Going to Hospital
- Things to know...
What to do in the first instance
Going to hospital in an emergency
If you have an extended stay in hospital
Your rights and responsibilities as a private patient in hospital
(The Private Patients Hospital Charter pdf)
What to do in the first instance:
As soon as you know that you will need hospital treatment, we advise that you:
1. Contact us at ACA Health to find out;
- Your level of hospital cover, making sure you will be covered for the treatment you will be needing.
- Whether waiting periods will apply. ie. If you have recently joined the fund, you may not have finished your waiting period for particular types of treatments.
2. Ask your doctor(s) whether they are participating in the Access Gap Cover Scheme to bill for your treatment (Using the scheme may help you avoid or lower your out-of-pocket expenses).
3. Check that the private hospital is contracted with ACA Health Benefits Fund through the Australian Health Service Alliance (AHSA). Most hospitals are contracted with the fund, but you can check specifically by clicking on the hospital search link at the top right of this page.
All of this will determine the benefit you receive from ACA Health for your stay in hospital.
When it comes to out of pocket expenses, as a general rule;
>> If your doctor participates in Access Gap Cover - You will have no out-of-pocket medical expenses, or your doctor will tell you what they will be upfront.
>> If your doctor does not participate in Access Gap Cover - ACA Health is only permitted to pay the 25% not covered by Medicare of the Medicare Benefits Schedule (MBS) fee. So, if your doctor charges more than the MBS fee, you will have to cover that cost personally.
>> If your hospital is contracted with ACA Health - Your benefits will depend on your level of cover.
- With Deluxe Hospital Cover you will have nothing to pay for hospital accommodation in contracted hospitals, unless the hospital informs you otherwise.
- Co-payments will apply for Private Hospital Cover.
- With Basic Hospital cover you will most likely have significant out-of-pocket expenses for treatment in a private hospital.
>> If your hospital is not contracted with ACA Health - You may only be paid the default hospital benefits. Co-payments will apply for Private Hospital Cover.
Going to hospital in an emergency:
In an emergency situation, you will be taken to the nearest Accident and Emergency section of a public hospital, or private hospital if they have this facility.
In NSW or ACT, you are covered in full for ambulance transportation with hospital or general treatments cover. All other states, ambulance is covered only under the general treatment products.
If you go to an emergency department of a private hospital, you will find that this part of the hospital does not admit patients. Because the services are classed as "out-patient", ACA Health is not legally permitted to pay benefits on these services.
These fees are instead reimbursed as services to 'not admitted patients' by Medicare at 85% of the Medicare Schedule fee, as they are for a visit to your GP. Likewise, the 'gap' above the 85% on fees for services such as blood tests or x-rays performed in the emergency department cannot be claimed through ACA Health.
Many private hospitals also charge a 'facility fee' for attendance at their emergency department to help off-set the cost of establishing and running this high cost facility. ACA Health does pay a benefit towards this fee.
If, after emergency treatment, you require admission to the hospital, you would then be covered by your Hospital cover with ACA Health (provided all waiting periods are served and the treatment is covered by your hospital cover).
Having a baby:
Check with ACA Health Benefits Fund as soon as pregnancy is confirmed as to the level of your hospital cover and whether you are still under any waiting periods (12 months for obstetrics). You may need to upgrade to a family membership.
Single hospital membership for mothers covers the cost of the birth of the baby but doesn't cover any costs incurred by the baby. For a baby to be eligible for benefits immediately upon birth, the mother must have contributed to a family membership for at least 2 calendar months prior to the infant's birth, regardless of whether or not the infant is premature.
When you have a baby as a private patient in hospital you are an admitted patient of the hospital but generally your newborn baby is not an admitted patient. The newborn (who is nine days old or less) will only be an admitted patient if the baby:
- Is admitted to an Australian Government approved neonatal intensive care unit; or
- Is the second or subsequent baby born in a multiple birth; or
- Is in hospital without his/her mother.
As your baby will most likely not be an admitted patient of the hospital, it is important to note that, as an out-patient, Medicare pays the first 85% of the schedule fee and you must meet all costs not covered by Medicare - ACA Health is not permitted to pay benefits on these fees.
If you have an extended stay in hospital:
If your hospital stay is longer than 35 days and your doctor considers that you no longer need acute care, you will need to pay a contribution to your living costs in much the same way as nursing home type residents contribute to the cost of their care. The patient contribution is payable by public and private hospital patients and ACA Health is unable to pay benefits on this fee.
If your doctor considers that you still need acute care, you will not be required to pay a contribution to your living costs.
Deluxe and Private rates for hospital accomodation are limited to a maximum of 100 days per calender year. Basic Hospital accommodation rates apply thereafter.