HCF Cover FAQs
Private hospital cover helps reduce the costs associated with treatment in hospital (e.g. doctors' fees, accommodation, operating theatre, intensive care, and pharmaceuticals in hospital).
Having private hospital cover also allows you to choose your own doctor (e.g. your own obstetrician), and choose when you have treatment for elective surgery.
- Overnight and same day accommodation charges, less your excess (if applicable)
- Operating theatre and critical care fees
- Intensive care and Neo-natal intensive care
- Prostheses for covered services (up to the amount on the government Prostheses List)
- Emergency ambulance.
- Medical and associated hospital benefits for which there is no Medical Benefits Schedule item number or when the medical services aren't approved for payment by Medicare
- Private room accommodation for same-day procedures
- Experimental treatments
- Experimental and high cost non-PBS drugs
- Procedures normally performed in a doctor's surgery or as an outpatient
- Private hospital emergency room fees
- Respite care
- Nursing home patients are limited to benefits set by the Commonwealth Department of Health
- Special nursing like your own private nurse
- Luxury room surcharge
- Donated blood and blood products and blood collection and storage
- PBS pharmaceutical benefits in non-participating hospitals
- Pharmaceuticals (including PBS pharmaceuticals benefits) and other sundry supplies not directly associated with the reason for admission
- Take home items (e.g. crutches, toothbrushes and medicines)
- Personal convenience items (e.g. phone calls, newspapers or magazines)
- Massage and aromatherapy
- Some services provided while in hospital by non-hospital providers
- Where a service isn't covered for the payment of benefits in a hospital, any associated items (e.g. medical gap, prosthesis, pharmacy) also aren't covered
- The gap on government approved gap-permitted prostheses items
- Any exclusions under your cover.
See our Member Guide for all the conditions relating to hospital cover.
Extras cover helps reduce out-of-pocket expenses associated with managing or improving your health. Examples include dental, optical, physiotherapy and chiropractic. Depending on your level of cover, you may be able to claim towards:
- Diagnostic and preventative dental
- Restorative dental (fillings), oral surgery, endodontic services
- Dentures, crowns and bridges
- Chiropractic, physiotherapy and osteopathy
- Occupational, speech pathology
- Pharmaceutical (HCF approved, non-PBS)
- School accident cover
- Selected natural therapies
- HCF approved artificial aids
- Hearing aids
- HCF approved Health Management Programs.
- You can't claim more than the actual cost of your treatment
- Artificial aids and hearing aids: your entitlements may not renew every year. Please check with us before you incur any costs
- See our Member Guide for all the conditions relating to extras cover.
- Psychological and developmental assessments. Where psychology is included in your cover, psychology treatment is only payable when your GP has prescribed a mental health plan under Medicare and your psychology entitlements from Medicare for that year are exhausted
- Goods and services while you're a hospital patient, except for eligible oral surgery
- Pharmacy items that aren’t on our approved pharmacy list (e.g. items listed on the PBS, items prescribed without an illness, items that are available without a prescription, or items that are not TGA approved)
- Goods or services that hadn't been provided at time of claim (e.g. pre-payment)
- Fees for completing claim forms and/or reports
- Goods and/or services received overseas or purchased from overseas (including items bought online)
- Where no specific health condition is being treated or in the absence of symptoms, illness or injury
- Routine health checks, screening and mass immunisations
- More than one therapy service performed by the same provider in any one day
- Co-payments and gaps for government funded health services (e.g. the co-payment for PBS items)
- Where a provider isn't in an independent private practice
- More than one of the following therapies received on the same day (physiotherapy, chiropractic and osteopathy)
- Any exclusions under your cover.
In addition to the hospital and extras exclusions listed above, there are situations where HCF health insurance doesn't cover you, including:
- Where there are exclusions on your cover
- Claims made 2 years or more after the date of service
- When you or your dependants have the right to recover the costs from a third party other than us, including an authority, another insurer (like motor vehicle or workers compensation), or under an employee benefit scheme
- Treatment for pre-existing ailments or conditions within waiting periods
- Goods and services received during any period where your payment is in arrears, your membership is suspended or you’re within waiting periods
- Treatment that we deem inappropriate or unreasonable, after receiving independent medical or clinical advice
- Any service where the treatment doesn't meet the standards in the Private Health Insurance Accreditation Rules 2011 or as amended
- Services that aren’t delivered face-to-face, like online or phone consultations, unless you’re participating in one of our chronic disease management or health improvement programs
- Goods or services supplied by a provider not recognised by us
- Goods or services provided outside Australia, which don’t meet the requirements under the Private Health Insurance Act (2007)
- Claims that don’t meet our criteria.
