An Accident and Emergency Facility fee is a fee charged to patients by private hospitals for the treatment in an accident and emergency department.

It is not covered by Medicare or private health insurance.

Other funds may charge an excess or co-payments. At Police Health our hospital cover has no excesses or co-payments (other than where a waiting period applies)

An excess is the amount you agree to pay towards the cost of hospital treatment. For example if you have an excess of $500, when you’re admitted to hospital you’ll have to pay the first $500 of the hospital costs on top of anything else not covered by your policy.

Similarly some insurers charge a co-payment, which is the agreed amount you’ll pay per day in hospital. 

An excess is the amount you agree to pay towards the cost of hospital treatment. For example if you have an excess of $500, when you’re admitted to hospital you’ll have to pay the first $500 of the hospital costs on top of anything else not covered by your policy.

A co-payment is the agreed amount you’ll pay per day in hospital.

At Police Health our hospital cover has no excesses or co-payments (other than where Waiting Periods apply for transfers) because we know that this can become a barrier to treatment when other unexpected and uncontrollable out of pocket costs hit at the same time – such as gap payments for doctors and anaesthesiologists who charge over the MBS fee, and legally uninsurable out patient consults with specialists.

These unexpected costs often hit patients at the same time that they’re dealing with a loss of income, so removing any excess or co-payments from the equation helps protect our members from the unforeseen – as we believe good insurance should. 

Police Health has agreements with most private hospitals that are likely to be accessed by members - we call these Contracted Hospitals. These agreements ensure that an agreed schedule of fees (including in-patient accommodation, theatre and special unit accommodation fees as appropriate) is charged by the hospital and paid by Police Health on the member’s behalf.

Member’s benefit entitlements will be affected by factors such as their level and type of cover and the financial status of their membership. This will affect the amount Police Health will reimburse to the hospital. We strongly recommend if you contact us on 1800 603 603 to confirm your benefit entitlement prior to receiving hospital treatment.

 If you choose a non-agreement hospital may incur out-of-pocket expenses for hospital related services irrespective of your level of cover.

Find a Contracted Hospital using our online search tool, or give us a call. 

Hospital benefits are payable 365 days a year. However, if your hospital stay exceeds 35 consecutive days you must obtain and 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. 

An exclusion is when you agree not to be covered at all for certain treatments. For example you may have hospital cover but it excludes joint replacements.

A restriction is when you agree to receive very limited benefits for certain treatments. For example you may be covered for joint replacements only at a public hospital, and if the joint replacement is undertaken in a private hospital, only basic accommodation benefits and no procedure benefits are paid – which may leave you with substantial out-of-pocket costs.

At Police Health our Hospital cover has no exclusions and no restrictions (other than where Waiting Periods apply for transfers before benefits or higher benefits, as applicable, are payable) because we don’t think our members should have to predict what health needs they or their family will have in the future. You wouldn’t insure just half of your house or car, so why insure just part of your health?

It’s important to note that all health insurers are governed by the Private Health Insurance Act 2007. This legislation sets out what health insurers can and cannot pay benefits towards. Within the hospital as an inpatient, health insurers can only pay benefits towards treatment and procedures where Medicare pays a benefit. That means for some services, like elective cosmetic surgery, health insurers cannot pay a benefit towards this treatment, and this is not classed as a restriction or an exclusion on a policy.

Items that are not covered by our Hospital policy, that are not considered exclusions or restrictions, include (but are not limited to);

  • Services incurred before Waiting Periods have been served.
  • Outpatient services, unless there is an agreement between Police Health and the hospital.
  • Treatment for which Medicare does not pay a benefit, including cosmetic surgery. (Some benefits may be payable for hospital treatment following this surgery. Please contact us for more details.)
  • Services that are provided outside of the Commonwealth of Australia.
  • Services where an entitlement exists or may exist under any compensation, sports club or third party insurance.
  • A claim for a service that is submitted more than two years after the date of service.
  • Pharmaceuticals not related to the reason for hospitalisation or not covered under the agreement with the hospital or provided on discharge.
  • Exceptional high cost drugs where no or limited benefits are paid.
  • Prostheses items that are not included on the Federal Government’s approved Prostheses List.
  • Charges greater than the benefit defined in the Federal Government’s approved Prostheses List.
  • Personal and take-home items. E.g. newspapers, toiletries, television, hairdressing, manicure, etc.
  • Treatment provided to a person in a private hospital emergency department (out-patient).
  • Aged care and accommodation in an aged care facility.
  • If you’re in hospital for more than 35 consecutive days and not classified as an acute care patient, your benefits will significantly reduce.
  • Benefits for ambulance services covered by a third party arrangement such as a State/Territory transportation scheme.
  • Fees from a podiatric surgeon (benefits may be payable under our Extras cover) or related anaesthetic fees.
  • Use of robotic assisted systems not covered under the hospital contract. 

Should you require information about a particular treatment or benefit please contact us. 

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
Police 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
Police 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 Police 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
Police 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 1800 603 603 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.