Hospital costs explained
An overview of hospital costs, what they cover, and key factors that can impact the cost of hospital treatment.
What are hospital costs?
Hospital costs typically include accommodation, theatre fees, intensive care, and items like dressings and bandages, which are usually billed directly to GMHBA.
- Depending on your policy and admission type, you may need to pay an excess and any out‑of‑pocket costs. For members with eligible GMHBA hospital cover, the excess is waived for same‑day hospital admissions.
- GMHBA has agreements with hospitals across Australia. If you attend a hospital that has an agreement with GMHBA, we can pay benefits that cover your hospital room, accommodation and meals, nursing care, intensive care, operating theatre fees, and Government-approved Medical devices and human tissue products. We recommend checking our participating hospital list for more information.
- If you use a non-contracted hospital, GMHBA pays only the default rate as set by the Australian Government, which may leave you with significant out-of-pocket fees.
What are medical costs?
Medical costs refer to the fees charged by the medical specialists who take part in your procedure.
- Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee, and GMHBA pays the remaining 25%.
- Out-of-pocket expenses occur when your specialist charges more than the price listed in the MBS, which is why it’s always important to understand their charges before treatment. Ask your specialist about informed financial consent.
The Medical Costs Finder provided by the Australian Government outlines typical fee ranges for common private procedures across Australia, giving people a sense of the likely out‑of‑pocket costs.
How your claim is processed depends on whether your specialist uses Access Gap Cover:
If your specialist participates in Access Gap Cover for your procedure
- They send the bill directly to Medicare and GMHBA.
- Medicare pays their part, GMHBA pays their part (up to the agreed benefit).
- You only pay for any remaining gap - sometimes no gap or a known gap (up to $500 per specialist or $800 for obstetrics).
If your specialist does not participate in Access Gap Cover
- You’ll receive the account and must submit a Two-way claim to Medicare.
- Medicare processes its portion (75% of the MBS fee) and forwards the claim to GMHBA.
- GMHBA pays the remaining 25% of the MBS fee and forwards the full MBS fee payment directly to the doctor (or to you, by cheque, to forward to the doctor)
- You pay the remaining balance (if applicable) of the account, if it was more than the MBS fee.
What GMHBA covers in a contracted hospital
If you’re admitted to a hospital that has an agreement with GMHBA, we can pay benefits towards eligible hospital costs, including:
- your hospital accommodation and meals
- nursing care
- intensive care
- operating theatre fees
- Government-approved Medical devices and human tissue products (protheses)
We recommend you check our participating private hospital list to confirm that GMHBA has an agreement in place with the hospital where your medical specialist wishes to admit you.
What if the hospital isn’t contracted?
If the hospital you choose doesn’t have an agreement with GMHBA, we’ll still pay benefits, but only up to the standard amount set by the Government.
This often means you may have higher out-of-pocket costs; fees at non‑contracted hospitals are often higher than the default benefit. Depending on your policy and the type of admission, you may also need to pay an excess on admission.
Additionally, if your surgeon or anaesthetist charges above the Medical Benefits Schedule (MBS) fee or if the service you’re admitted for is excluded from your policy, you may still have out-of-pocket costs.