Many people don't know that Medicare doesn't cover you for ambulance costs. And ambulances can be expensive, especially if you live in a rural or remote area.
Depending on your level of cover, HCF ambulance insurance covers the cost of emergency ambulance services with State Government services if you need hospital or on-the-spot treatment in Australia.
Some levels of cover also include State Government non-emergency ambulance services.This is payable if your doctor requests ambulance transport because your condition requires monitoring and support in transit (up to $5,000 per person per calendar year).
Here’s a high level explanation of how it works across Australia:
Residents of NSW & ACT
In NSW or ACT
Emergency ambulances aren’t fully covered by the state government unless you hold certain government concession cards. To avoid out-of-pocket costs you should get private health insurance that includes ambulance cover.
HCF hospital and extras insurance covers state provided emergency ambulance services to the nearest hospital able to treat you. On some levels of HCF cover, you may also be able to claim up to $5,000 per person, per year for non-emergency, medically necessary ambulance transport by state providers.
If you have HCF hospital cover you’re entitled to fully covered state emergency ambulance transport across most of Australia under a levy arrangement. This excludes services in Qld and SA (and also WA for ACT residents) but you may be able to claim under your HCF cover).
If you have standalone HCF extras cover you may be covered for unlimited emergency ambulance for transport in NSW or ACT. On some levels of cover there’s an annual limit of 1 claim per person and 2 per policy for states other than NSW and ACT.
Residents of Queensland
State ambulance services are covered by your state government Australia-wide, so you don’t need separate insurance.
Residents of Tasmania
State road ambulance services are covered by your state government across Australia, with the exception of Qld and SA. You may be able to claim for services not covered by your state scheme under your HCF cover (limits may apply if you have standalone extras cover).
Residents of Victoria, SA, WA & NT
You need either private health insurance which includes ambulance cover or an ambulance subscription.
Please note: A waiting period of 1 day applies for emergency and 2 months for non-emergency cover.
Please ensure you understand who's covered under your policy. Review it at least once a year to identify changes in your circumstances that could affect your health cover needs. If your family situation changes, let us know so that we can suggest adjustments to your cover.
- Partner listed on the policy
- Dependants listed on the policy.
Only the policyholder can determine who's covered under a membership.
The children listed on your membership are automatically covered at no extra cost under your family cover until the day before they turn 22.
If your children are full-time students and single, simply register them as Student dependants at the start of each academic year, and they'll be covered for no extra cost until the day before they turn 25 or cease full-time study (whichever comes first).
If your children aren't full-time students but are single, you can also continue to cover them until they turn 25 with Extended Family Cover which is only, available on certain levels of HCF cover. Otherwise, your adult children will need to take out their own cover.
All new dependants must serve waiting periods, unless they're transferring from another membership or another health fund where they've already completed their relevant waiting periods. In this case they'll need to request an Interfund Transfer Certificate from their previous fund when they join HCF.
- Dependants listed on the policy.
Single parent families may get a discount (approximately 20% of the family rate) on their hospital and extras cover on certain levels of HCF cover.
- Partner listed on the policy.
If they're listed on your policy, your children are covered under your family cover until the day before they turn 22. If they're full-time students and single, register them as student dependants, and they'll be covered for no extra cost until the day before they turn 25 or cease full time study (whichever comes first).
If your children aren't full-time students but are single, you can also continue to cover them until they turn 25 with Extended Family Cover on selected levels of HCF cover. As long as they're not married or in a de facto relationship, you can take out this cover for a surcharge of 25% of your existing premium – even if your children are living away from home.
If you're under 22, you don't need to do anything. You're covered under your family's membership.
If you're between 22 and 25, you may be eligible to be covered under Extended Family Cover for an extra cost of 25% on top of your family's current membership.
