise it?
If you have extras cover, don’t forget to use it if you need ongoing treatment
(eg physiotherapy). By using our Members First network providers you can save
money and claim most services on the spot by swiping your membership card.
Also take advantage of our range of health and wellness programs by visiting
 our
 website at bupa.com.au

H ow to c l aim

The following information will help you work through the claims process so you
can return home without the worry of extra paperwork and unexpected bills.
Your ho s p ita l co s t s
All Members First and Network hospitals will ask you to complete claim forms,
which they will submit directly to Bupa on your behalf. The hospital would have
asked you to pay any excess, co-payment or fixed fee upon your admission.
If you’re treated at a non-agreement hospital, you’ll have out-of-pocket expenses
and may be asked to pay the whole amount up front. If that’s the case, you can
submit a claim form to Bupa to be reimbursed for some of these fees.

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Your me d ica l co s t s
If your specialist doesn’t use our Medical Gap Scheme, you’ll need to complete
a ‘two-way claim form’ for all your medical costs. The form is available at any
Medicare or Bupa centre. Medicare will process your claim and pay you the
benefit, and liaise with Bupa to pay a portion of the bill.
If you can’t visit a Medicare office during your recovery, contact either Bupa
or Medicare and ask for the relevant forms to be sent to you.
Statement o f Bene f it s
After your hospital and medical (from doctors and specialists) claims have been
processed, we’ll send you statements showing what has been paid on your
behalf. Please check that these details are correct and contact us straight away
if you have any queries. Your medical statement may include costs charged by
specialists you may not have seen directly such as pathologists.
M e d icare an d PBS Sa f ety N et s
The Government’s Medicare Safety Net provides financial assistance to people
with high out-of-pocket expenses for out-patient services that pay a Medicare
benefit. Once you reach a threshold, you may be eligible for additional Medicare
benefits for the rest of the calendar year. The PBS Safety Net is also available
to those who need a lot of medicines each year.

For more information or to register for these schemes visit

 
medicareaustralia.gov.au

AFTER  alk to your specialist about how to maximise your

T
ho s p ita l recovery. Also call us to find out how you can benefit
check l i s t from your extras cover and our health and wellness
programs.
If treated at a Members First or Network hospital, you’ll
be asked to complete a claim form which the hospital
will send to us.
If your specialist hasn’t used our Medical Gap Scheme
and you receive a medical bill, complete Medicare’s
two-way claim form to be reimbursed.
When you receive your Statement of Benefits from us,
check that the details are correct and contact us if you
have any queries.

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G l o s s ary

25
G l o s s ary

alli e d h e alth s e r v ic e s
Services provided by allied health professionals. Examples include
but are not limited to: chiropractic, dietetics, exercise physiology,
occupational therapy, osteopathy, physiotherapy, podiatry, psychology,
social work and speech pathology.

B u pa M e d ical G ap S ch e m e
An arrangement managed by Bupa under which medical providers
can claim reimbursement for the provision of medical services. Private
patients are covered for the cost of medical treatment up to the MBS
fee. Medicare pays 75 percent of the MBS fee and Bupa pays the
remaining 25 percent. If specialists charge more than the MBS fee there
will be a ‘gap’ to pay. However, if a specialist uses Bupa’s Medical Gap
Scheme, the gap can be reduced or eliminated.

co - pay m e nt
An amount you agree to pay towards the cost of your daily hospital
bill. A co-payment is similar to an excess except that the co-payment
is charged per day and capped after five days. In return for choosing a
co-payment, you pay reduced premiums compared to a similar cover
without a co-payment.

e m e r g e nc y a m b u lanc e s e r v ic e s
Emergency ambulance services are used when there’s reason to believe
that your life may be in danger or that you should be attended to
without undue delay.

e x c e ss
An excess is a set amount you pay upfront before your benefit is paid.
In return for choosing an excess, you pay reduced premiums compared
to a similar cover without an excess. Before going to hospital, contact us
to see what excess (if any) will apply to your hospital stay.

e x cl u sions
Exclusions are specific procedures or services that are not covered. If
your treatment is an exclusion under your chosen level of cover, you will
be responsible for all expenses related to your hospital admission for
that procedure or service.

