Welcome to Bupa Your Important Information Guide - Health Insurance
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Welcome to Bupa Your Important Information Guide Health Insurance
Effective 1 December 2020
We believe that life is a gift
In everything we do, our focus is to make your life longer, healthier and happier.
That’s why we offer a broad range of services and support to take care of your health and
wellbeing. From the protection of health, travel, car, home and pet insurance to the reassurance
of access to aged care and accredited healthcare providers. Plus, a range of projects, tools and
programs to promote health, wellbeing and sustainability in the community.
Health Insurance Other Insurance Villages & Aged Care Community Health Services
As one of Australia’s leading We support you when We are one of Australia’s We’re also taking care of our Whether you’re after
health insurers, we have you need it most, through largest residential Aged Care community with projects, dental care, an eye or
agreements with most a range of other insurances, providers, offering a range tools and programs to hearing check, we’re all
private overnight and day including pet, car, travel of respite, residential and promote health, wellbeing about giving you the
hospitals, plus a huge Extras and home and contents specialised dementia care. and sustainability. We’re personalised help and
network so you’ll know insurance. We help ensure your older sharing our wealth of advice you need quickly
you always have lots of family members continue knowledge through our and easily. That’s why we
to enjoy life, while having
affordable choices. online health resource have accredited healthcare
access to support when
Bupa Health Link, and providers, who focus on Stay up to date
they need it.
innovative health tools like preventative health, Click the links below to
mummatters and the Stroke and are always there visit Bupa online.
Foundation’s enableme. when you need them.
We’re also helping to
bupa.com.au
fund breakthrough
medical research that
enables real health and
Bupa Twitter
care improvements for all
Australians through our
Bupa Health Foundation.
Bupa Facebook
Bupa YouTube
2 3
Effective 1 December 2020
We get it.
Health insurance can be confusing.
That’s why we’ve designed this guide to explain how it works generally. Your membership 6 Members First providers 41
It applies to anyone with full access to public healthcare (from Medicare).
Health insurance explained 7 Extras waiting periods 42
This includes Australian citizens, permanent residents and some of those in
the process of applying for permanent residency. Private health insurance reforms 8 Claiming for Extras 42
If you need more specific information, like the services you’re covered for on Switching from another insurer 9 Knowing your claim limits 44
your policy, please check your policy information. Changing your existing Bupa cover 10 Restrictions on making claims 45
If you’d prefer to speak to us in person, call 134 135 (or +613 9487 6400 Your toolbox 11 Special types of Extras services 47
if you are overseas). Going to hospital 12 Making an Extras claim 50
This guide does not replace the Bupa Fund Rules, which outline the terms Hospital waiting periods 13 Accident cover 52
and conditions of your cover and are available here.
Costs of going to hospital 14 Health cover and accidental injuries 52
Please read this guide carefully and keep it available for reference.
Deciding whether to go to hospital 24 Paying for your health cover 54
Choosing a hospital 25 Community rating 55
Choosing a private hospital 26 Why your premium goes up
every year 55
Choosing a public hospital 28
Late and overdue payments 56
Choosing a specialist 30
Government policies and tax
Reducing your medical costs 32
considerations 58
Potential ‘out of pocket’ costs 34
Things to note 62
Paying your hospital expenses 36
Privacy and personal data 63
Your Extras cover 38
Health cover and overseas travel 64
Understanding Extras cover 39
Suspending your membership
Choosing your provider 40 when you go overseas 65
Complaints and feedback 66
4 5
Effective 1 December 2020
Your membership Health insurance explained
Whether you’re new to Bupa, have switched from As Australians, we’re lucky enough to have access to a quality, public health
another insurer or want to change your cover with system. But this system has its limitations. For example, it doesn’t cover all
us, read on to find out what your next steps are. treatments and services, and limits things like where and when you’re treated.
Private health insurance means:
1. M
ore control if you need to go 4. Y
ou could avoid or minimise the
to hospital for a non-emergency Lifetime Health Cover (LHC) loading if
procedure. You’ll have more choice when you’re 31 or over and don’t have hospital
it comes to your hospital, your specialist cover. The LHC loading is a Government
and when you’d like your procedure to initiative designed to encourage
take place. You might also be able to Australians to take out hospital
request a private room. insurance earlier in life. If you don’t have
hospital cover by July 1 following your
2. R
educed wait times for non-emergency 31st birthday, but then decide to take it
hospital procedures (like having your out later in life, you’ll pay a 2% loading
tonsils out) at a private hospital. If on top of your premium for every year
you’re not privately insured, you might delayed (up to a maximum of 70%).
have to choose between being on a This extra loading remains in place for
public hospital waiting list for months 10 years. For example, if you delayed
(sometimes over a year)+ or paying a getting hospital cover for 3 years after
hefty fee to go to a private hospital. you turned 31, you’ll pay an additional
6% on top of your premium for the next
3. The ability to claim money back on 10 years.
some everyday health services that may
not be covered by Medicare, such as 5. T
ax time savings Depending on your
dental and physio. Depending on your income, you may have to pay an extra
cover, you may even be able to claim 1-1.5% tax (on top of the Australian
money back for services like remedial Government’s Medicare Levy) if you
massage and acupuncture. don’t have appropriate hospital cover
for you and all your dependants over
the whole year. That’s similar to the
cost of some of our hospital covers. The
Government will also contribute to the
cost of your premium – this is known as
a ‘rebate’. The amount is based on your
age and income and you can choose to
get it as a reduced premium or offset in
your tax return.*
+ Source: Australian Government Institute of Health and Welfare Report: Elective surgery waiting times 2017-18. * Current rebate
percentages are effective for payments made from 1 April 2019 and are indexed annually. The income thresholds will remain the same
from 1 July 2015 until 30 June 2021. On a family or single-parent membership, income thresholds increase by $1,500 per child after the
6 first. The family thresholds also apply to single parent families and de facto couples. For more information go to ato.gov.au 7
Effective 1 December 2020
Australian Government private Three things you need to know when
health insurance changes moving to Bupa from another fund
From April 2019, the Australian Government introduced a number of changes to
private health insurance. These changes aim to make health insurance easier to
understand when it comes to comparing your health cover with other insurers. 1. Making your move 3. Making a claim
When you join Bupa, an information When it’s time to make your first claim,
Here’s a quick guide on the changes exchange takes place between us and like a trip to the opticians for example,
Age-Based Discount Changes to natural therapies your previous fund. This exchange tells you have three options to pick from:
If you’re aged 18-29, you are entitled The mandatory reform to natural therapies us your claims history including any
to receive an Age-Based Discount on means that all health insurers are no longer waiting periods you may have served, Online
your Bupa Hospital cover. This is an able to pay benefits for certain therapies provided to us as a clearance certificate Log onto myBupa and enter
optional reform that Bupa chose to adopt. on Extras cover. Bupa will continue to from your fund. This can take up to 14 the details found on your
The discount is calculated at 2% for each pay benefits for acupuncture, Chinese days, in which time you may not be able receipt. We’ll transfer the
year you’re aged under 30. The maximum herbalism, and massage therapy including to make a claim. payment directly to your bank
discount is 10% for 18 to 25 year olds. remedial massage, myotherapy and account.
