Question 1

Which hospital can I go to?

Accepted Answer

We have agreements with most private hospitals across Australia, which cover the costs of things like theatre fees, hospital accommodation, food and nursing care.

These costs are charged by the hospital and paid for by Westfund on your behalf. By choosing a contracted hospital, you can minimise or avoid out-of-pocket fees related to your hospitalisation.

Once your surgery/treatment has been decided, it’s important to confirm that the procedure is covered by your policy and that the hospital is contracted with us – just ask your doctor for the name of the hospital, and we can do this for you, or you can search online.

Question 2

Why do I have out of pocket costs?

Accepted Answer

Cost can be one of the biggest factors when it comes to making decisions about our health. Although we always strive to make things as easy as possible for our members, the bottom line is that private health insurance is complicated and there are many things that influence the costs of treatment. Through your treatment journey you will see lots of terms that may be unfamiliar, like 'Medicare Benefit Schedule’, ‘Item number’, ‘scheduled fee’ for example. We’re here to help you understand these terms and the role they play in the costs associated with your hospital treatment.

Medicare Benefits Schedule

The Medicare Benefits Schedule (the MBS) is a list of the medical services for which the Australian Government will pay a Medicare rebate, to provide patients with financial assistance towards the costs of their medical services. The ‘schedule fee’ or ‘set fee’ is the set amount defined by the government. Each service contained in the MBS is allocated a unique item number which should be included on your quote.

Doctors are not required to charge the schedule fee and may choose to charge above this amount. The ‘gap’ between the schedule fee and the amount charged by your doctor becomes an out-of-pocket expense for you.

You should ask your doctor to explain the costs of your hospital admission including any Medical Devices and Human Tissue Products gap amount, their own fees, any fees for other doctors involved (such as assistant surgeons and anaesthetists) and any other expenses involved. If there are any out-of-pocket costs for you to pay ask for a written cost estimate. Don't forget, you can also search online for doctors who have previously participated in Access Gap Cover to help reduce or avoid out-of-pocket costs associated with your treatment.

Other out-of-pocket costs can come from:

Excess
Going into hospital for restricted service
Additional hospital expenses (e.g. fees for TV, internet)
Not a contracted hospital
Gap for Medical Devices and Human Tissue Products
Pharmacy (items prescribed outside of pharmaceuticals required as part of treatment)
Allied Health services (if not part of hospital contract)
Parking fees or travel costs.

Question 3

How do I know if I’m covered for my procedure?

Accepted Answer

One of the most important things to do before booking in your procedure is to confirm whether or not it’s covered in your hospital policy. All hospital procedures are defined by their Medicare Benefit Schedule Item number, which are sorted into Clinical Categories. The Clinical Category simply refers to grouping similar types of hospital treatments together. These categories are standard across all private health insurers and each product tier (Gold, Silver, Bronze and Basic) has specific Clinical Categories that must be included, making it clear what is and isn’t included. If you need to find out what you’re covered for, check your policy summary – it contains everything you need to know.

Still not sure? We’re here to help. Give our team a call on 1300 937 838 and we’ll be able check for you. Don't have time to call? Email us.

Question 4

What if my policy has an excess?

Accepted Answer

An excess on your hospital cover is just like having an excess on home or car insurance – it’s an amount payable upfront should you be admitted to hospital. Choosing a policy with an excess means your premiums will be cheaper. It can sound complicated, but it’s a pretty straightforward process – if your policy has an excess of $500, you pay this amount to the hospital and we deal with the rest – provided your procedure is covered by your policy. Westfund members only need to pay an excess once per person, per calendar year. If you have Gold or Silver tier hospital cover, you won’t need to pay an excess for your dependants.

Accidents – if you are admitted within seven days of an accident into a private hospital you will not be required to pay the excess (depending on your level of cover)

Question 5

What is ‘informed financial consent’?

Accepted Answer

You have the right to ask questions about the cost of your treatment.

Knowing how much your treatment may cost is known as ‘Informed Financial Consent’. If you are facing potential out-of-pocket costs, we encourage you to ask for a written estimate of fees before making a formal decision on the treatment. This way, you will be able to make an informed choice.

Question 6

Understanding your hospital options

Accepted Answer

If you have hospital cover, you have a few options when receiving treatment. You can be treated as:

a public patient in a public hospital,
a private patient in a public hospital, or
a private patient in a private hospital.
Each option offers different levels of choice, timing and potential costs.

Being treated as a public patient (public hospital)

If you choose to be treated as a public patient:

Your treatment is covered by Medicare
You are treated by the hospital’s available doctors
For non-urgent procedures, you may experience longer wait times

Being treated as a private patient in a public hospital

If you choose to use your hospital cover in a public hospital:

You may be able to choose your doctor (where available)
You may have more control over your treatment timing
Westfund helps cover the cost of your hospital stay

However:

There may be out-of-pocket costs, depending on your doctor and treatment
Not all services or specialists may be available privately in public hospitals

Being treated as a private patient in a private hospital

If you choose to be treated in a private hospital:

You can usually choose your doctor or specialist
You usually will have shorter wait times for planned procedures
You’ll typically have more control over when and where you’re treated
Westfund contributes to your hospital costs based on your level of cover

However:

There may be out-of-pocket costs, depending on your doctor, hospital and treatment
Some services may have waiting periods, exclusions or restrictions depending on your cover

Things to consider

Choosing the right option will depend on your personal situation, including:

The urgency of your treatment
Whether you want to choose your doctor
Potential out-of-pocket costs
Waiting times for planned procedures

Making the right choice for you

All options provide access to care. The right choice comes down to what matters most to you - whether that’s timing, choice, or cost. If you’re unsure, we’re here to help. You can:

Speak with your doctor or specialist
Contact Westfund before your admission to understand what’s covered

Question 7

How is my Hospital account paid? I haven’t seen a bill or request for payment from the hospital.

