Hospital Cover
Peace of mind means having one less thing to worry about with GMHBA hospital cover.
All about hospital cover
No-one wants to go to hospital, but if you do, it’s comforting to know that hospital cover gives you options. You decide where your treatment takes place, and you can choose who treats you.*
Our hospital covers start with our Accident Only Hospital (Basic), to policies with a few more clinical category inclusions, such as Basic Plus Starter Hospital or Bronze Plus Advantage Hospital to the mid-level Silver Plus Hospital, right up to cover for every clinical category on Gold Optimum. All you have to do is choose the policy that best fits your needs.
*subject to level of hospital cover, hospital and doctor availability
Why choose GMHBA for hospital cover?
GMHBA is a not-for-profit health insurance provider, which means we’re run to benefit members, not shareholders. We keep members in mind in everything we do.
In 2024, GMHBA has claimed the Canstar Outstanding Value Award – Hospital Cover (VIC) for the third consecutive year.
It's our mission to provide thorough and friendly support to all our members. Our Geelong-based contact centre is here to help our members when they need it most.
No one can predict when an accident is going to happen. If you need hospital treatment as a result of an accident and hold an eligible GMHBA hospital product, we will pay benefits towards hospital treatment for services that are normally excluded or restricted on your cover. Find out more.
Emergency ambulance transport is currently covered under all hospital policies. Ambulance services vary from state to state.
Not the right cover for you? That’s OK, you can cancel within the first 60 days and if you haven't made a claim, you’ll receive a full refund of any premiums paid.
Why take out private hospital cover?
You can’t control when you or your loved ones get sick, but holding hospital cover can increase the control you have on your healthcare journey.
Instead of only being able to access the public system, GMHBA's hospital cover gives you peace of mind, the ability to choose your doctor and the potential to elect to have your treatment in a private hospital as a private patient (subject to your level of cover and hospital availability).
Understanding hospital cover
Hospital cover is all about choice. It’s a more flexible way to support your health.
While Medicare is a good public health system, it doesn’t always suit everyone. In public hospitals, non-emergency treatment or surgery may face lengthy wait times. With GMHBA hospital cover, depending on your cover, you can choose to have your elective surgery performed at a private hospital as a private patient instead. It pays benefits towards inpatient medical costs like surgeons and anaesthetists, as well as patient accommodation and meal costs.
You have the following treatment options;
| Accommodation Type | Choice of hospital | Choice of doctor |
| Public patient, public hospital | No | No |
| Private patient, public hospital | No | Yes |
| Private patient, private hospital | Yes | Yes |
Hospital vs Extras Cover
There are two ways you can take out hospital cover. The first is a standalone hospital cover, which contributes to the costs when you’re admitted into hospital. The second is taking out hospital and extras cover (known as combined cover). Combining hospital and extras means you get the benefits of hospital insurance, plus your extras cover can help with the cost of common services that Medicare generally won’t pay for. Extras cover helps with things like dental, physio, remedial massage, optical and more.
Additional things to know about having hospital cover
Lifetime Health Cover Loading (LHC) is an age-based initiative, introduced by the Australian government to encourage more people to get hospital cover earlier in life. If you don’t take out hospital cover before 1 July following your 31st birthday, you’ll incur a 2% loading on your premium that grows by an additional 2% every year you go without cover (up to a maximum of 70%).
The Australian Government provides an income-tested rebate to help people with the cost of private health insurance. If eligible, you can either use it to reduce the cost of your premiums up front, or you can pay the standard premium amount and get a refund at tax time, it’s your choice.
The Medicare Levy Surcharge (MLS) is an additional tax that Australians need to pay if they earn over a certain amount (like rebate, it’s income tested) and don’t have hospital cover. This is to encourage more people to take out hospital cover to help take strain off the public health system, this is paid in addition to the standard Medicare Levy.
Age-based discount
The age-based discount is a perk for the under 30s. It's a 2% reduction on premiums for each year that a person is aged under 30 when they purchase eligible hospital cover. The highest age-based discount that can be applied is 10% for 18 to 25 year olds.
Is it worth getting private health insurance?