Once we receive this information,
Traditional Chinese Medicine we’ll recognise the level of cover you
Once you’ve received your Age-Based
remedial massage. had, carrying over any remaining limits On-the-spot
Discount, you’ll retain that discount until
such as optical on your Extras cover. Where on-the-spot claiming
you turn 41, if you hold Hospital cover
If you want to be covered for is available, simply swipe your
with us. From 41 years of the age the
Learn more about something new or to a new amount, membership card. No forms,
discount will reduce 2% each year
these changes a waiting period may apply. and you’ll only pay the
until it reaches 0%.
remaining balance.
Gold, silver, bronze and basic tiers,
and standard clinical definitions By post
You may notice that from 1 July the name Fill out a claim form, attach
of your Hospital cover includes the words your invoice and receipt and
gold, silver, bronze, or basic. This refers post it to us. We’ll make the
to the Hospital product tier your cover payment by bank transfer or
falls into. There are set minimum hospital cheque.
services which need to be covered within 2. Private Health
each product tier. Where an insurer has Insurance Rebate
chosen to provide more than the minimum You might be asked to complete an
requirement, you’ll see the word “Plus” in One last thing
Australian Government Rebate Form You can also claim for hospital and
your tier. and you can do this by logging in to medical costs. If you go to a hospital
In addition, all health funds are required to myBupa.com.au. that has a network agreement with
use the same standard clinical definitions This may help to reduce the cost of Bupa, you may not even see a bill.
when referring to in-hospital treatments your health insurance premiums based
for your health cover. If you do receive a bill, send it to
on your income. us with a claim form attached. If you
Your premiums could go up if we need more information about your
don’t receive the form within 30 days. new membership visit,
Don’t worry though, you can claim the bupa.com.au/your-membership
cost back with your tax. or call 134 135
8 9
Effective 1 December 2020
Changing your Your toolbox
existing Bupa cover There are a few quick steps to complete to make sure you get the most
out of your new Bupa membership.
Your Bupa card myBupa
It will arrive shortly after you join and: mybupa.com.au is our online portal.
• Contains your membership number Once you register, simply log in using
and a list of the people who are your secure log-in details to:
covered by your policy. • Access your policy documents and
• Allows you to make on-the-spot tax information.
claims when you have received a • Submit an Extras claim and see your
treatment or service from many of claim history.
our recognised Extras providers, such
as a dentist or physio. • Update your personal details.
• Is used as identification if you are • Access exclusive health tools and
Here’s what you need to know admitted to hospital. discounts.
1. You may not be able to claim 3. Your Extras limits will transfer • Helps you to redeem member
new additions straight away All insurance policies have limits on discounts in person.
If your new Bupa policy covers the amount of money you can claim. Check these out here.
services that your old policy didn’t, or It might be per month, year, by family
allows you to get more money back, or over an individual’s lifetime. These
there might be a waiting period that limits are transferred when you
you’ll need to serve before we will change your Bupa cover. For example,
pay claims for the additional services, any claims you have already made Our team
or you may only be able to claim that year will count towards your new Small changes to your circumstances
the lower amount until your waiting yearly limit. (like new contact details or payment
period is up. information) can be made online at
4. You have a 30 day mybupa.com.au Bigger changes, like
2. Lower levels of cover cooling-off period adding or removing people from your
apply immediately If you want to reverse any change cover or moving interstate can affect the
If you have chosen to change to a to your cover, you can reverse the cost and level of cover, including things
lower level of cover, the lower level change within 30 days, as long as like ambulance services. In these cases,
of benefits will apply immediately. you haven’t claimed. After 30 days, you’re best to speak to us to ensure your
you can change your cover back, but cover is still appropriate. We can also
it will only apply from the day you clarify what your cover includes.
requested to change it back. If you are
going back to a higher level of cover,
• Call us on 134 135
you may need to wait before you can • Find a local Bupa Health
use any extra benefits. Insurance store here
10 11
Effective 1 December 2020
Going to hospital Hospital waiting periods
In this section, you’ll find out how to navigate going to When you first take out or upgrade health cover there’s a period of time before
hospital – from deciding where to go, to choosing you can make a claim on your new level of cover. This is common across the health
your hospital, specialists and more. insurance industry and is known as a waiting period.
You can’t claim for services during a waiting period. Once the waiting period is over,
you’ll only be able to claim services from the date the waiting period ends.
Different waiting periods apply to different hospital services:
Service/Treatment Waiting period
Emergency ambulance and on the spot treatment None
Accidents that occurred after joining Bupa None
Palliative care, rehabilitation and hospital psychiatric services* 2 months
All other treatments included in your cover 2 months
Pre-existing conditions, ailments or illnesses 12 months
Pregnancy and birth services 12 months
Pre-existing conditions Planning for a baby
A pre-existing condition is any condition, If you are thinking about starting a family
ailment or illness that you had signs we recommend that you contact us to
or symptoms of during the six months check in advance whether your current
before you joined or upgraded to a level of cover includes pregnancy and
higher level of cover with us. It is not birth services. This is because there’s a
necessary that you or your doctor knew 12-month waiting period for this.
what your condition was or that the
No waiting periods apply to a newborn
condition had been diagnosed.
provided they have been added to your
If you knew you weren’t well, or had level of cover within 90 days of their birth.
signs of a condition that a doctor would
have detected (if you had seen one)
during the six months prior to joining or
upgrading, then the condition would be
classed as pre-existing.
