ADF Top Hospital
The ADF Top Hospital product provides comprehensive benefits for hospital accommodation, theatre fees, medical, surgical and other agreed charges in more than 475 Defence Health agreement private hospitals and day hospital facilities.
This product may also provide benefits for medical, surgical, nursing and other services provided outside of hospital where those services are intended to substitute for treatment provided in hospital. These treatments will only be available to you if they are clinically appropriate to your personal circumstances. Your treating practitioner will work with the service providers to put the most appropriate services in place for you.
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Agreement private hospitals & public hospitals |
Non-agreement private hospitals |
| Accommodation |
100% covered for private or shared room accommodation. If an excess option is selected, and the patient is aged 16 or over the excess will apply. |
Cover is limited to the ‘minimum benefit’ set by the Federal Government – you will be significantly out-of-pocket. |
| Intensive/coronary care |
100% covered. If an excess option is selected, and the patient is aged 16 or over the excess will apply. |
| Same day hospitalisation/day surgery |
100% covered, no excess applies. |
| Theatre fees |
100% covered. If an excess option is selected, and the patient is aged 16 or over the excess will apply. |
No cover is available for theatre fees. |
| Labour ward |
100% covered. If an excess option is selected, and the patient is aged 16 or over the excess will apply. |
No cover is available for the costs of a labour ward. |
| Pharmaceuticals supplied in hospital |
100% covered if related to the reason for admission and covered under the terms of the agreement with the hospital. Pharmaceuticals are generally supplied without charge in a public hospital. |
No cover is available for pharmaceuticals supplied in a non-agreement private hospital. |
| Surgically implanted prostheses |
100% covered for no-gap prostheses as defined in the Federal Government’s Prostheses Listing. There is a no-gap prosthesis available for every Medicare procedure. More expensive prostheses may be available but the benefit will be limited to the equivalent no gap prostheses. |
| Doctor’s fees |
The difference between the Medicare rebate and the Medicare Benefits Schedule (MBS) fee is the minimum amount Defence Health will cover for services received during a hospital stay. If your doctor chooses to apply the Defence Health Access Gap Cover schedule of fees we can also cover up to 100% of the amount above the MBS fee. More information... |
| Hospital in the home |
Defence Health has agreements with a number of hospitals to deliver out of hospital care to hospital patients for services such as wound management, IV therapy and antenatal care. |
| Ambulance treatment |
100% covered for all treatment provided by a registered ambulance service in Australia, including emergency services, non-emergency services, mobile intensive care, air and sea ambulance services. |
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Hospital substitute treatments and health management programs |
| Home care treatment |
Defence Health has agreements with a number of approved health care providers to deliver services such as wound management, IV therapy, administration of blood products and ambulatory sleep studies in your home. We cannot guarantee that a participating provider will be available in your area. |
| Midwifery |
Defence Health pays up to $790 for midwifery per financial year. This is made up of $550 for your midwife’s attendance at the delivery, $20 per pre natal visit and $40 per post natal visit. Your midwife must be registered and in private practice. Midwifery benefits are not payable if a doctor is required to intervene in the delivery. |
| Home nursing |
Defence Health pays up to $1,400 per person per financial year, payable at $70 per day when provided by a registered nurse in private practice and certified by a medical practitioner as being in place of hospitalisation. |
| Recovery Assist – early discharge program |
When your doctor agrees that it is clinically appropriate you could choose to leave hospital early and receive care in the comfort of your own home. You may even be able to avoid a hospital admission. Treatments most suited to Recovery Assist include obstetrics, wound management, palliative care, IV antibiotics, musculoskeletal and coronary bypass care. More information... |
| Mother Care – maternity early discharge program |
When new mothers leave hospital early, services such as midwifery, lactation consultation, home cleaning or nappy service may be able to be put in place to make the transition from hospital to home easier. More information... |
| Family Assist – maternity support program |
Family Assist is a unique program designed to provide an education and information service for eligible expectant mothers. More information... |
| Mental Health Relapse Prevention program |
The Mental Health program provides an assertive telephone based support that is focussed on relapse prevention and education. It has been designed for insured persons who have had an appropriate hospital admission and is a supplement to existing mental health services. |
| What's covered |
What's not covered |
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In general, hospital and hospital substitute benefits detailed in the ADF Top Hospital and ADF Public Hospital tables are payable where:
- a Medicare benefit is payable for the hospital treatment
- a Medicare benefit is payable for the hospital substitute treatment, provided the Medicare benefit is not separately claimed by you
- prostheses are surgically implanted
- treatment is related to psychiatric care, rehabilitation or palliative care, and
- hospital costs are associated with treatment provided by a Commonwealth accredited podiatric surgeon.
Hospitalisation in excess of 35 days must be supported by an acute care certificate. Where supported, hospital benefits will be paid at the insured rates.
Some preventative and health management programs for psychiatric care and rehabilitation are available for a limited period.
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Neither ADF Top Hospital nor ADF Public Hospital will pay for:
- Treatments received during an applicable waiting period
- Treatments for which a Medicare benefit is not payable (psychiatric care, rehabilitation and palliative care excepted)
- Treatments not clinically necessary (eg. cosmetic surgery)
- Doctors’ fees above the MBS fee where your doctor has chosen not to apply the Defence Health Access Gap Cover schedule of fees
- Doctors’ fees above the MBS fee where your doctor is employed by a public hospital
- Pharmaceuticals not related to the reason for hospitalisation or not covered under the agreement with the hospital
- Pharmaceuticals provided on discharge
- Exceptional (high cost) drugs that may be excluded or limited
- Additional charges for luxury suites
- Personal and take home items (eg. newspapers, toiletries, television, hairdressing, manicure, crutches, etc.)
- Accident and emergency services, and
- Aged care and accommodation in a aged care facility.
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