If you're under 25 and single, you can be covered under Extended Family Cover at an additional cost of 25% on top of your family's current membership.
If you're single, under 25 and studying full-time, you can continue to be covered under your family membership as a student dependant on selected covers.
We have an extensive network of service providers and private hospitals throughout Australia, where charges have been negotiated on your behalf.
The Australian Government subsidises medical services listed on the Medicare Benefit Schedule (MBS). When a doctor charges a fee higher than the MBS, it's called a 'medical gap'.
To help you minimise your of out-of-pocket expenses for doctors and specialists fees in hospital, we've negotiated 'no gap' agreements with thousands of doctors across Australia. Ask yours if they're willing to participate. If not, they may agree to charging a 'known gap', capped at $500.
Always ask your doctor to detail their charges (and any out-of-pocket expenses) before you're treated.
An HCF participating hospital is a private hospital where we've negotiated charges for accommodation and other services, so they don't cost you extra.
Any excess and conditions relating to your hospital cover will still apply in any HCF participating hospital. You may still have to pay for doctor's bills if your doctor or other specialists don't agree to participate in our no-gap or known gap scheme (see above).
- Check your hospital insurance covers you for the procedure.
- If you'll need a prosthesis, ask your doctor which will be the best for you and which no-gap prostheses are available. If the doctor recommends one for which a gap is payable, ask why they're recommending it.
- Ask your doctor to explain the costs of your surgery including any medical gap, prosthesis gap (if any) and any other expenses. If there are any out-of-pocket expenses ask for a written cost estimate.
- Call us on 13 13 34 if you're unsure whether you'll have to make any gap payments.
HCF participating hospitals include most private hospitals throughout Australia. You're fully covered (except for any exclusions, excess and conditions relating to your hospital cover which still apply) in every one of them for the following in-hospital expenses:
- Overnight and same-day accommodation
- Operating theatre and critical care fees
- Supplied pharmaceuticals directly associated with the reason for admission (including the Pharmaceutical Benefit Scheme benefits)
- Allied services such as physiotherapy, occupational therapy and dietetics
- Surgically implanted government recognised prostheses
- Emergency ambulance.
A non-participating hospital is a private hospital that we don't have an agreement with. If you're treated at one you could face significant out-of-pocket costs.
- If you're treated as a public patient, you're fully covered under Medicare
- If you're treated as a private patient, your HCF hospital cover will pay for some of the costs associated with your treatment (if it's listed on your policy) and may be able to choose your doctor.
- You have little say over who treats you
- You have little control over when you get treated for elective procedures
If you're treated at a private hospital, Medicare will cover a portion of your medical costs, but won't cover your accommodation and theatre expenses. This is where hospital cover can help.
Our hospital cover contributes to the portion of treatment costs not covered by Medicare:
- The government sets a dollar amount for in-hospital medical treatments, known as the 'schedule fee'. Medicare pays 75% of this and your hospital cover pays the remaining 25%
- Some doctors and specialists charge more than the schedule fee. The difference between the two is the 'gap', which falls to you to pay. If you choose an HCF participating doctor you'll either pay no-gap or a known-gap (up to $500).
These are services that are directly related to hospitalisation for pregnancy and childbirth. They include things like pregnancy complications, the delivery and prenatal and postnatal care of the mother.
You need to be on cover that includes pregnancy and birth-related services at least 12 months before you give birth, as there's a 12 month waiting period.
If you’re on a single or couples membership, it’s important to call to tell us your expected due date as soon as possible. We’ll transfer you to a family membership from the expected date of birth.
This will ensure your baby is covered and won’t have to serve any waiting periods. If you don’t tell us your expected due date, you still have 2 months to transfer to a family membership from the date your baby was born and your baby will be covered from this date.
Travelling interstate or overseas
Yes – you're covered throughout Australia.
On selected levels of hospital cover, HCF members who live in isolated and rural communities can claim travel benefits if specialist medical and hospital treatment isn't available locally. If you're intending to move interstate permanently, please call us on 13 13 34 to change your contact details.
No – your HCF insurance only covers you in Australia.
HCF offers travel insurance. You can find more information here.