A doctor, appointed by us, decides
whether your condition is pre-existing,
not you or your doctor. The appointed *Existing members: If you need
doctor must consider your treating to discuss how you’re covered for
doctors’ opinions on the signs and urgent mental health treatment
symptoms of your condition, but is in-hospital, please contact us.
not bound to agree with them.
12 13
Effective 1 December 2020
Costs of going to hospital
What you might have to pay and what can be covered
The five types of costs you might encounter during your hospital stay: Hospital costs Prostheses costs
Charges related to staying in the The cost of items that are surgically
actual hospital such as the use implanted in hospital. For example,
of the bed, food and operating artificial hips or cardiac devices like
theatre, plus nursing and allied pacemakers.
health services.
• Y
ou’re covered for all prostheses
• H
ow you’re covered for hospital on the Australian Government’s
costs when you’re admitted as Prosthesis List, up to the value
Hospital Medical Prostheses Pharmacy Emergency
an ‘inpatient’ depends on your stated on the list.
costs costs costs costs ambulance costs
choice of hospital.See page 25
for more details. Check with your
The next few pages will help you understand the type of costs you might encounter doctor whether your treatment
during your hospital stay (assuming you are covered by your policy for the treatment will require you to be admitted
you’re receiving in hospital and that you have served all relevant waiting periods). to hospital.
Medical costs before you go to hospital • D
epending on your level of cover,
In the lead-up to a hospital admission, customers will generally need appointments with we might also pay some of the
their GP and/or specialist(s). There may also be a need for tests such as blood tests, costs for a partner, immediate
x-rays, etc. Under health insurance legislation, we are not permitted to cover these family member, carer or next of
appointments through health insurance, so please check with your GP and relevant kin to stay in hospital with you.
specialist for the exact costs, as these will be your out-of-pocket costs to pay. • If a treatment is listed as having
‘restricted cover’ on your policy
Knowing your hospital costs before you’re admitted information, we pay less toward
If you are in hospital for a pre-booked admission, it is important that you make your hospital costs. This means
sure that the hospital or specialist tells you the costs that you can expect to pay you’re likely to have more to pay
yourself, after we have paid our part of your costs. The hospital should make sure they for these services. You can read
get your consent for these costs before you’re admitted. If you have anything to pay more about restricted cover on
yourself, and need clarification, please contact us directly. page 34.
14 15
Effective 1 December 2020
Medical costs How fees for medical Pharmacy costs • To be eligible, all waiting periods must be
treatments are set served and your membership payments
The fees charged by a surgeon, physician, The cost of prescribed medication
• The Australian Government recommends must be up to date at the time you
anaesthetist, or other medical specialist provided to you, or purchased by you, for
the fees for medical services. However, a receive the medication.
when they are treating you in hospital. treatment of your condition. This includes
doctor can charge more than this.
pharmaceuticals listed on the Australian By your Extras cover
• We make arrangements directly
Find out more about how the Government’s Pharmaceutical Benefits
with specialists, separate from our This is medication you purchase when
Australian Healthcare system works. Scheme Schedule (PBS), and, in some
arrangements with hospitals. This means you’re not in hospital or once you’ve left
cases, non-PBS ‘High Cost Drugs’. hospital, as well as unopened medication
your specialists will bill separately, and How medical costs are covered
in addition to, what the hospital bills for Pharmaceuticals listed on the PBS might be provided to you when you are discharged
• Medicare and Bupa both pay a portion
your stay. covered in one of two ways: from hospital. Go to page 48 for more
of the fee for medical services set by the
Australian Government (75% and 25% information.
By your Hospital cover
respectively). However, your specialist
This is medication you take in hospital
may choose to charge more than the
(not discharge medications) required to
set fee. This means you would have a
treat and manage the condition for which We do not cover:
‘gap’ to pay yourself. The Bupa Medical
you are in hospital. In most cases, these • Over the counter or non-prescription
Gap Scheme is designed to eliminate or
medications are fully covered by our pharmacy items.
minimise the amount you’ll have to pay in
hospital agreement – this just means that
cases like this. Go to page 32 for • Compounded medications, which
the hospital will bill Bupa directly and you
more information. are mixed from the individual
won’t have to make a claim.
ingredients to the strength and
• Remember, you might have to see
• If you’re at a private hospital with a dosage required for an individual.
multiple specialists for one procedure.
Bupa agreement, we pay some of the • Body enhancing medication
cost of medications that are not on the (e.g. anabolic steroids).
Discover the average PBS (known as High Cost Drugs), if they
cost of your procedure are provided to you in hospital and are • Weight loss medication.
Use our handy online tool approved by the Therapeutic Goods • Medication provided by the hospital
to find out more. Administration (TGA) for the treatment that isn’t essential to your care.
of your specific condition.
16 17
Effective 1 December 2020
Emergency ambulance costs
The costs associated with transport services (via air or road) from the place
where you are treated, to the emergency department of a receiving hospital.
There are two main categories of ambulance services:
Emergency Non-Emergency
For unplanned events where your life For times where you may use an
may be at risk and you need medical ambulance but don’t need treatment
treatment immediately. straight away, or your life is not at risk.
For more information about what we For example:
define as an emergency, read our fund •
Transport from a hospital to your
rules here. home or nursing home.
•
Transport to a hospital, your home, or
nursing home for ongoing treatment,
like dialysis or chemotherapy.
•
Where you’ve been admitted to one
hospital and need to be taken to
another (the hospital should include
this in the cost of your procedure).