Accepted Answer

In most cases, when you are treated in a Westfund-contracted hospital, the bill will come directly to us for payment. Once we’ve paid the hospital account, a Benefit Statement will be available at the start of the following month. If you would like to view a Benefit Statement at any time, you can do so through your correspondence history in Members Online or our app, or by requesting a copy over the phone.

Question 8

What's the inpatient travel benefit and how is it calculated?

Accepted Answer

The Inpatient Travel benefit allows you to claim a benefit to help with the travel costs associated with an inpatient hospital admission.

The benefit is calculated on a grouped kilometre basis, where the round trip from your home to the hospital you're being admitted to is in excess of 150 kilometres.

There are criteria that apply to the inpatient travel benefit:

An inpatient travel benefit is payable when there is a corresponding hospitalisation record on the membership (must be admitted as a private patient)
12 month waiting period applies
Benefit only available for travel to an inpatient hospital admission for an active person listed on the membership
This benefit is limited to one service per member per episode of hospitalisation.

Calculate your Inpatient Travel Benefit

The Inpatient Travel benefit is based on round-trip distance. Use the table below to help estimate the benefit based on distance travelled:

Distance Travelled	Eligible Overseas covers benefit	All other eligible Hospital covers benefit
0 - 149 km	Nil Benefit	Nil Benefit
150 - 200km	$20	$40
201 - 250km	$25	$50
251 - 300km	$30	$60
301 - 350km	$40	$70
351 - 400km	$50	$80
401 - 450km	$60	$90
451km+	$70	$100

Refer to your Policy Summary for further information.

Question 9

Claiming the outpatient travel benefit

Accepted Answer

If you need to travel for outpatient medical specialist services, like a consultation with your specialist, e.g. orthopaedic surgeon, you may be able to claim a benefit.

The travel benefit is payable for outpatient medical specialist services when referred by a Medicare Registered Practitioner and when travelling more than 150 km per round trip for the service.

There are criteria which apply to the travel benefit:

A Travel Benefit will only be paid for outpatient medical specialist services where a Medicare item number is billed for that service or;
in the case of a Specialist Dentist, a dental consultation item number is billed for that service.
If you're not billed for a medical service (e.g. post-operative consultation), a letter of attendance from the medical specialist is required.
A 12 month waiting period applies.
The provider must be a recognised specialist as per Westfund’s Recognition Criteria.
This benefit is limited to one service per member per day.

Calculate your Travel Benefit

The Travel Benefit is based on round-trip distance. Use the table below to help estimate the benefit based on distance travelled.

Distance travelled	Benefit
0-149 km	Nil
150km-200 km	$20
201-250 km	$25
251-300 km	$30
301km-350 km	$40
351km-400 km	$50
401-450 km	$60
451 km+	$70

Question 10

What is Access Gap Cover?

Accepted Answer

Access Gap Cover is one way to eliminate or reduce your out-of-pocket medical costs (gap) while you are an admitted patient of any contracted hospital or day procedure hospital.

Medicare pays 75% of the Medicare Benefits Schedule (MBS) services while you’re in hospital; we cover the rest up to the MBS schedule fee. Where the charge exceeds the MBS fee, we’ll pay an additional benefit that will eliminate or reduce any out-of-pocket medical gap expenses if the doctor participates in our Access Gap Cover Scheme.

Doctors can choose whether they take part in this scheme on a case-by-case basis. You should ask your doctor to explain the costs of your hospital admission including any Medical Devices and Human Tissue Products gap amount, their own fees, any fees for other doctors involved (such as assistant surgeons and anaesthetists) and any other expenses involved. If there are any out-of-pocket costs for you to pay, ask for a written cost estimate.

Question 11

How do I find a doctor who will use Access Gap Cover?

Accepted Answer

There’s a handy online search available for you to find doctors who have previously treated patients under Access Gap Cover Scheme.

You can search by name, specialty and location.

If you’ve been referred to a doctor and their name does not appear in this search, remember to check with your doctor to see if they will participate in the Access Gap Cover Scheme.

Question 12

What if my doctor won't treat me with Access Gap?

Accepted Answer

A large number of doctors throughout Australia have been invited to provide their services using Access Gap Cover however there are some doctors who choose not to. If your doctor chooses not to treat you as a Westfund Access Gap Cover patient, they will raise a fee for the service provided and the claims process will be as normal.

We recommend that you discuss the charge with your doctor as early as possible – preferably before you are admitted to hospital if possible – and request full disclosure of any out-of-pocket expenses.

Going to hospital

Information about going to hospital

Patient Travel Benefit

Access Gap