You should know exactly what you’re covered for and be aware of any out-of-pocket expenses you may need to pay.
Hospital costs
While you are admitted to hospital, your accommodation, meals, nursing care and theatre fees will be charged directly to Defence Health.
If a hospital excess applies, you will need to pay this to the hospital at the time of your admission. Children are not charged an excess.
Depending on your level of cover, you may be able to claim travel and accommodation expenses related to an eligible hospital admission, when travel between your home address and the hospital (calculated in a straight line) is over 200km return. Accommodation benefits are payable for either the patient or their accompanying person, in a commercial premises (i.e. hotel, Airbnb).
Refer to your Product Guide to see what's included in your cover.
Agreement hospitals
Defence Health has contracts with most private hospitals – these are called agreement hospitals. These agreements ensure that an agreed schedule of fees is charged by the hospital and paid by Defence Health on your behalf.
If you choose a non-agreement private hospital, you may incur out-of-pocket expenses for hospital- related services.
Medical costs
Medical services provided in hospitals by doctors, surgeons, anaesthetists, radiologists, and pathologists are charged separately from the hospital costs. If your doctor chooses to charge more than the Medicare Benefits Schedule of fees and does not use Access Gap, you may have an out-of-pocket or ‘gap’ to pay.
For most surgical procedures requiring a prosthesis (a device designed to replace a missing part of the body or to make a part of the body work better, e.g. a pacemaker), your doctor will discuss with you the choices available. If you choose a no-gap prosthesis from the Government’s Prescribed List, it will be fully covered by Defence Health.
Other 'non-listed' prostheses may be available for your surgery. If you agree to have one of these, you may need to pay for the whole prosthesis.
To make sure you’re getting the right prosthesis for your needs, discuss your options with your specialist and ask for a written estimate of any out-of-pocket costs.
Defence Health has negotiated no-gap agreements with a number of diagnostic service providers, such as radiologists and pathologists. If your diagnostic service has been provided under such an arrangement, the bill will be sent directly to Defence Health for processing.
If there is no agreement with the provider, you may need to pay a gap for the services.
Medicare Benefit Schedule
The Medicare Benefits Schedule (MBS) is a government list of medical services, each with a set fee (called the schedule fee). For inpatient doctor services—like surgeons or anaesthetists:
- Medicare and Defence Health will together cover up to 100% of the MBS fee.
- If your doctor charges more than the MBS fee, you’ll pay the gap (unless your doctor participates in Access Gap).
Your doctor or specialist should inform you of the MBS codes relating to your procedure, by way of an invoice and/or their informed financial consent form.
Access Gap
Under Access Gap, Defence Health will pay higher benefits for your medical procedure, up to certain limits. In return, your doctor agrees to charge a lower amount. If your doctor chooses to participate in Access Gap, Defence Health will:
- cover the gap completely, or
- reduce the gap so that you only have a reduced amount to pay (your doctor should tell you exactly how much you have to pay).
With Access Gap, your doctor should send their account to us. If your doctor sends the bill to you, just send it on to us.
Always ask your specialist about the cost
Your medical specialist must provide you with a written estimate of the cost of your treatment before you are admitted to hospital. It will include a breakdown with the Medicare benefit, the amount your private health insurance will cover, and any out-of-pocket expense you will have to pay.
With this information, you can give your informed financial consent to the specialist’s charges.
Check your cover
Log in to your Member Portal to review your cover. For more information, refer to your Product Guide or give us a call on 1800 335 425.