What you’re covered for depends on your cover type:
Cover type
Basic, bronze and Gold tier and selected Premium Ultimate Health
selected silver tier silver tier Hospital Ambulance Cover and Ultimate
Hospital covers, most covers, Corporate Cover Corporate
Extras covers Hospital Cover & Health Cover Only
Emergency Only
Ambulance Cover
What’s included per calendar year
NSW/ACT Hospital Cover
• Emergency Cover only • Unlimited • Unlimited • Unlimited
Through the cost of your Hospital Cover,
• 1 service for Singles Emergency Cover Emergency Cover Emergency Cover
Bupa collects a levy which contributes
• 2 services for • Up to $5,000 Or, we’ll refund the
towards a NSW/ACT State Ambulance in Non-Emergency costs of an Ambulance
Couples and Families
Scheme. As a part of this scheme you per person subscription from our
recognised provider
are provided with uncapped emergency
in your state (VIC, SA,
transportation when provided by and NT only).
NSW/ACT Ambulance within the state.
18 19Effective 1 December 2020
Ambulance services across states
When it comes to ambulance services, each state is different. You should consider
what you’ve chosen to be covered for, the state you live in and whether you need
cover interstate. The below table compares your options.
State you normally live in Options at home Options while interstate
ACT
Private cover
NSW
VIC
Private cover OR
NT
A subscription
Country WA
Metro WA & Norfolk Island Private cover
When can I use my Ambulance cover?
1. When you can’t claim the costs from another source. For example, when your
Private cover OR State Government doesn’t cover you and you can’t claim from a subscription or
SA
an SA Ambulance subscription Government levy. See page 35 for more information.
2. If your ambulance service was provided by our recognised provider in the state
The Government The Government covers you, you had that service. These are listed in the table below.
TAS
covers you at home except for in QLD and SA
QLD The Government covers you everywhere in Australia
State you normally live in Recognised provider State subscription available
VIC Ambulance Victoria
It’s worth noting that some states:
SA SA Ambulance Service
ffer free or subsidised ambulance services to pension and concession
O
card holders. Check your State Government website for more details.
NT St John Ambulance
Have agreements with other states to cover their residents, and vice versa.
What’s covered under these agreements varies, so if you travel interstate Country WA St John Ambulance
frequently, it might be worth considering private cover or a subscription.
Metro WA & Norfolk Island St John Ambulance
ACT ACT Ambulance Service
NSW Ambulance Service of NSW
TAS Tasmanian Ambulance Service N/A
QLD QLD Ambulance Service N/A
20 21Effective 1 December 2020
How do I pay my ambulance costs?
If you receive an invoice for ambulance services, and you’re covered for ambulance,
the table below will show you what to do. If you need to send the invoice to us,
check page 50 for how to claim.
State you normally live in What do I need to do?
Send the invoice to us. We’ll either organise it with your State
ACT
Government, or pay it ourselves.
Send the invoice to us. We’ll either organise it with your State
NSW
Government, or pay it ourselves.
SA
If it is included in your subscription
– send it to them to pay it.
VIC
If it is not included in your subscription
– send the invoice to us.
NT
There’s nothing for you to pay. Send the invoice to
QLD
the Queensland Government to pay.
If you have the service in QLD or SA
– send the invoice to us.
TAS
Otherwise, send it to the Tasmanian
Government for payment.
If included in your subscription,
send it to ‘St John’s Ambulance’ to pay it.
Country WA
If it is not included in your subscription
– send the invoice to us.
Metro WA & Norfolk Island Send the invoice to us.
22 23Effective 1 December 2020
Deciding whether to go to hospital Choosing a hospital
Sometimes you need to go to hospital, and other times you might not. 1. Consider what you’re covered for
For example, if you injure your shoulder, you might be able to manage the The amount that we will pay is determined by your level of cover
injury through physio or other treatments rather than surgery. (your policy), the agreement that Bupa has with the hospital you go to,
and whether or not you’ve served the relevant waiting periods.
2. Choose whether or not to go public or private
If you have private hospital cover with Bupa, the choice is yours.
When deciding, consider our range of You might make your decision based on location, familiarity, cost,
urgency or a range of other factors.
health programs designed to:
Here’s a summary of your hospital options
Network Fixed Public hospital
Members First & Network & Non-agreement
Improve your health Benefit
Day hospitals Day hospitals
Fee & Day
hospitals
hospitals Private patient Public patient
Choice of
hospital
Empower you to make informed
choices about your health and care Choice of
specialist
Reduced
waiting time
Ensure that you receive the right care,
in the right place, at the right time
Covered
for hospital Most Limited Limited
costs By Medicare
Some of these programs might help you with your
condition or injury, without a trip to hospital.
Private room
guarantee
(overnight)*
Find out more
Covered for
extra services Some
and benefits
New travel and accommodation benefit
We can now help cover the costs of your travel and accommodation expenses, Explore our
if you need to travel 200km or more for medically essential treatment not hospital network
available in your local area. The benefit is per person, per trip (limits apply),
and can be used as many times as needed throughout the year. If you have an
* ‘Private room or money back guarantee’ means that, at our Members First hospitals, you’ll receive a private
extras cover with us, we’ll only pay the travel and accommodation benefit on room when you book and request one at least 24 hours before the overnight admission. If a private room is
your hospital cover. See your policy information for more details. not available, you’ll receive $50 back, per night, from the hospital. You’ll also receive a complimentary daily
newspaper and complimentary local calls. Applies to overnight admissions only. Excludes ‘nursing home type
24 patients’, emergency care same-day or occasions where a private room is medically inappropriate. 25Effective 1 December 2020
Choosing a private hospital
Private hospitals do vary in cost and the facilities they provide. If cost is important
to you, make sure you choose a hospital that has an agreement with Bupa. Please note: You may still experience out-of-pocket
Provided your cover includes private hospital cover for the treatment you need, and costs for specialist fees. To help reduce your medical
you’ve served your waiting periods, the table below will help you choose a hospital. costs, consider the Bupa Medical Gap Scheme.
These costs and benefits are based on you being admitted to that hospital as a patient. Visit bupa.com.au/medicalgapscheme for more.