Travel insurance is issued and managed by AWP Australia Pty Ltd ABN 52 097 227 177 AFSL 245631 trading as Allianz Global Assistance as agent for the insurer Allianz Australia Insurance Limited ABN 15 000 122 850 AFSL 234708 (Allianz). The Hospitals Contribution Fund of Australia Ltd ABN 68 000 026 746 AFSL 241414 (HCF) arranges this insurance as agent for Allianz. We do not provide any advice based on any consideration of your objectives, financial situation or needs. Terms, conditions, limits and exclusions apply. Before making a decision, please consider the Product Disclosure Statement available at hcf.com.au/travel. If you purchase this insurance, we will receive a commission that is a percentage of the premium. Ask us for details before we provide you with any services.
Health insurance won't cover you outside Australia.
If everyone on your health cover is overseas for more than 30 days, you may be able to suspend your policy for that time.
Be aware that suspending or cancelling your HCF hospital cover may mean you have to pay additional Medicare Levy Surcharge (MLS). If you'd like more information about this call us on 13 13 34 and we'll go through your options with you.
Suspending your policy also means you won't be eligible for free travel insurance, if it's included on your cover.
Periods of suspension won't count towards any waiting periods or benefits that accrue based on a length of membership.
If you cancel completely and don’t have cover with another Australian health fund, you'll need to re-serve all waiting periods.
There's nothing in the tax legislation that requires you to suspend or cancel your policy if you go overseas. It's your choice but there may be MLS implications if you do so.
Not necessarily. Contact your accountant or tax agent for advice on this.
Travel insurance isn't hospital cover for MLS purposes. So you'll be considered to be without hospital cover during the period of suspension or cancellation.
If you cancel your cover, you won't be deemed to have had continuous membership and will need to re-serve all waiting periods.
Having cover with an overseas fund isn't considered having hospital cover during the period of suspension or cancellation.
Individuals on a policy can't be suspended. In family situations, this means everyone on your policy must be suspended.
You and your dependants may need to have private patient hospital cover to avoid paying the MLS. Cancelling or suspending cover for yourself will mean that you and your partner may each still be liable for the MLS if your taxable income exceeds the relevant threshold.
By maintaining your hospital cover in Australia, you won't be liable for the MLS while you're overseas.
If you're admitted to hospital for your wisdom teeth extraction your hospital cover will contribute towards the cost.
Extras cover contributes towards the cost of wisdom teeth extraction in the dentist’s chair, subject to your level of cover.
There's a 12 month waiting period for this procedure.
The benefits paid for extraction in the dentist's chair is taken from the annual limits of your extras cover so you'll have an out-of-pocket expense.
For more information on wisdom teeth extraction call us on 13 13 34.
Prostheses are items used in surgery to augment or replace a part of the body (e.g. pacemakers or joint replacement devices).
We cover government approved, non-cosmetic prostheses that are surgically implanted. Ask your doctor which prosthesis is best for you and whether a no-gap option is available.
If this is the first time you're having insulin pump therapy, and you're being treated as an outpatient, we'll pay 100% of the highest costing insulin pump on the Federal Government Prosthesis List (currently up to $9,500) when we receive your completed insulin pump claim form.
If you're admitted to hospital to start your pump therapy, we'll provide a benefit, provided the Type C certification is completed in accordance with the legislation. Please note that education is not a valid reason for hospitalisation. We may ask for additional information to verify the reasons for hospitalisation.
If you've been on Top Plus, Top Hospital, Fit & Free, or Healthmate Ultimate, Premium or Ultimate hospital cover continuously over a 5 year period you'll be eligible to claim 100% of the highest costing insulin pump on the Federal Government Prostheses List (currently up to $9,500) – you'll have no out-of-pocket expense.
If you've maintained any other level of hospital cover during the previous 5 years, you'll be eligible to claim up to half of that amount (currently up to $4,750) provided your cover doesn't exclude insulin pump treatments.
The replacement cycle doesn't reflect the manufacturer’s warranty period. It's the reasonable life expectancy of an insulin pump. If you wish to replace your insulin pump in less than 5 years, a pro-rata benefit may be offered depending on your individual circumstances, provided the pump isn't under warranty.
Please note that we don't replace damaged, lost or stolen pumps. We also don't pay for consumables for insulin pumps, which are available through the National Diabetes Services Scheme.
Complete and submit a replacement insulin pump claim form.