Going to hospital

It’s essential that you understand your cover, including any excesses, excluded services, restricted services and waiting periods. Here we provide an overview of excesses, the difference between being treated in a private vs a public hospital, and how waiting periods can be affected by pre-existing conditions.

Understanding what you’re covered for before your stay means you will avoid any surprise out-of-pocket expenses. Some of the issues to be clear about include the following.

• Level of cover - Check your level of cover by logging into your Member Service Centre or by contacting us directly.
• Excesses - You should be aware of any excess that you’re required to pay. You can find out if you have an Excess by reviewing your last CBHS Corporate Health cover statement or by logging on to your Member Service Centre.
• Exclusions - These services are not covered in a private or public hospital and are services that are not eligible for benefits from Medicare, such as cosmetic services, podiatry surgery, laser eye surgery are not covered under CBHS Corporate Health hospital products and you will be responsible for the full cost of fees raised by hospitals and doctors.
• Restricted services - These services are covered in a public hospital in a shared room. If your chosen hospital level of cover with CBHS Corporate Health has restricted services and you receive treatment in a private hospital, these services are eligible for benefits at a minimum default rate and you will incur large out of pocket expenses.
• Waiting periods and pre-existing conditions - Waiting periods and rules relating to pre-existing conditions for benefits apply, so it’s important that you check if you are currently subject to a waiting period for coverage. Find out more by reviewing this page or by calling us directly for more information.

You can contact us if you have any questions about whether your chosen hospital product has exclusions or restricted services. Alternatively, you can log into the Member Service Centre to find out if your chosen level of hospital cover has exclusions or restricted services. 

In most cases you will have spoken to a GP before being referred to a specialist, who then recommends the appropriate hospital treatment. There are several things that you will need to ensure that you ask your specialist before commencing any treatment programs, particularly in regards to out-of-pocket expenses and the Access Gap Cover scheme.

You will probably already have spoken to your GP and specialist before being recommended for treatment in hospital. You should have a discussion with your GP and specialist about minimising your out-of-pocket expenses, and you can ask your Specialist to participate in CBHS Corporate Health's Access Gap Cover scheme if they don't already.

You can also ask your GP to refer you to a specialist who participates in the Access Gap Cover scheme, or for a list of specialists who may be willing to participate. To prevent from being locked into seeing a specific specialist, you should ask your GP for an open referral so that you can choose from a list of specialists.

When speaking to your specialist, make sure that you ask him or her to explain your condition in plain language. Ask the doctor to outline the different treatment options that are available to you, and ask the doctor to explain the risks and benefits of each option. Make sure they let you know about all the medical professionals who will participate in your treatment so that you understand all the costs that may be applicable.

If your procedure includes the use of a prosthesis, check with your doctor about any out-of-pocket expenses that are payable. You will be covered up to at least the minimum benefit for the prosthesis listed under the Government's Private Health Insurance legislation. You may want to discuss other issues such as recovery and continuing current medications while in treatment, and to also have the doctor provide you with a medical certificate for leave from work.

Please note that whether a doctor participates in the Access Gap Cover scheme or not is completely at his or her discretion. Doctors may choose to participate in the scheme on a patient-by-patient basis, and the fact that the doctor has participated in the scheme before doesn't guarantee that he or she will do so again.

Once your specialist has selected a hospital with which to commence your treatment program, you will need to check the hospital has an agreement with CBHS Corporate Health.

Once you and your specialist have agreed upon a treatment plan and you have determined if a hospital stay is necessary, your specialist will nominate the hospital that they prefer to work with. This choice is at the discretion of the specialist but sometimes you will be presented with 2 or 3 hospital choices, so it’s important that once you know the name or names of the hospital that you check if they have an agreement with CBHS Corporate Health. You can find out whether your hospital has an agreement with CBHS Corporate Health by using this search tool.

If the hospital that your specialist chose does have an agreement with CBHS Corporate Health, as one of our members you will be covered according to your hospital coverage level and the terms of the hospital/fund agreement. This might include accommodation, theatre and labour ward, intensive care and coronary care.