Hospital costs and benefits by hospital type
Type of hospital Cost to you Member benefits Important to note Type of hospital Cost to you Member benefits Important to note
Members First Low – In most instances Our ‘private room or To take advantage of the Members First Day Low – In most instances You will pay nothing for We now have over 80
hospital you’ll be covered for money back guarantee’.* ‘private room or money hospital you’ll be covered for your treatment by a specialist Members First Day
hospital costs. Plus, complimentary daily back guarantee’,* you’ll hospital costs and there at these hospitals. Hospitals.
newspaper, local phone need to book and request a will be no gap to pay on You will also receive (Not available in NT)
calls and free-to-air TV. private room in a Members your specialist’s fees. complimentary local
If pregnancy and birth First hospital at least 24 phone calls and free-to-
services are included in hours before admission. air TV.
your cover, you get:
We have over 100
• child-birth, Members First Hospitals. Network Day Low – In most instances Complimentary local
breast-feeding and you’ll be covered for your phone calls and
parenting education
hospital
hospital costs. free-to-air TV.
classes
• postnatal clinics for
up to 8 weeks after you
leave hospital
Non-agreement High – These hospitals None. You will be If you attend one of these
and day hospital haven’t entered into any responsible for the cost hospitals, you are likely
• parental support agreement with Bupa, of your stay and may to encounter significant
services. meaning we only cover be charged directly expenses.
minimal costs. for your hospital
You will not be able to
accommodation,
use the Bupa Medical Gap
Network hospital Low – In most instances You will be covered The ‘private room or surgically implanted
Scheme at these hospitals
you’ll be covered for for a private room if money back guarantee’ prostheses and personal
to lower your out of pocket
your hospital costs. you request one. Plus, does not apply.* expenses such as TV
medical costs. This means
complimentary local hire. Some of these
the costs for you to pay
phone calls and hospitals bill Bupa
could be higher at
free-to-air TV. directly for the limited
these hospitals.
benefits we pay.
If your specialist/s
Network hospital Medium – You may be You will be covered for At some of these hospitals,
charge more than what
with a fixed fee charged a fixed daily a private room if you a fixed fee applies to
we pay (with Medicare),
fee and generally be request one. You’ll also all services offered. At
There’s only a small you’re likely to have
covered for your hospital receive complimentary others, a fixed fee applies
number of these. some medical costs
costs (this fee does local phone calls and to either a psychiatric or
to pay yourself.
not apply if you are on free-to-air TV. rehabilitation service only.
Ultimate Health Cover). This fee is capped at a
maximum number of days
per overnight stay. The Find Members First or
fixed daily fee charged Network Hospitals near you
by the hospital is in
addition to any excess or * ‘Private room or money back guarantee’ means that at our Members First hospitals, you’ll receive a
co-payment you may need private room when you book and request a private room at least 24 hours before the overnight admission.
to make. If a private room is not available, you’ll receive $50 back per night from the hospital. You’ll also get a free
daily newspaper and free local calls. Applies to overnight admissions only. Excludes ‘nursing home type
26 patients’, emergency care same-day or where a private room is medically inappropriate. 27Effective 1 December 2020
Choosing a public hospital
As a Bupa member attending a public hospital, you can choose to be treated
as a public patient or as a private patient. Each has its pros and cons.
Public patient in a public hospital
Things to remember What should I ask
Pros • The cost will usually be covered by Medicare.
before choosing the hospital before
public I decide?
• You won’t be able to choose who treats you or when you’re treated.
• You will be subject to public waitlists which can be lengthy 1. The choice is yours “What are the benefits to me
Cons – sometimes over a year long.
If you need to be admitted to a public if I choose to use my private
• Your procedure may be postponed if more urgent cases come up. hospital, the hospital will provide you with cover?"
• You are less likely to get a private room.* a form where you will elect to be admitted
as a private or a public patient. The
hospital must clearly explain what both “Will there be any difference
options mean for you. to my care if I use my private
cover?”
Private patient in a public hospital 2. Once you’re admitted, the choice is made
Once you decide whether to be a private
or public patient, it applies to your whole “Can I choose my doctor?”
• You’ll get your choice of your doctor, if they are available. admission. It generally can’t be changed,
• We’ll pay the cost of you staying in a shared room. except in unforeseen circumstances. “Can you ensure I will have a
(This amount is set by the Australian Government).
private room for my entire stay?”
• If a private room* is available and you choose to stay in it, Bupa may
Pros cover some of the additional cost of this, depending on your level of cover.
If this won’t cover all your costs, the hospital should let you
know the amount you will need to pay.
• We’ll contribute to the cost of prostheses and specialists as we would
if you were treated in a private hospital.
Keep in mind
A hospital should not ask you to
• You may still be subject to public hospital waiting lists. charge your stay to your private cover
• Depending on your illness or condition, you may get the same doctor after you’ve already elected to be a
who would have been allocated to you if you were a public patient. public patient. There is no need for
Cons
• You’ll be responsible for personal expenses such as TV you to do this. If you were to do so,
and telephone calls. you may have out of pocket costs for
• You may experience out of pocket expenses. your treatment.
* A private room in a public hospital is a room in a hospital which is purpose built and suitable
for no one other than a single admitted adult patient; holds one single sized bed; and has a
28 dedicated ensuite. 29Effective 1 December 2020
Choosing a specialist
Questions to ask when choosing your specialist
You are entitled to be fully informed about your specialist and any
associated costs before you start your treatment. Here are some
questions that will help you make your decision.
Once you’ve had your Ask your GP:
initial consultation with “Can you refer me to a specialist who
your GP, ask Bupa: uses the Bupa Medical Gap Scheme?”
Can you provide me with a list of
“ “Can you refer me to a specialist who
specialists who use the Bupa Medical can treat me in a hospital that has an
Gap Scheme?” agreement with Bupa?”
“Can these specialists treat me in a Attending a private hospital that Bupa
If you have private health cover, you have more choice as to which specialist
hospital that has an agreement with has an agreement with could help to
treats you. It’s important that you feel informed before you make this decision.
Bupa, and which hospitals are they?” reduce your hospital and medical costs.
As with your choice of hospital, your decision may be based on factors such as
cost, reputation, how often they’ve conducted your surgery, their location and
how comfortable you feel with them. You should also discuss with your GP
whether the recommended specialist is appropriate for your needs.
