WHAT IS AN EXCESS

An excess is the amount you agree to pay upfront if you go into a public hospital, private hospital or private day facility. It is that simple!

The higher your excess amount, the less you pay in your regular premiums. Just decide the excess amount that suits your individual circumstances, and you are on your way to lower premiums.

Your excess is only payable should you be admitted to a private hospital, private day facility or a public hospital as a private patient. For singles, couples and family type cover, the per person excess is only payable once per calendar year, 1 January to 31 December, to the maximums shown in the table below, irrespective of the length of stay or the number of admissions that year.

HOSPITAL COVER IMPORTANT INFORMATION

Benefits are payable for treatment received in a recognised hospital or facility in Australia only.

Benefits will not be payable unless all applicable waiting periods have been completed.

Restricted benefits will be payable at the Minimum Benefit Payable (MBP), this is the minimum benefit the Private Health Insurance Act requires health funds to pay for treatment under a hospital cover. If you hold the Basic Plus cover and are admitted to a private hospital or day facility, benefits will be payable at the MBP which may leave you with large out of pocket expenses to pay.

Treatment where no Medicare benefit is payable will not be covered by your hospital cover. However, limited benefits are payable towards the cost of hospital inpatient treatment for Podiatric surgery provided by an accredited podiatric surgeon depending on level of hospital cover. Cosmetic surgery is specifically excluded where there is no Medicare benefit payable

Benefits are payable for 365 days of the year provided your doctor certifies your need for ongoing acute care. If after 35 days, your doctor doesn’t provide certification you will be classified as a long term ‘nursing home type’ patient. We will cover you for the minimum benefit amount as determined by the Department of Health (DoH) leaving you with a daily co-payment to pay. Depending on your length of stay your co-payment amount may be significant.

Gap Medical benefits are payable on all inpatient services where a Medicare benefit is payable. If you, or your family, are being admitted to hospital always contact us first to confirm your cover.

Our ‘Going to Hospital’ brochure can be downloaded here.

GAP MEDICAL BENEFITS

When you are admitted to hospital you will be charged separately for medical fees by your doctor, medical specialist, surgeon, anaesthetist, radiologist or pathologist.

These fees will be in addition to your accommodation and theatre fees, and are always negotiable between you and your health care provider. You will receive 100% of the Medicare Benefit Schedule (MBS) fee, the Medicare benefit plus the Fund Benefit, for inpatient services. If your specialist chooses to charge above the MBS fee, we will pay a further benefit towards this amount, known as the gap, which may result in a gap payment or no out of pocket cost to you. If your doctor has an agreement in place with us, they will bill us direct. Otherwise you can submit your unpaid account to us for claiming.

Please contact the Fund prior to any planned hospitalisation with the MBS item numbers, and fees the doctor will be charging, so that we can ensure that you will be covered and advise you of any out of pocket amounts you may need to pay.

NO GAP MEDICAL BENEFITS AT MHPH

Mildura Health Fund has no gap medical agreements with a number of medical specialists, doctors and surgeons who operate at Mildura Health Private Hospital (MHPH).

Your doctor will bill us direct and you will have no out of pocket costs if treated at MHPH by a no gap provider.

The current list of no gap medical providers can be found here.

PROTHESES

A prosthesis is a surgically implanted medical device or artificial body part, such as a hip, knee joints or a cardiac pacemaker.

If you are having a procedure that involves implantation of a prosthesis, we will pay a benefit up to the minimum benefit as defined on the Government approved prosthesis list. You will be responsible for the gap where the prosthesis charge is above the defined minimum benefit.

OTHER COSTS YOU MAY INCUR

Depending on the procedure you are having whilst an inpatient in hospital, your doctor may need to use high cost items that are not normally covered.

When this occurs, long term Mildura Health Fund members may qualify for an ex-gratia benefit to be paid to the hospital, on their behalf, towards the cost.

This can include items such as high cost disposables associated with certain procedures, and high cost drugs.

MEDICAL COST FINDER

The Department of Health’s Medical Cost Finder online tool can be used to help you understand the cost of common medical procedures provided by medical specialists in Australia.

The Medical Cost Finder can be found here

What is not covered?

There are hospital costs we do not cover, these include:

• Treatment received whilst serving a waiting period
• Treatment that relates to a pre-existing condition whilst serving a waiting period
• Treatment provided at the emergency department of a public or a private hospital
• Pharmaceuticals and other supplies not directly associated or essential to your admission
• Take home items such as crutches and pharmacy itemsl
• Boarder accommodation for a partner or dependent
• Personal expenses such as TV hire, phone calls, newspapers and parking