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fixed fee
A daily charge billed by a small number of Members First and Network
hospitals that you’re responsible for paying. The fee is charged per day
and capped at a maximum number of days, and is in addition to any
excess or co-payment you may have as part of your hospital cover. In
most instances a fixed fee will only apply to certain types of services
at a hospital (eg psychiatric or rehabilitation services). In very few
instances, it applies to all services provided by the hospital.

I n f o r m e d Financial C ons e nt
Knowing how much your treatment will cost you including any extra
money you may have to pay out of your own pocket.
The hospital must obtain your agreement in writing for any out-of
pocket costs before admission. Likewise, your specialist should also
inform you of any costs and obtain your agreement before admission.

in - pati e nt
You’re an in-patient if you’re admitted into hospital for either same-day
or overnight treatment. If you’re admitted as a private in-patient, you’ll
be covered for the services listed in your chosen level of hospital cover.

l e v e l o f co v e r
Refers to the type of product(s) you have. For example, if you have
chosen Top Hospital Cover and Platinum Extras, these products make
up your level of cover.

m e d ical gap
Also referred to as an ‘out-of-pocket expense’ or ‘gap amount’, the
‘medical gap’ is the difference between the doctor’s fee for services
provided in hospital and the combined Medicare benefit and health
insurance benefit.

M e d ica r e B e n e f its S ch e d u l e ( MB S ) f e e
The MBS fee is the amount set by the Government for each medical
service covered by Medicare.

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M e d ica r e S a f e t y N e t
The Medicare Safety Net provides families and individuals with financial
assistance for high out-of-pocket costs for out-of-hospital MBS services.
Once you meet a Medicare Safety Net threshold, you may be eligible for
additional Medicare benefits for out-of-hospital MBS services for the
rest of the calendar year.

M e m b e r s Fi r st hospitals an d d ay
faciliti e s
Bupa has entered into a special agreement with these hospitals and day
facilities to help reduce or eliminate your out-of-pocket expenses and
provide you with special benefits not available at other hospitals and
day facilities.

N e t w o r k hospitals an d d ay faciliti e s
Bupa has entered into a special agreement with these hospitals and
day facilities to help reduce or eliminate your out-of-pocket expenses.

non - e m e r g e nc y a m b u lanc e
Ambulance transportation that’s provided when your life isn’t in danger
or when you don’t require treatment without undue delay. Examples
include: transportation from a hospital to your home; transportation
from a hospital to a nursing home; transportation from a hospital to
another hospital where you’ve been admitted to the transferring (first)
hospital; and transportation from your home, a nursing home or a
hospital for ongoing medical treatment.

non - ag r e e m e nt hospitals an d d ay
faciliti e s
These are private hospitals and day facilities that Bupa doesn’t have an
agreement with. If you visit a non-agreement hospital or day facility,
we pay benefits for your stay but the hospital may still charge out-of
pocket fees over and above these benefits.

n u r sing ho m e t y p e pati e nt
You may be classed as a ‘nursing home type patient’ if you’re assessed
during your hospital stay as no longer needing acute care.

op e n r e f e r r al
Where you can choose from a list (provided by your GP) of relevant
specialists.

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o u t- o f - poc k e t e x p e ns e
This is an expense you’ll need to pay to settle your bill. Examples of when
you’ll have an out-of-pocket expense are when the service or treatment
is not covered at all (eg exclusions) or when you receive benefits from
us that are not sufficient to cover the full cost (eg restricted benefits or
medical gaps).

o u t- pati e nt s e r v ic e s
Out-patient services are provided to a person who has not been admitted
to hospital. They can include medical, nursing or allied health care. No
benefits are payable by health funds for out-patient services except for
a small range of selected services. Out-patient medical services may be
eligible for Medicare benefits.