Medical costs
These are the fees charged by a doctor, surgeon, anaesthetist, or specialist
when they are treating you in hospital. The level of cover we provide for
medical costs depends on what fee the specialist decides to charge
and whether they use the Bupa Medical Gap Scheme. Ask your specialist:
• We make arrangements directly with specialists, separate to our agreements
“Do you use the Bupa
with hospitals. This means you will be billed by your specialist separately and
Medical Gap Scheme?”
in addition to your hospital bill. We may cover some or all of this.
If not, ask them what you will
• The Australian Government sets a fee for the cost of a medical service. have to pay.
Medicare pay 75% and Bupa pay 25% of that set fee. Some specialists will
“Will any other specialists be
choose to only charge that set fee. However, your specialist may choose to
involved in my treatment?”
charge more than the fee. This means you would have a ‘gap’ to pay yourself.
Sometimes you’ll also need the
• The Bupa Medical Gap Scheme is designed to minimise or eliminate the services of specialists like an
amount you’ll have to pay in cases like this. We do this by paying more than anaesthetist, pathologist, radiologist Find a no gap radiology
the set fee, and we have an arrangement with the specialist on a fixed cost or assistant surgeon. If so, ask if they provider for services in hospital
for your treatment. Go to page 32 to find out more. use the Bupa Medical Gap Scheme, or
if they are In-Hospital Pathology and Find a no gap pathology
Radiology contracted providers that provider for services in hospital
have ‘no gap’ arrangements with Bupa.
30 31Effective 1 December 2020
Reducing your medical costs
The Bupa Medical Gap Scheme What can I expect if my doctor uses Here’s an example of how it might work:
The Bupa Medical Gap Scheme is the Bupa Medical Gap Scheme?
designed to eliminate or minimise the You will usually have multiple doctors or
Scenario 1
amount you will have to pay in ‘medical specialists involved in your treatment. Your specialist charges the fee set by the Government
costs’, or doctors’ fees when you’re If each doctor involved in your treatment
admitted into hospital. chooses to use the Bupa Medical Gap Your specialist’s fee is $2,000
Scheme for your treatment:
How does it work? Medicare pays $1,500 Bupa pays $500 You pay $0
We pay more, so that you pay less. In a Public Hospital:
Where a doctor or specialist has signed If you have a pre-booked admission, you
up to the Bupa Medical Gap Scheme, and will never have to pay more than $500 per
agrees to use it for your treatment, the doctor while you’re in hospital. If you are
Scenario 2
costs you pay are reduced. Your doctor Your specialist uses our Medical Gap Scheme with no gap to pay
admitted any other way such as through the
or specialist agrees to only charge up to Emergency Department, your doctor will bill Your specialist’s fee is $3,000
a certain fee. We then pay a much higher Bupa directly and you will pay nothing while
amount than what we normally would. you’re in that hospital. Medicare pays $1,500 Bupa pays $1,500 You pay $0
Where can my doctor use the Bupa In a Private Hospital with which
Medical Gap Scheme? Bupa has an agreement:
Your doctor or specialist can use the Bupa You’ll never have to pay more than $500 Scenario 3
Medical Gap Scheme in: for medical treatment per doctor – we may Your specialist uses our Medical Gap Scheme, which minimises what you pay
• Public hospitals, or even pay for the full cost while
you’re in that hospital. Your specialist’s fee is $3,500
• Private hospitals that have an
agreement with Bupa. You pay
What happens if my doctor doesn’t Medicare pays $1,500 Bupa pays $1,500
$500
Over 96% of all private hospital beds across use the Bupa Medical Gap Scheme?
Australia are in hospitals that Bupa has an The specialist or doctor can decide what
agreement with. to charge you and you’ll need to pay any
Scenario 4
‘gap’ (or amount above what we pay) in
Your specialist doesn’t use our Medical Gap Scheme
costs yourself.
Your specialist’s fee is $5,000
Find Members First, Network Hospitals Bupa pays
and Medical Gap Scheme providers Medicare pays $1,500 You pay $3,000
$500
No Gap Cardiac Services
Bupa has partnered with Genesis Heart Care, Australia’s largest group of privately
practising cardiologists, to help achieve better health outcomes for patients
with heart disease.
As a Bupa member, you’ll have no out-of-pocket expenses for services from a
Genesis Heart Care cardiologist when you’re admitted to hospital.
(Not available in NSW, TAS & NT).
Find out more about
Genesis Heart Care
32 33Effective 1 December 2020
Potential ‘out-of-pocket’ costs
1. Excesses 3. A daily, fixed fee
An excess is a one-off payment you make This is a fee charged by a small number
each calendar year if you need to go of private hospitals that you may have to
to hospital. You pay this before you are pay. If they do charge one, they should tell
admitted to hospital and before we will you when you make a booking. This is in
cover the rest of the hospital costs that addition to any excess or co-payment you
your policy includes. You will have agreed may have to pay. It may be charged by the
on this amount when you chose your level hospital, and is not related to your health
of cover and can find it in your policy insurance. It might influence your choice
information, available by logging in to of hospital.
myBupa.com.au
4. A ‘gap’ for specialist fees
An excess is paid once per person, The Australian Government sets an
and not by the same person in that year. amount for the cost of specialist medical
An excess is only paid twice per policy. services. Medicare and Bupa both pay a This example shows what someone with The amount we pay for other costs you
This applies even if you change your cover. portion of this. However, your specialist restricted cover might pay in hospital may incur in hospital (like medical costs),
The exception is that if you change your may choose to charge more than the costs. The actual amount depends on a is not lower under restricted cover.
cover to a policy with a higher excess. set fee. This means you would have a number of factors, including your choice See page 25 for more details.
In that case, you’d only pay the difference ‘gap’ to pay yourself. The Bupa Medical of hospital. Your hospital must let you
between the smaller and higher excess Log in to myBupa.com.au to access your
Gap Scheme is designed to minimise or know the specific amount before you
if you were to be admitted to hospital policy information, which shows the
eliminate the amount you’ll have to pay are admitted – this is called ‘Informed
again that year. Other conditions apply. services this applies to.
in cases like this. Go to page 32 for Financial Consent’.
