When you are admitted to hospital as a private in-patient, there are usually a number of different costs involved, such as:

Hospital Costs  E.g. the cost of theatre, in-patient accommodation, and use of the special care unit

Emergency Services Health has contracts with most private hospitals that are likely to be accessed by members. When members have treatment in a Contracted Hospital,  Hospital Fees are agreed in advance and paid by us, making it unlikely that you'll incur any out-of-pocket costs. However, if you choose to have treatment in a Hospital that isn't in contract with us, you may have to pay out-of-pocket for some of the Hospital Costs.

Health Insurance Excess The cost to claim on your health insurance

Emergency Services Health's Hospital Cover has No Excess so this is one less cost you need to worry about. However, if you've recently transferred to Emergency Services Health from another fund that did have an Excess on your policy, the Excess may still apply until you've served a 12 month waiting period.

Medical Costs  E.g. the cost of your treatment, such as the doctors fee, and the anaesthetists fee

When it comes to Medical Costs, Medicare will pay 75% of the Medicare Benefit Schedule (MBS) fee for each MBS item that makes up your eligible treatment. The Australian government holds the final authority in setting the MBS fees. On top of that health insurers, like Police Health, will cover the cost of the additional 25% for eligible treatment. Meaning 100% of the MBS fee is accounted for.  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 it often varies case by case. This is what creates a 'gap' payment for patients to pay out-of-pocket

Access Gap Cover
Emergency Services Health and other health insurers offer an Access Gap Cover program to help control out-of-pocket fees on Medical Costs. 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 specialists agree to use the Access Gap Cover program (which is done on a case by case basis), it eliminates, or substantially reduces, the out-of-pocket expenses of treatment for people with private health insurance.

Our Access Gap Cover arrangements are able to 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 the Access Gap Cover option when billing their patients, so we encourage members to discuss this option with their treating doctor as early as possible. 

Your doctor and health service providers must inform you of the costs of your proposed treatment and any potential out-of-pocket expenses, then get your consent in writing before you undergo treatment. If you’re not sure whether Access Gap Cover is being used, this is a good time to ask.

Recommendation
We strongly recommend members contact us on 1300 703 703 to confirm their Hospital benefit entitlements prior to receiving hospital treatment. Factors such as level and type of cover, waiting periods, and financial status of membership can affect benefit payments, so speaking to a member of our friendly team is the best way to get personalised advice for your situation. In terms of out-of-pocket costs, you will need to speak to your treating doctor or specialist to confirm these. Doctors are legally obligated to ensure Informed Financial Consent for all medical expenses prior to surgery, and this includes advising about out-of-pocket costs.