Agreement private hospitals

Simple: you may be able to save money. Choosing a hospital that has an agreement with your insurer means you’re more likely to either reduce or eliminate out-of-pocket expenses for hospital services.

You’ll still have to:

• Hold the right type of cover (i.e. private hospital insurance)
• Hold adequate cover (i.e. the relevant inclusions)
• Have served any waiting periods in order to claim on these services.

You may also need to pay an excess when admitted to hospital as a private patient and/or a co-payment for each day you stay in hospital. An excess payment is typically limited to once per person per year, regardless of how many times you are admitted to hospital depending on your policy.

When you’re admitted to an agreement hospital as a private patient for a procedure included on your level of cover, the amount you can expect to pay will depend on whether your insurer has a no-gap or known-gap agreement.

On a no-gap agreement, the amount your health fund agrees to pay towards your treatment is the same as what the hospital agrees to charge (excluding any excess or co-payments).

On a known-gap agreement, there is still a gap between what your health fund will pay and what your hospital will charge, but it will be less than if there was no agreement in place.

While you may still be required to pay an excess or co-payment, your health fund will help pay for many of the costs associated with your hospital stay, including but not limited to:

• Intensive care
• Inpatient accommodation costs (including meals)
• Theatre costs
• Doctors’ fees (up to the Medicare Benefits Schedule of fees)
• Coronary care
• Labour ward costs.

Before you go to the hospital, we recommend you ask your insurer and treating doctors for an estimated cost of your treatment, also known as an Informed Financial Consent Form.

As long as you are admitted as an inpatient to the day hospital, you have the right level of cover, and your procedure is listed on the Medicare Benefits Schedule Fees, you can claim a benefit from your health fund for day surgery procedures.

If you’re going in for an outpatient procedure that’s not covered by Medicare or private hospital cover, an extras policy may be able to help. Some health funds will also have a gap cover scheme for extras providers, although they may work slightly differently.

If you choose to be treated at a private hospital that doesn’t have an agreement with your health fund, your health fund and Medicare will typically pay 100% of the Medicare Benefits Schedule fee. If your hospital or doctor charges more than that, you will be responsible for covering the gap.

The exact amount paid will depend on your health fund and policy, but keep in mind that you’ll most likely incur some out-of-pocket costs during your treatment.

Insurers typically consider public hospitals as agreement hospitals, despite no official agreements being in place.¹ However, you may have to serve public waiting lists for treatment.

An ambulance typically takes you to the nearest public hospital in an emergency, but if you require ongoing care after an incident, you can do it on your terms through your health insurance subject to your situation.

If you decide to go through the public health system as a public patient, Medicare covers your treatment. As a result, you will have less control over your healthcare, meaning no choice in your doctor, reduced options for a private room (private rooms are only given to those who need them most) and will be subject to public waiting lists for treatments.