I'm a member of Health Care Insurance (HCI) with hospital cover.

What happens if I find myself in a public hospital?

At some point in time, you may find yourself in a public hospital emergency department due to an accident or illness, and you or a loved one will be asked if you have health insurance when being admitted.

As an Australian citizen, you may choose not to use your private health insurance and to be admitted as a public patient - you will be covered by Medicare and are entitled to be treated for no charge. Your accommodation, surgical fees and all associated costs with your admission will all be covered by Medicare.

As a member of HCI however, you may at this point choose to be admitted as a private patient in a public hospital. If you have HCI Gold Hospital cover, you will be covered for all hospital and medical services which Medicare covers and are listed under the Medicare Benefits Schedule (MBS)1 . You will need to confirm the fee scales charged by treating doctors and specialists – there may be additional out of pocket costs for any fees above the MBS prescribed amount.

Should you hold Silver or Bronze hospital cover, you will need to check your health insurance policy which outlines what procedures you are and are not covered for.

Your policy generally will cover hospital accommodation, specialist, and surgical costs unless you have any exclusions or restrictions.

You’ll need to ensure you are covered for the procedure and check under these circumstances if specialist is going to charge any out of pocket fees for surgery and consultation fees for follow ups.

Your health insurance policy may also cover you for prostheses, anaesthetics, pathology and any medical imagery services.

Why do public hospitals ask if you’re insured?

Public hospitals benefit from being able to claim higher costs from private health insurers and still receive funding from Medicare for your treatment. The additional payment shouldn’t affect the quality of your treatment, however it may affect future policy premium increases.

What might public hospitals offer if you are admitted as a private patient?

You may be able to choose your treating doctor, but this is not guaranteed. It may depend on the hospital, your condition, the specialists employed by the hospital and their practising rights at the hospital.

Your hospital may offer additional benefits for being a private patient including: Wi- Fi, Free parking and alternative food menus, however these are not guaranteed and will vary between hospitals, so it’s best to ask at the time of your admission what is offered.

If you are covered for a private room you may get one, but only if one is available and there are no other patients with higher needs of care.

You should also check on any specialised follow up care that may be needed post your procedure. Being admitted as a Private Patient may exclude you from Medicare outpatient services and community health programs.

If you choose to go to a public hospital as a private patient, public hospital waiting lists may still apply.

Can I be refused treatment in a public hospital as a private patient?

The answer is no, there is a National Healthcare Agreement between the State and Federal Governments that ensures “all Australians have timely access to quality health services based on their needs and not ability to pay 2”. You will receive the same access to treatment being a private patient in a public hospital, or….

What if I want to be transferred to a private hospital?

You can choose to be treated by your own doctor, and you may request to be transferred to a private hospital for follow up care. You maybe out of pocket for patient transport costs so be sure to check with the hospital if they will cover your patient transport costs.

Who pays for what?

Should you choose to use your private health insurance in a public hospital, Medicare and HCI will cover the fees set under the Commonwealth Medical Benefits Schedule which means we will generally cover your doctor or specialist costs - you should check with us however to see if your policy covers the service or procedure you are having performed. You will of course have to pay the excess on your policy and any out of pocket costs the doctor may choose to charge.

Your accommodation charges may be covered, depending on your level of cover.

Will there be any out-of-pocket costs?

It is important to discuss fees with your doctor prior to treatment as there may be out of pocket expenses. If your doctor charges above the Commonwealth Medical Benefit Scheme, HCI generally does not cover these expenses. The hospital should ensure you have provided informed financial consent before your procedure.

Public hospitals may not be aware of your level of health insurance coverage, in which case we recommend you contact us before consenting to any procedure, that a public hospital propose to treat as a private admission.

How do I make sure I give informed financial consent?

Your hospital is required to seek your full financial consent on any costs related to your treatment as a private patient. You will be asked to sign an agreement acknowledging your consent to pay any out-of-pocket costs.

So, remember to ask “Will I have any out-of-pocket expenses? Can you please provide an estimate of these costs?”.

1. Services which are not listed on the MBS, such as elective cosmetic surgery or laser eye surgery, are only covered by hospital policies to a limited extent or may not be covered at all, depending on the policy.
2. Council on Federal Financial Relations, National Healthcare Agreement, accessed 31 May 2021. <https://www.federalfinancialrelations.gov.au/content/npa/health/_archive/healthcare_national-agreement.pdf>

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