P ha r m ac e u tical B e n e f its S ch e m e ( P B S )
The PBS gives Australians access to prescription medicines by
subsidising their cost as part of the Australian Government’s broader
National Medicines Policy.

PBS Safety Net

If you or your family need a lot of medicines in a year, the PBS Safety
Net helps you with the cost of your medicines. Once you or your family
reach a Safety Net threshold, you can apply for a PBS Safety Net card
— then your PBS medicine will be less expensive or free* for the rest of
the calendar year.

p r e - e x isting ail m e nt, illn e ss o r con d ition

Any ailment, illness or condition that you had signs or symptoms of
during the six months before you joined or upgraded to a higher level
of cover with us. It’s not necessary that you or your doctor knew what
your condition was or that it had been diagnosed. A condition can still
be classed as pre-existing even if you hadn’t seen your doctor about
it before joining or upgrading to a higher level of cover. If you knew
you weren’t well, or had signs or symptoms that a doctor would have
detected (if you had seen one) during the six months prior to joining or
upgrading, then your condition is classed as pre-existing.

* If you choose a more expensive brand of medicine, or your doctor prescribes one, you may need to pay more.

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P r osth e s e s
Prostheses are designed to replace a part of the body or to make a
part of the body work more efficiently. Prostheses include pacemakers,
defibrillators, cardiac stents, hip and knee replacements, intraocular
lenses and other devices implanted surgically to replace or augment a
part of the body.

P r osth e s e s L ist
A list of prostheses with applicable private health insurance benefits,
published by the Department of Health and Ageing under the Private
Health Insurance Act.

r e st r ict e d b e n e f its
When you choose to pay a lower premium for your private health cover
in return for agreeing to lower benefits on some services. Restricted
benefit services attract minimum default benefits which means you
won’t be fully covered in private hospitals and will have out-of-pocket
expenses.

S tat e m e nt o f B e n e f its
These are statements you receive after your treatment that detail the
benefit paid and, for hospital expenses, any excess or co-payment
deducted. You’ll receive separate statements for your hospital and
medical treatments.

t w o - way clai m f o r m
Medicare’s two-way claim form aims to make lodging health claims
easier, saving you from making separate trips to both Medicare and
your health fund. If your specialist doesn’t use our Medical Gap Scheme
(where your doctor bills us directly) you’ll need to complete this form
for your medical costs.

waiting p e r io d s
A waiting period is a period of time during which you are not covered
for a particular service. It generally applies from the time you joined
or upgraded your cover with us. If you receive a service or treatment
during a waiting period, you’re not eligible to receive a benefit from us,
regardless of when you submit your claim.

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W e ’ re l i s tening
We hope this guide has helped you to better understand
how your private health cover works in the event that
you have to go to hospital.
Other resources you may find useful when visiting
hospital include:

°° Australian Government’s Private Patients’ Hospital

Charter — health.gov.au
°° Private Health Insurance Ombudsman website
— phio.org.au
°° Medicare Australia website
— medicareaustralia.gov.au
If you have any feedback about your hospital experience
(good or bad), let us know. We welcome your thoughts
so we can keep you happy, healthy and enjoying life.
Simply call us — we’re here to help.

Call us on 134 135

Visit bupa.com.au

Drop by your local Bupa centre

Effective 23 December 2011. The information in this booklet is intended to

be a guide only and is not intended to be, nor should be, relied on as a
substitute for professional medical advice. Bupa makes no warranties or
representations regarding the quality, accuracy or completeness of the
information. Bupa is not liable to readers for any loss or damage suffered
arising out of the use or reliance on the information, except that which cannot
be excluded by law.

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 Mailing details:
Bupa
F O R M O RE I N F O RM AT I O N : PO Box 14639
MELBOURNE VIC 8001
Call us on 134 135
Bupa Australia Pty Ltd
ABN 81 000 057 590
Visit bupa.com.au
Effective 23 December 2011
10272-12-11S
Drop by your local Bupa centre

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