As always, that’s up to you. When deciding whether to get hospital cover, you need to consider factors like your budget, where your nearest private hospital is located, your health needs, any services you might need in the future as well as your family medical history.
As a public patient you won’t have a choice of hospital or doctor. If you elect to be seen as a private patient in a public hospital you will be able to choose your doctor but hospital waiting lists still apply. As a private patient in a private hospital, you have the right to choose your own doctor and may also have more choice as to when you’ll be admitted pending your doctors’ availability. If you have hospital cover, you have the option not to use your insurance and be treated as a public patient in a public hospital. By having private hospital cover the choice is still up to you!
There’s four levels of hospital cover (called product tiers) set by the Australian Government. Each product tier has been set with a minimum list of included services and must offer cover for certain clinical categories.
The higher the tier, the more included services. GMHBA has different levels of hospital cover, and it’s important to find the right one for you.
Included services are either restricted or unrestricted, it's important to know the difference.
- Unrestricted services simply means that you will be covered in a private hospital
- Restricted services means you’re only covered in a public hospital as a private patient (out of pockets may apply). If you're admitted to a private hospital for a restricted or excluded service, sizeable out of pocket costs will apply.
There’s more information on your product fact sheet and also in our fund rules about restricted services.
Choosing the right hospital cover for your life stage
The right level of hospital cover will depend on all sorts of things, including your age, lifestyle, health requirements, your family’s medical history and your budget. The best place to start? Give us a call and speak to one of GMHBA’s friendly team members. They’ll be able to assess your needs and recommend some options.
If you’re a young, healthy single looking to start out with a more affordable hospital cover, something like Basic Plus Starter or Bronze Plus might be enough for you.
If you're a higher income earner and you simply want the lowest premiums while avoiding the Medicare Levy Surcharge, selecting a hospital cover like our Accident Only Hospital (Basic) might be for you.
You may want to consider our Bronze Plus Advantage Hospital, which offers great value hospital cover, with more than just the basics. Or our Silver Plus Hospital, mid level cover with few exclusions, if you want a policy that covers your family for more than just the basics.
If you want hospital cover that offers peace of mind which covers additional clinical categories our Silver Plus Premium may be for you.
Our Gold Optimum Hospital is our most comprehensive cover, with no restrictions. It includes services such as pregnancy and birth, hospital psychiatric services and weight loss surgery (waiting periods apply).
Switching to GMHBA
Find the right cover for you
View our range of hospital and extras products, and choose the cover that best suits your needs.
We'll do the paperwork
We’ll cancel your old membership, request the transfer certificate from your old insurer and handle all of the paperwork for you.
You won't re-serve waiting periods*
We'll recognise the waiting periods you served with your previous fund.
*Waiting periods apply for increased cover, must join within 30 days of ceasing your previous cover.
Frequently asked questions about hospital cover
When you’re admitted to hospital, your insurance will pay benefits towards your in-hospital treatment and admission costs, subject to the level of hospital cover you hold. Learn more about how health insurance works.
Taking out hospital cover gives you access to be treated in the private healthcare system, as long as the service is included on your policy. You’ll have the ability to choose your preferred doctor and the wait times might be shorter if you choose to be treated in a private hospital as a private patient rather than going to a public hospital.
Learn more about the benefits of private health insurance with GMHBA.
GMHBA hospital cover will pay benefits towards eligible medical and hospital accommodation costs. However, not all costs are covered as part of your private health insurance.
Hospital coverage as a private patient only kicks in when a person is admitted to hospital as a private patient. Services received before or after you’re admitted, like attending a private hospital emergency department, outpatient diagnostic tests or visits to a specialist’s room are not covered.
It’s important to discuss the cost of any treatment with your specialist and health fund prior to being admitted to understand any medical gaps (out-of-pocket costs) that may apply.
You may still have out-of-pocket expenses including:
- An excess that must be paid to the hospital before you're admitted
- Pharmacy items that you’re given when you leave hospital
- Medical gap fees (including Access Gap Cover & Known Gap)
- Hospital gap fees if you are admitted to a private hospital for a service that is restricted on your cover
- Prosthesis
As always, it's important to receive Informed Financial Consent for proposed treatment which provides you with an estimate of fees and potential out-of-pocket expenses. Also ask your provider if they will charge you using Access Gap Cover to ensure you know how much you'll have to contribute towards the admission and treatment.
