Going to hospital
This guide helps to explain what to expect and how to prepare for a hospital visit, to make using your health insurance simpler and less stressful. If you prefer you can always contact our friendly team.
Your guide to using your hospital cover
You may have already seen your GP, received a referral, and visited your specialist. Now it's time to understand how to use your health insurance. This guide explains when and how to use your hospital cover and what you need to do for each step of the process. If you have any questions, we're here to help.
Step 1: Am I covered for my procedure?
Before going to hospital, it's a good idea to check your cover to understand any waiting periods, benefits and potential out-of-pocket costs. This can help you avoid unexpected expenses. Some services may also have restrictions that affect the benefits you'll receive.
You can check your cover details in your fact sheet through the member area, the GMHBA app, or by contacting us.
If you're not covered for a specific procedure, you'll need to upgrade your cover and serve a 12-month pre-existing condition waiting period before you can make a claim for that treatment.
If you're new to GMHBA or have recently upgraded your cover, waiting periods may apply and can vary by service.
Pre-existing conditions generally have a 12-month waiting period, so we recommend checking your cover early through the member area, mobile app, or by contacting us.
Your hospital cover only applies to services included in your policy once any waiting periods have been served and you're admitted to hospital as a private patient.
This means services provided before or after your hospital admission, such as emergency department visits, outpatient tests or specialist appointments, aren't covered by your hospital insurance.
Step 2: What does it cost to go to a private hospital?
Going to hospital may involve some costs, including:
- Out-of-pocket costs, which could be reduced by checking whether your specialists participate and agree to bill using the Gap Cover scheme.
- An excess fee, if this applies to your policy.
With hospital cover, your health insurer will contribute towards both your hospital and medical costs if you are admitted as a private patient in a private or public hospital for a procedure included on your health insurance policy.
When talking with your specialist it's important to discuss the costs of your care and agree to informed financial consent.
Your health insurance will only help pay for services included on your policy once you've served any applicable waiting periods and are admitted to hospital as a private patient.
This means that services provided before or after your hospital admission aren't covered by your hospital insurance. This includes hospital emergency department visits, outpatient tests, specialist consultations, and discharge medications or pharmaceutical items.
Step 3: What do I need to know about my hospital journey?
Taking a few simple steps can help you feel informed and prepared:
- Choose the specialist and hospital that's right for you.
- Check your cover, including what's covered, what's not, and any restrictions that may apply.
- Ask about your procedure and any out-of-pocket costs.
- Review and agree to your informed financial consent.
- Know when your procedure is scheduled and what you'll need to bring on the day.
Before your admission, the hospital will let you know when to arrive, how to prepare, what to bring, any costs you may need to pay, and whether you'll need someone to drive you home.
Before you leave hospital, your specialist should explain your recovery plan and who to contact if you have any questions or concerns, be sure to ask before you leave hospital.
Eligible GMHBA members may be able to access programs such as Rehab in the Home and Care Coordination. Talk to your specialist, nurse or discharge planner about a referral.
How does hospital claiming work?
Hospital costs such as accommodation and theatre fees are usually billed directly to GMHBA. You'll just need to pay any applicable excess or agreed out-of-pocket costs before admission. It's also a good idea to check whether your hospital is a GMHBA participating private hospital.
Medical costs, such as your specialist's fees, are shared between Medicare and GMHBA. Out-of-pocket costs occur when your specialist charges more than the Medicare Benefits Schedule (MBS) fee. If your specialists bill using Gap Cover, your out-of-pocket costs are reduced or capped.
Before your treatment, ask your specialist for a quote so you understand any costs involved. This is known as informed financial consent. You can also contact GMHBA for help understanding your cover and costs. Be sure to ask your specialist for the MBS item numbers for your procedure, as these help us provide the most accurate advice.
What are the benefits of having hospital cover with GMHBA?
You can choose who treats you and may have options about where you receive treatment.
Please note that costs can vary depending on hospital and specialist agreements.
Avoid lengthy public hospital waiting lists and potentially access elective surgery sooner through the private system.
Every GMHBA hospital cover available for purchase includes an excess waiver for same-day procedures, along with emergency ambulance transport in eligible states.
Help after you go home with GMHBA support programs
Recovery continues at home. Before you leave hospital, make sure you understand your recovery plan, any follow-up appointments, who to contact if you have concerns, and whether you'll need rehabilitation, physiotherapy, a medical certificate or time off work.
GMHBA can support your recovery with a range of programs like Hospital in the Home, Rehabilitation in the Home, and Care Coordination, if eligible your specialist or treating hospital can provide a referral for these services with GMHBA.
If you have extras cover, you might be able to use it to help with some rehabilitation services and related costs during your recovery.
Going to hospital FAQs
Going to hospital may involve out‑of‑pocket costs, as well as any excess that applies on your policy.
We recommend contacting us to review your level of cover and to understand what information you’ll need from your specialist. Ask your specialist about informed financial consent, this will help you work out any potential costs before proceeding with your treatment.
You have several choices when planning a hospital stay as a private patient. You can choose:
- Your specialist or surgeon - you’re not limited to the specialist recommended by your GP.