Excesses are still payable If you have more information.
transferred from a different health fund,
regardless of whether you have already 5. What is restricted cover? 6. Things your Hospital policy doesn’t cover
paid an excess to your old insurer in the The Australian Government sets an This varies, but here are some common examples:
same calendar year. amount to charge for hospital costs, which
is called the ‘minimum benefit’. If your Type of service Covered by
2. Co-payments policy says you have ‘restricted cover’ for
A co-payment is where you pay a set a type of treatment, it means we will only GP visits, blood tests, X-rays and MRIs,
Medicare
amount each day that you are in hospital, pay the minimum benefit for your hospital when you are not admitted to hospital
up to the first five days, for each time you costs. In most cases, if you were to stay in
are admitted to hospital. Only some Bupa a shared room in a public hospital, you’d Non-emergency ambulance transport* Check page 19 for more details
members have co-payments. If you do, be covered but there may be an amount
you will have agreed to this amount when for you to pay. For a private room, or a Services and treatments specifically
You
you first chose your level of cover and can private hospital, the hospital may charge excluded from your cover
find it in your policy information, available even more, leaving a significant amount
by logging into myBupa.com.au for you to pay. Cosmetic surgery You
For example, travel insurance or workers’
Visit mybupa.com.au Services covered by another source
compensation
*If you have Premium Ambulance cover with Bupa, you will be covered for non-emergency ambulance
transport, capped at $5,000 per person per calendar year. Waiting periods, fund and policy rules apply.
34 35Effective 1 December 2020
Paying your hospital expenses
Paying your hospital costs Paying your medical costs Paying your prosthesis
• If you’re admitted to a private hospital • I f your specialist uses our Medical and pharmacy costs
that has an agreement with Bupa, they Gap Scheme, they’ll send the bill to us • If the prosthesis is on the Australian
will send the bill directly to us, so there’s directly. You won’t see the paperwork Government’s Prostheses List, and you’re
very little paperwork for you. Where until you receive your Statement of admitted to a private hospital with a Bupa
applicable, the hospital may ask you to Benefits. If you have had to pay an agreement, then the hospital will bill Bupa
pay any excess, a co-payment or a daily, amount (up to $500), the specialist will directly.
fixed fee when you’re admitted. bill you for the fee directly. If the medication is on the Australian
•
• I f you’re admitted to a If your specialist doesn’t use our
• Government’s Pharmaceutical Benefits
non-agreement hospital, you may be Medical Gap Scheme, the specialist Scheme (PBS), it’s essential to your care
asked to pay the whole amount up front. could charge any price and you’ll need and you have taken it or it has been opened
In this case, you can submit a claim form to pay any ‘gap’ in cost yourself. You for you in hospital, you will be covered and
to Bupa to be reimbursed for some of will receive the bill directly and you can the hospital will bill Bupa directly. Also,
these fees. You’re likely to have to pay make a claim in one of three ways. if you’re at a private hospital with a Bupa
a significant amount yourself if you visit agreement, we pay some of the cost of
1. P
ay in full, then visit a Medicare office
one of these hospitals. medications that are not on the PBS (known
to claim a portion (75% of the set fee).
as High Cost Drugs).
• I f you’re admitted to a public hospital Bring your Medicare receipt to a Bupa
See page 17 for more information.
as a private patient, store to claim another portion (25% of
the hospital also sends the bill directly the set fee). Your Statement of Benefits
to Bupa. After your hospital and medical claims have
2. P
ay in full, then complete a Medicare
• I f you’re admitted to a public hospital claim form and a two-way claim form. been processed, we’ll send you a statement
as a public patient, Medicare will usually That means Medicare will liaise with showing what’s been paid on your behalf.
fully cover your costs. Bupa on your behalf to ensure you This is known as your Statement of Benefits.
receive your refund. Please check that these details are correct
and contact us straight away if you have any
3. Do not pay – instead complete both a
questions.
Medicare and two-way claim form. If
These forms Medicare confirm you’ve not paid, you’ll Your Statement may include costs for
are available at any receive two cheques made out to the specialists you haven’t seen in person, but
Medicare centre or via the who have still performed a service for you,
specialist – one from Medicare and one
Department of Human
from Bupa. You can then send these to such as a pathologist.
Services website.
If you can’t get to a your specialist as payment for the Sometimes we will also include a
Medicare centre, contact set fee. cheque made out to your specialist with your
either Bupa or Medicare
Statement. You should simply forward this on
and ask for the relevant
forms to be sent
to the specialist (usually to the hospital or to
to you. their clinic).
Remember, you might have
to see multiple specialists
for one procedure.
36 37Effective 1 December 2020
Your Extras cover Understanding Extras cover
If you’ve got Bupa’s Extras cover, we’ve covered Not everything that keeps you healthy is covered by Medicare. That’s why Extras
just about everything you need to know on the cover can be a big help. Extras cover is all about covering some of the costs that
following pages. If you’ve still got questions, aren’t hospital related. Some of the most common services and treatments that
just ask. We’re happy to help. people make Extras claims for include:
Dental check-ups and cleans
Physiotherapy, chiropractic,
occupational therapy and podiatry
Optical products, such as
prescription glasses and
contact lenses
Health aids and appliances, such as
asthma pumps/nebulisers, blood
pressure monitors and hearing aids
Providers of Extras services have to be recognised by Bupa in order for
us to pay towards the cost of your treatment. The following information
is important for you to understand what is required for a claim, and how
your choice of provider can affect what we will pay.
38 39Effective 1 December 2020
Choosing Members First providers
your provider We have agreements with a network of dentists, chiropractors, podiatrists,
physiotherapists and optical stores across Australia. We call them our
‘Members First’ providers.
e all have different priorities when it
W There are great advantages in ou’ll know how much you can claim
• Y
comes to choosing a healthcare provider. visiting a Members First provider: and how much you’ll be out-of-pocket.
Your choice could be based on location, ou can usually expect to claim
• Y Depending on your cover, you’ll get from
recommendations, cost, or other factors more money back than if you go 60% up to 100% of the cost back on
that are important to you. to a provider who doesn’t have an most dental, physio, chiro and podiatry
agreement with Bupa. consultations, up to your yearly limits.
The amount you’ll pay for each Plus, you’ll have access to the ‘no gap’
treatment can depend on: • M
embers First Platinum Network
range of glasses and contact lenses.