What is a medical gap fee?
Medical gap fees (also known as out-of-pocket costs) are the difference between the amount that GMHBA and Medicare can pay and what a doctor charges for their service. Healthcare providers set their own fees, so you should always get a written estimate of fees from your specialist, the hospital, the anaesthetist and anyone else involved in your treatment (known as Informed Financial Consent). Learn more about hospital fees and charges.
What is the Access Gap and Known Gap?
The Australian Health Service Alliance (AHSA) Access Gap Cover scheme is a billing system that provides higher benefits than the Government’s scheduled fee. It is designed to reduce or even eliminate any gap for medical fees for private patients being treated as an inpatient in hospital or patients receiving hospital-substitute treatment.
Specialist doctors who are registered for, and choose to use, the Access Gap Cover scheme get a higher benefit from GMHBA (more than the standard 25%), in exchange for limiting the gap they charge to you.
There are two scenarios for how you may be billed by your specialist doctor when they use the Access Gap Cover scheme:
- No Gap – this is where there will be no gap for you to pay following the procedure
- Known Gap – this is where you will be charged a maximum gap of $500 per doctor, per episode. This excludes obstetricians who can charge up to $800 per confinement for management of labour and delivery.
If you choose a doctor that does not participate in the Access Gap Cover scheme for your procedure, you will still be covered by Medicare and GMHBA for the scheduled fee, but will need to pay any gap.
You may also receive services from an assistant surgeon and anaesthetist for your procedure – they can also choose whether or not to participate in the Access Gap Cover scheme. You may have separate gaps to pay for their services.
Before deciding to have a procedure, you should discuss the cost of treatment with your specialist doctor. Your specialist must advise of any gap that you will have to pay and provide a written estimate of the fees for treatment, before you go into hospital.
What is a prosthesis?
As part of surgery you may require a prosthesis (such as a joint replacement, cardiac device, stents, and human tissues, for further information on what products are included on this list visit health.gov.au). This is an artificial substitute for a body part that is either implanted or surgically applied, as listed by the Prosthesis List administered by the Department of Health and Aged Care. If the charge for the prosthesis is more than the government prescribed benefit, then you will be required to pay for the gap to the hospital.
Your ideal level of hospital cover will depend on your age, your health requirements, your lifestyle, your medical history, and what you can afford. The easiest thing to do is to get a quote online. Or, if you want to talk to a person, we’re here to help. We can run through your circumstances and then recommend some products based on your needs.
Again, this will depend on your circumstances. If you need glasses, massage, physio or regular dental check-ups, and also want the peace of mind of being covered for inpatient hospital treatment, then a combined hospital and extras cover might be right for you. Keep in mind, you can choose an extras-only policy, but this won’t cover you for in-hospital treatment, and you may still have to pay the Medicare Levy Surcharge (if you’re a higher income earner).
Lifetime Health Cover loading can also apply if you first purchase hospital cover after 1 July following your 31st birthday, so you may want to lock in your certified age of entry sooner rather than later by taking out hospital cover.
A pre-existing condition is defined under the Private Health Insurance Act 2007 as "any ailment, illness, or condition where, in the opinion of a medical adviser appointed by a health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day which the person became insured on the policy."
If you have a pre-existing condition that needs treatment, you’ll need to hold the appropriate level of hospital cover for 12 months before you can claim eligible benefits. This means you need either forward planning or a comprehensive cover for ‘just in case’ scenarios.
Being a private patient does not automatically guarantee you a private room – room types vary from hospital to hospital and are subject to availability.
However, if you choose our Gold Optimum Hospital Cover we offer a single room guarantee. If you request a single room in a private hospital and this is not available, GMHBA will pay you $100 per night, up to a maximum of $300 for three nights. Please contact us following your admission to claim the Single Room Guarantee payment. Please refer to our Important Information Guide for full terms and conditions.
As always, regardless of whether you attend a private hospital or elect to be a private patient in a public hospital, prior to your hospital admission ensure you have written informed financial consent so you are aware of any costs that may be incurred.