Silver Plus Premium Hospital

A waiting period is the time between joining when you first take out health insurance or upgrade your cover and when you’re covered for a treatment or service. If you receive a service or treatment during a waiting period, you are not eligible to receive a benefit payable from us, regardless of when you submit the claim.  

Hospital waiting periods apply to: 

• New members who have never held private health insurance before. While serving waiting periods, you won't be covered for treatments or services, and will not be entitled to claim a benefit.
• Members who transfer from another health fund and have had a gap in and/or upgraded their cover (see Switching to GMHBA below for more information).
• Members who upgrade to a higher level of cover or reduce their excess payable. If treatment or service was included on the previous cover at a lower level, and waiting periods have previously been served, members are entitled to the lower benefits on their previous cover while serving the new waiting period for higher benefits or reduced excess.
• Additional members added onto a policy (unless they've already served their relevant waiting periods). Exceptions apply for newborns, adopted and permanent foster children (where the family membership has been in existence for at least two months).

Switching to GMHBA
If you have already served your waiting periods on an equivalent or higher level of cover with another fund, and joined GMHBA within 30 days of leaving that fund, you won't have to re-serve your waiting periods. Otherwise, waiting periods will apply from the date you take out your new cover with GMHBA. If you’ve upgraded your cover, your waiting periods for higher cover will start on the date you upgraded, but you can still claim the equivalent benefit to your previous level of cover during that period.

Waiting Period – 0 days (accidents must occur after joining) 
Accidents – bodily injuries resulting from accidents which occur after the date of joining or upgrading to a higher cover.  

Waiting Period – 2 months
Rehabilitation, palliative care, psychiatric and non-pre-existing conditions. 

Waiting Periods – 12 months
Pre-existing conditions.

Going into hospital can be an emotional and confronting experience for either yourself or a loved one. At GMHBA we’re here to support your hospital stay and encourage you to contact us as soon as you may need a hospital admission. 

Our Going to hospital guide steps you through what happens when you go to hospital, how to use your cover, what to expect from specialists and the right questions to ask to ensure that you feel comfortable with your upcoming admission. 

A 'medical gap' or out-of-pocket cost can be incurred when the fee charged by a specialist exceeds the combined benefit provided by Medicare and GMHBA for an inpatient procedure. Medicare will pay the first 75% of the Medicare Benefits Schedule fee (MBS) and GMHBA will contribute at least 25% of the remaining amount.

The MBS fee is only a recommendation and private surgeons in Australia are able to charge what they deem appropriate for their services. If the fee they charge is greater than the set MBS fee, you will be required to pay the difference; this is called a ‘medical gap’ or an out-of-pocket cost. 

To reduce the out-of-pocket costs associated with medical procedures, the Australian Health Service Alliance (AHSA) Access Gap Cover scheme is an opt-in billing scheme that provides higher benefits than the Government’s schedule fee (MBS) and limits the out-of-pocket costs for inpatient procedures. Specialists must be registered for Access Gap Cover (AGC) and choose to opt in to the scheme for the billing of each procedure. 

There are two scenarios for how you may be billed by your specialist when they use the AGC scheme: 

• No Gap – this is where there will be no gap from the specialist to pay following the procedure 
• Known Gap – this is where you will be charged a maximum gap of $500 per specialist, per admission to hospital or a maximum of $800 for obstetric services. 

Find out more about Access Gap Cover.

We won't pay on any services that are:

• excluded on your level of cover
• received whilst you are within waiting periods
• treatment that occurred outside of your policy being active
• treatment with unregistered providers
• claimed for people not listed on the policy
• treatment outside of Australia
• emergency department fees
• procedures for which Medicare does not pay a benefit
• claimable for compensation, damages, or benefits from another source (e.g. TAC or WorkCover)
• non-admitted hospital visits, and
• any outpatient medical costs.

If you elect to be treated as a private patient in a registered public hospital or a non-participating private hospital, GMHBA will only pay minimum shared room benefits (^~except for NSW public hospitals), and you may incur significant additional out-of-pocket expenses. Make sure you get written financial consent for any hospital admissions, and always call us first to check your coverage.

^~For NSW public hospitals, GMHBA will pay for a private room where a member has:

• Signed the Inpatient Election form to be treated as a private patient; and
• Ticked ‘yes’ to a single room if one is available on the Inpatient Election form.

As a private patient in a public hospital, you may have a choice of doctor however you cannot avoid public hospital queues. The length of a public hospital queue is determined by the hospital and is not influenced by GMHBA.