1. How much the provider charges Members First Platinum is intended
to make common preventative dental • If your employer pays for your
for the service.
treatment available, without any out-of- cover, you may be on a level of cover
2. Any agreements between the provider pocket costs, to eligible members. where you can be sure of the percentage
and Bupa. you’ll get back at any recognised
At a Members First Platinum dentist, provider. Check your policy information
3. The amount you can claim back, if you’ve got Hospital and Extras cover to see if this applies to you.
determined by your level of cover. with us, you may be eligible to pay
nothing for your regular dental check- • If you have kids, depending on your
We understand that factors other than cost
up, including consults and dental exams, cover, they may be able to access
can be important to you, such as familiarity
scale and cleans, bitewing x-rays, special ‘gap free’ arrangements where
or location. If your dentist, chiro, podiatrist,
mouthguards, and flouride treatments. the costs of most services at dentists,
physio or optical provider isn’t in our
Plus, you’ll get all the benefits of chiropractors, physiotherapists and
Members First network, you can still make a
Members First on most other podiatrist consultations will be fully
claim. However, you may have a larger out-of-
dental services. covered, up to your yearly limits.
pocket expense when you get the bill.
Plus, your kids will have access to
the ‘no gap’ range of glasses and
Find out more contact lenses.
Click here to check whether or Note: Some of these benefits depend on your level of Extras cover.
not your current provider has an Yearly limits, waiting periods and our Fund Rules apply.
agreement with Bupa, or find a
Click here to Read our Fund Rules.
Members First provider to visit.
Making a claim is really simple, too. At these providers you can usually
make your claim on the spot by swiping your Bupa card. You’ll know
instantly if there’s anything extra for you to pay.
40 41Effective 1 December 2020
Extras waiting periods
When you first take out or upgrade your health cover there’s a period of time before
you can make a claim on your new level of cover. This is common across the health
insurance industry and is known as a waiting period.
You can’t claim for services that you receive during this period at your new level
of cover, even if you wait to submit the claim once the period is over.
Service or treatment Waiting period
Hire and repair of health aids and appliances 6 months
Health Management programs 6 months
Major dental 12 months
Orthodontics 12 months
Purchase of health aids and appliances 12 months
All other Extras services 2 months
You can make claims for services you received up to two years in the past.
Claiming for Extras
You can make a claim for a treatment or service provided in Australia if it’s covered by
your policy and the provider is recognised by Bupa. For example, you might purchase
a pair of glasses, but we might not recognise the provider, so you’ll not be able to
make a claim. Extras providers must meet certain requirements to be recognised by
Bupa – we do this because we are focused on the health and care of our members.
Before you book a treatment or buy
a health appliance, it’s a good idea to
check with us. We can confirm that
we recognise the provider and what
your cover includes.
42 43Effective 1 December 2020
Knowing your claim limits Restrictions on making claims
Claim limits are the maximum dollar amounts that we’ll pay for specific treatments
and services. This is common for most types of insurance. Other health insurers
might set the same or different limits to us.
If you move between health funds, your use of limits usually moves with you.
For example, most funds have a lifetime limit on orthodontics, so if you have
claimed your lifetime limit at your old fund, Bupa would recognise this and
you wouldn’t be able to make a further claim.
Here are some of the most common limits that might apply to your policy:
Yearly limit Person limit
This is the maximum amount you can This is the maximum amount that each
claim for a service from 1 January to 31 person covered by your Bupa membership
December. If you haven’t claimed up to can claim in a calendar year. If you’re on
your yearly limit, this doesn’t ‘roll over’ to a policy with a family member, then you’ll
the next year – it resets on 1 January. have your own individual limits.
Sub limit Membership limit You need to have served any waiting periods that apply. If you’re new to Bupa and
This is like a limit within a limit. It applies This is the maximum amount that can be Extras cover, it’s good to be on top of what waiting periods apply to you and when
to a very specific service, per person, per claimed collectively, by everyone covered they will end.
year. For example, if you have Your Choice by your membership within the calendar
Extras 60, there’s a yearly limit of $500 in year, for a specific type of Extras service. You can’t claim twice We have rules around
the first year for natural therapies. A sub Remember, these limits apply in addition If you’ve made a claim with Medicare or claiming for dental services
limit applies to massage therapy of $100 to your individual per person limits. Also, another insurance policy, such as Work We have rules about what you can
per person, so once you have reached the membership limit might not be high Cover or travel insurance, then you can’t claim, based on usual clinical practice.
that limit for massage therapy, you can enough for all your family members to claim the cost under your Extras cover. It means that specific services may have
no longer claim for massage therapy that claim their individual limits. For example, There are some exceptions, such as a limit to the number of times they can
year. However, you could make up to $400 you may have a person limit of $500 for hearing aids and breast prostheses, so be claimed within a certain time frame.
more in claims for other permitted natural chiropractic services, but a membership check with us if you’re not sure. For example, we generally only pay for a
therapies, like acupuncture. limit of $1,000. This could be used by two dental check-up claim every six months.
family members even if you have four If you’re not sure if you’re covered for a
Service limit You can’t claim for multiple services
people listed on your policy. service, or if your dental condition means
For some types of Extras services, there of the same kind from the same
provider on the same day you need treatment outside these rules,
are limits to the number of times that Lifetime limit please give us a call.
benefits are payable for the same service. Health insurers usually have a lifetime This rule only applies to therapy
For example, you can only claim a scale limit for orthodontics. This applies to an services. For example, if you went to
and clean from your dentist once every six individual. If you have reached this limit, see an acupuncturist and then received
months. These limits apply from the date you can’t make any further claims for this a massage from the same provider on
you receive the service, not from the time at Bupa again. It doesn’t reset, even if you the same day, you can’t claim for both
you submit the claim. leave Bupa and start your cover again services as they are both ‘natural therapy’
with us. treatments. However, if we recognised that
provider as both an acupuncturist and a
chiropractor and they provided you with
Find information acupuncture and a chiropractic treatment
on your policy limits
on the same day, then we would recognise
both treatments, as they are different
44
types of services. 45You can also read