If your specialist has chosen a hospital that does not have an agreement with us, you will still be covered up to pre-set limits - which are set by the government - but you may also incur large out-of-pocket costs. Contact CBHS Corporate Health to discuss applicable benefits.

Identify what will be involved in your hospital stay, including planned treatment program and whether you will be staying overnight.

The next step is to check what will be involved in your stay and treatment. For example, you might be receiving surgery as a day patient (on the basis of a same-day admission). You should also clarify what types of services or treatment you will be receiving. This will make it easier to check if you have services subject to restrictions or exclusions and if you need to pay out-of-pocket cost.

Before going into hospital, you should obtain a quote or informed financial consent from all the specialists and medical professionals involved in your hospital treatment. This way you will be aware of all out-of-pocket expenses before your admission. You should also obtain a quote from CBHS Corporate Health to understand your hospital out-of-pocket costs.

The next step is to obtain an informed financial consent or itemised quote from your doctors. These medical professionals may include your anaesthetist, surgeon, radiologist and pathologist. Having access to quotes allows you to plan for the costs of your stay more effectively.

Note that if your doctors participate in CBHS Corporate Health’s Access Gap Cover scheme, you may not receive a bill as the doctor may forward the bill directly to CBHS Corporate Health for payment.

You should also get a quote from CBHS Corporate Health to understand the out-of-pocket payment related to medical services.

For planning purposes, you will probably also want to be aware of the claiming process before your hospital admission.

Getting to know the claiming process before your hospital admission will allow you to better plan. The two items to be claimed are your hospital fees and your doctor and specialist bills. For your hospital fees, your hospital will bill CBHS Corporate Healthdirectly. If you are required to pay for any part of your admission, you pay this fee directly to the hospital. Ask the hospital about their procedure for payment.

For your doctor and specialist bills, your doctors may bill CBHS Corporate Healthdirectly if they are participating in the Access Gap Cover scheme. If you receive a bill from your doctor, forward it to us for payment rather than to Medicare first. We will process it and forward it to Medicare on your behalf.

If your doctors and specialist are not participating in the Access Gap Cover scheme, take the bill to Medicare and complete a two-way form there to submit the claim. Medicare will process the claim and we can then provide you with your benefits.

One of the most important things to do before leaving hospital and/or right after discharge is to consult your specialist. You should find out if you need to take any medications after discharge and obtain clear instructions on how many and how long to take these for.

You will also want to ask your specialist about commencing your daily routine or work during your recovery and rehabilitation. For example, does your doctor recommend that you go back to work or take a few weeks or more off from work for your recovery? Are they able to complete a sick certificate for your leave period from work?

Your specialist will probably set up a follow-up appointment to take place some days or weeks after you’re discharged from hospital. He or she will usually take time to discuss the risk of complications or issues (if any) that might arise after your operation or treatment. You might also discuss at-home nursing or help at home, if you require it.

Your rehabilitation program might be as simple as resting for a few days at home, or it could be more complicated and require ongoing treatment such as physiotherapy or nursing. Your specialist doctor will discuss any rehabilitation services you might need with you. 

If you need at-home nursing care after discharge and the hospital provides this, CBHS Corporate Health will cover the costs of this service as part of your hospital admission costs. 

In some cases, you may continue to receive hospital treatment after being discharged. This home-based service will be fully covered by CBHS Corporate Health where you’re eligible (members who have hospital cover), but your doctor must first approve your hospital substitute treatment program as clinically appropriate for your circumstances.

For example, you can receive wound management, nursing services, physiotherapy, or occupational therapy in your own home. Support services such as meal and domestic help may be included. These services must be an appropriate substitute for treatment that you would be fully covered for if received in hospital.

Your doctor and hospital will usually bill CBHS Corporate Health directly. If your doctor does not participate in our Access Gap Cover scheme, he or she will bill you. You should submit your claim to Medicare by using a two-way claim form. After Medicare has processed the claim, CBHS Corporate Health will reimburse you with any payable benefits.