On this page
- Medicare Benefits (MBS) fees
- Access Gap Program
- Inpatient vs outpatient
- What your Gold Hospital cover pays for
Medical costs
Medicare Benefits (MBS) fees
When you are admitted to hospital as a private patient, Medicare will pay 75 per cent of the Medicare Benefit Schedule (MBS) fee for each MBS item.
The Australian government holds the final authority in setting the MBS fees. On top of that health insurers like Police Health will pay the additional 25 per cent.
However, doctors and health care providers are free to charge more than the MBS fee and many do.
There is no cap on the amount a doctor or health care provider can charge for their services, and when they do you will need to pay it.
Access Gap Program
To help combat this, Police Health and other health insurers offer an Access Gap Program.
Access Gap cover has its own set schedule of fees, where private health insurers have agreed to pay above the MBS fee set in the Medicare Schedule and doctors are able to choose to bill health fund members at the Access Gap Schedule amount, reducing the out of pocket medical gap for their patient.
When doctors and specialist agree to use the Access Gap cover program (which is done on a per patient basis), it eliminates, or substantially reduces, the out-of-pocket expenses of treatment for people with private health insurance
Our Access Gap Cover arrangements can be used by all doctors around Australia and in most cases, our members will be fully covered or have a known-gap for any in-hospital medical treatment.
However, it comes down to the doctor to choose Access Gap Cover option for their patients.
Inpatient vs Outpatient
It’s very important to know the difference between being an ‘Inpatient’ and ‘Outpatient’.
It will show you when you’ll be covered by Medicare, Police Health, or when you’ll need to pay for something yourself.
Inpatient
An inpatient is when you’ve been formally admitted to a hospital for overnight surgery (like if you need a knee replacement) or day surgery (such as arthroscopies or endoscopies).
You can also be classified as an inpatient if you’re admitted to a registered day clinic by a doctor, and receiving short term medical treatment, like cataract removal, colonoscopies and skin cancer removals.
There are two ways you can be admitted as an inpatient: through an emergency or a pre-booked surgery, or treatment by a doctor.
Who pays when you’re an inpatient?
If you’re admitted to a private hospital as a Police Health member with Gold Hospital cover or Gold Combined cover, you’ll be covered for all treatments and procedures where Medicare pays a benefit.
You can read more about what Gold Hospital covers below.
However, we can provide benefits for inpatient services that are only recognised by Medicare.
Why? Because the Private Health Insurance Act says so.
What happens when you visit the emergency department?
You will only be classified as an inpatient if you have been formally admitted to the hospital for medical treatment following your visit to the emergency department.
Any medical services you receive in a private hospital emergency department are outpatient services, and not covered by Police Health.
In private hospitals, an emergency facility fee is charged which is not covered by Medicare, and therefore not private health insurance, regardless of whether you’re admitted for further medical treatment in that hospital.
Some hospitals may choose to waive this fee at their discretion.
Outpatient
You’re an outpatient if you receive treatment at a doctor’s office, clinic, or emergency department (without being admitted).
Examples include GP visits, specialist consultations, scans, injections, and minor procedures in clinics.
Who pays when you're an outpatient?
Medicare, but if you’re not bulk billed you’ll most likely have to pay something.
Medicare will pay 85% of the Scheduled Fee for these services, and you pay the remaining 15%.
An exception to this is visits to your GP. Medicare pays 100% of the Scheduled Fee for these appointments, and you will only have to pay anything if the GP charges above the Scheduled Fee.
Why doesn't Police Health help? Well, by law private health insurers aren’t allowed to cover outpatients’ consultations or treatments.
What your Gold Hospital cover will pay for
Police Health’s Gold Hospital covers you in any recognised hospital or day-surgery of your choice (public or private) anywhere in Australia for the following;
- Theatre fees/labour ward
Covered for eligible treatments in recognised hospitals - Hospital accommodation
Covered for intensive/coronary care accommodation, same day hospitalisation and day surgery accommodation, in either a private or shared room (subject to availability) for eligible treatments in recognised hospitals. Subject to the 35 day hospital rule - Drugs supplied
Covered when related to the reason for admission in hospital and covered under the agreement we have with the hospital. Some high cost drugs are excluded. Public hospitals generally supply medication without charge - Doctor’s fees for hospital treatment
At a minimum, we will cover the difference between the Medicare rebate and the Medicare Benefits Schedule (MBS) Fee. If your doctor chooses to use the Access Gap Cover schedule of fees, we can cover up to 100% of the doctor’s agreed fee. See above for more details
Still need help?
What's the hospital 35-day rule?
Hospital benefits are payable 365 days a year. However, if your hospital stay exceeds 35 consecutive days you must obtainand send us an Acute Care Certificate to continue receiving comprehensive benefits.
Benefits will be reduced and out of pocket expenses apply where an Acute Care Certificate is not obtained. The hospital is aware of this and will usually arrange a certificate on your behalf.