- The hospital you prefer - provided your specialist has admitting rights at the private hospital (choosing a participating private hospital may also help reduce your out-of-pocket costs).
- A specialist who uses Access Gap Cover - this may help reduce, or in some cases eliminate out‑of‑pocket costs.
- Whether you're treated as a public or private patient – in some situations, private treatment may also be available in a public hospital.
- When to have your procedure - in many cases, choosing private treatment can reduce waiting times.
You can help manage your hospital costs by:
- Checking your level of cover by reviewing your fact sheet in your member area or app so you know what’s included and what isn’t.
- Choosing specialists who participate in and bill using Access Gap Cover, which may reduce or eliminate out-of-pocket costs.
- Asking your specialist for a detailed cost estimate (also known as Informed Financial Consent) before agreeing to any treatment.
- Confirming your excess so you know exactly what you’ll need to pay on admission.
- Reviewing any waiting periods, if they haven’t been served there will be charges for your procedure.
- Contacting GMHBA for a cover review - we can explain your benefits, the costs you're likely to pay, and what questions to ask your providers.
The Medical Costs Finder provided by the Australian Government outlines typical fee ranges for common private procedures across Australia, giving people a sense of the likely out‑of‑pocket costs.
What you’re covered for will depend on the type and level of cover you hold. We recommend reviewing your cover fact sheet, which is available in your member area, or you can contact us if you’d like help understanding your cover.
Emergency Ambulance Transport is currently covered under eligible extras policies and all hospital policies. Learn more
Depending on your cover you may also be eligible to access services through GMHBA to support your health including telehealth services, Hospital in the Home, Rehab in the Home, Healthier Heart at GMHBA - Cardiac rehab, chronic disease management programs, care co-ordination services, GHMBA + Baby program, or other screening and pilot programs.
Hospital benefits only apply once you’re admitted to hospital as a private patient. This means services provided before or after your hospital admission, such as private hospital emergency department visits, outpatient tests, discharge pharmaceutical items or specialist consultations, aren’t covered by hospital insurance. It’s also important to keep in mind any restrictions on your cover which may mean that some things are not included. For help working out what is or isn’t covered by your policy, you can contact us.
Yes, you can upgrade your hospital cover if you’re not currently covered for the treatment you need. However, it’s important to note that waiting periods will apply to any services that weren’t included on your previous policy, before you can start claiming.
A 12‑month waiting period applies to pre‑existing conditions, while other hospital treatments may have shorter waiting periods.
Upgrading your cover can still be a good idea if you want broader protection in the future. We recommend contacting us before making any changes so we can help you review your options and understand any waiting periods before proceeding.
Restricted categories help keep health insurance premiums more affordable.
For restricted services, benefits are limited to the minimum (default) benefit as set by the Australian Government, which covers accommodation as a private patient in a shared room of a public hospital. The benefit does not cover the cost of a private room in a public hospital or any room in a private hospital, and does not cover theatre costs. If you are admitted to a private hospital for treatment that is restricted by your policy, large out-of-pocket expenses will apply.
An out‑of‑pocket cost (also called a gap payment) is the amount you pay for inpatient medical treatment that isn’t fully covered by your private health insurance and Medicare.
These costs can occur when your specialist charges above the Medicare Benefits schedule (MBS) fee, your procedure isn’t included on your level of hospital cover, or when an excess applies on your policy.
An excess is the amount you may need to pay towards a hospital admission as a private patient.
Many of GMHBA’s hospital covers include an excess, which helps members share some of the cost of hospital admissions in return for lower premiums (the amount you pay each fortnight, month or year for your policy).
When an excess applies, it will be capped, so you only pay the maximum excess once per person, per calendar year.
If something doesn’t feel right during your recovery, such as increasing pain, fever, unexpected bleeding, worsening symptoms, or anything that concerns you, contact the healthcare team listed in your discharge instructions straight away. This is usually your specialist’s rooms, your hospital’s post‑operative care line, or your GP.
If your symptoms are severe or urgent, go to your nearest emergency department or call 000.
It’s always better to seek help early rather than wait and worry. Readmissions can happen, and hospitals are prepared for this. Bringing your discharge paperwork and a list of your medications can help your team support you more quickly.
Self‑advocacy means speaking up about what you need and making sure you understand your recovery plan. Here's some simple ways to do this:
- Know your instructions - keep your discharge paperwork handy and refer to it often.
- Ask questions - if something is unclear such as medications, activity limits, or symptoms to watch for, you should contact your healthcare provider.
- Track your symptoms - take notes or photos so you can describe changes accurately.
- Use support people - a family member or friend can help you remember instructions or raise concerns at appointments.
- Trust your instincts - if something feels off, reach out to your care team. You know your body best.
Most public and private hospitals employ Patient Liaison Officers (or Patient Advocates) to assist with complaints, feedback, or misunderstandings directly. National patient‑ and family‑initiated escalation systems have also been implemented in hospitals, allowing patients and families to formally raise concerns about deterioration or care quality directly with hospital clinical leadership.
Advocating for yourself helps you stay safe, informed, and confident throughout your recovery.