Private Health Insurance Claim - GMHBA Hospital Guide

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STEP 6 - UNDERSTAND YOUR PROCEDURE AND COSTS
HOW DO I CLAIM IF I GO TO HOSPITAL?

How do I claim if I go to hospital?

When you go to hospital, it can be confusing to work out what can be claimed against your private health insurance, what can be claimed against Medicare, and whether there are any out of pockets. As a starting point, it’s important to understand the difference between hospital and medical costs.

Hospital costs

This is the cost of services provided by the hospital, and typically includes things such as the hospital accommodation, operating theatre fees and dressing and bandages.

Private hospitals

In a private hospital with health insurance - provided that the hospital you have chosen is on the GMHBA participating hospital list and your policy does not exclude this procedure, then all you have to pay for hospital costs is your excess and co-payments (if applicable). All other agreed costs are billed to GMHBA after you’ve gone home.

If you chose to have no excess or co-payments on your hospital cover, generally there will be nothing to pay.

Public hospitals

In a public hospital with health insurance - referred to as 'private patient in a public hospital' - provided your membership does not exclude the procedure then all you will have to pay towards your hospital costs is your excess if you have one. All other costs are billed to GMHBA after you've gone home.

Which hospitals are on GMHBA's "participating hospital list"?

Check the list of participating private hospitals. This is subject to change, so to be 100% sure, either ask the hospital, or contact us.

Medical costs

Medical costs are processed differently to hospital costs. The Medicare Benefit Scheme (MBS) outlines a list of procedures Medicare covers, as well as what they’ll pay towards it. When you have hospital treatment, your specialists’ bills are covered between Medicare and GMHBA. Medicare pays for 75% of the MBS 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.
How medical costs are paid depends upon whether or not your specialist is participating in the Access Gap Cover Scheme. Specialist doctors who are registered for, and use, the Access Gap Cover scheme get a higher fee from GMHBA (more than the standard 25%), in exchange for limiting the gap they charge to you. There are 2 scenarios for how you may be billed by your specialist doctor when they use the Access Gap Cover scheme:
1 – No Gap: this is where there will be no gap for you to pay following the procedure
2 – Known Gap: this is where you will be charged a maximum gap of $400 for each Medicare item number and $800 for obstetrics services You can find out if your specialist is participating by asking them prior to treatment.

If your specialist is participating in Access Gap Cover	If your doctor is not participating with your health insurer
The bill for your medical costs is sent to GMHBA, processed and then sent to Medicare. Medicare and GMHBA pay their portion directly to the specialist. The specialist sends you a bill for whatever is not covered by Medicare or GMHBA. These are your out of pocket expenses.	If your specialist does not participate in Access Gap Cover, they will bill you before or after your hospitalisation. If they bill you before you go to hospital: Once you have left hospital you can submit your accounts to Medicare. Complete a Medicare Two Way form and Medicare will share your accounts with GMHBA for processing. You can also send your Medicare statements into GMHBA with a signed claim form for processing. If you receive a bill after going to hospital: You complete a claim form and send the medical statements to GMHBA, you will be sent cheques for payment. You send these cheques and the Medicare cheques to your doctor. The doctor sends you a bill for whatever is not covered by Medicare and GMHBA. These are out of pocket expenses.

If your specialist is participating in Access Gap Cover

If your doctor is not participating with your health insurer

The bill for your medical costs is sent to GMHBA, processed and then sent to Medicare.
Medicare and GMHBA pay their portion directly to the specialist.
The specialist sends you a bill for whatever is not covered by Medicare or GMHBA. These are your out of pocket expenses.

If your specialist does not participate in Access Gap Cover, they will bill you before or after your hospitalisation.

If they bill you before you go to hospital:

Once you have left hospital you can submit your accounts to Medicare. Complete a Medicare Two Way form and Medicare will share your accounts with GMHBA for processing.

You can also send your Medicare statements into GMHBA with a signed claim form for processing.

If you receive a bill after going to hospital:

You complete a claim form and send the medical statements to GMHBA, you will be sent cheques for payment.
You send these cheques and the Medicare cheques to your doctor.
The doctor sends you a bill for whatever is not covered by Medicare and GMHBA. These are out of pocket expenses.

Which doctors are participating with GMHBA?

Specialists can opt to use the Access Gap Cover Scheme on a case by case basis, so it's best to confirm with them directly. If they aren't registered you can ask whether they would be willing to participate and you can also contact us to check whether they have previously registered to participate in the Access Gap Cover Scheme.