Hospital Cover 101 Webinar

Peoplecare Health Insurance

Hospital Cover 101 Webinar Transcript

Welcome & Introduction

Tara: Welcome to our Hospital Cover 101 webinar. Thank you so much for joining us. My name is Tara and I work here at Peoplecare Health Insurance. Peoplecare Health Insurance is a not-for-profit, member-owned health insurer based here in the Illawarra and we have been supporting our community for over 70 years. And we continue to focus on supporting our members' health and wellbeing.
Before we kick off, I would like to do an Acknowledgement of Country. Peoplecare acknowledges Aboriginal and Torres Strait Islander peoples as the traditional custodians of the lands on which we live and work. We pay our respects to Elders past, present and emerging. Peoplecare's headquarters has been located on Dharawal country for over 70 years and we are privileged to continue working on these lands today.
So why are we here? Health insurance can be confusing. There's lots of terminology, different options and many different rules. Today is about helping you, our members, feel more confident in navigating the healthcare system and using your hospital cover.
I'm the Health Strategy Manager Tara and joining me today is a team of fabulous Peoplecare members.
Natalie: Hi everyone.
Tara: Natalie is a member advocate helping members to navigate a complex healthcare system and understand their hospital cover. We also have Karina.
Karina: Hi.
Tara: Karina is a member experience specialist here at Peoplecare. And Sophie.
Sophie: Hello.
Tara: Who is one of our amazing customer service consultants. Both Karina and Sophie work closely with our members every day, helping them navigate their cover and understand their claims.
So what will today's webinar cover? Everything to do with hospital cover. We'll let you know what it is, the different levels of cover, how members use their cover, key terminology and give you some tips for getting value out of your hospital cover. We'll answer the questions and topics most members commonly ask about.
Information provided to you today is general in nature. If you would like any information or advice on your specific situation regarding your hospital cover, please reach out to us here at Peoplecare Health Insurance on 1800 808 690.
So let's get started with the basics. Over to you, Natalie.

What is Hospital cover?

Natalie: So your hospital cover with Peoplecare Health helps you cover costs when you're admitted as a patient to a contracted private hospital or a private patient in a public hospital. So hospital cover includes costs associated with things like accommodation, theater fees, in-hospital medical treatment, human tissue and medical devices used during surgery or a hospital stay and your in-hospital pharmacy.
So what this means is we will cover you for your bed fees, your theatre fees, in-hospital medical specialist treatment and any medical devices and human tissue products, which are formally known as a prosthesis, listed on the Australian Government prosthesis schedule that may be used in your procedure.
So what it doesn't cover is private health insurers can't cover cosmetic procedures that aren't medically required. So in general services where you're outside the hospital setting and not admitted as a patient in hospital for. So this could include dental, optical, physiotherapy, for example, and these are generally covered under your extras if you have chosen to have these on your Peoplecare Health membership.
So let's put it simple. Your hospital cover will assist you when you're admitted into hospital as a patient, not when you're in a specialist room or a general doctor's rooms. And your extras cover can be utilised with everyday services outside of the hospital. So if you do have concerns about what your extras cover you for, it's important to reach out to our customer service team to understand your membership benefits.
Tara: Thank you so much, Natalie. I think that's some really useful information and put simply, a really important distinction. So thanks so much. And what about public versus private hospital cover? That's always an interesting topic. Over to you, Karina.

Public vs private hospital

Karina: Yeah, thank you. So absolutely. Public patient versus being a private patient. So public patient, you're in the public system. You're in a public hospital and on the public Medicare waiting list. Generally, you do not get your own choice of treating doctor or surgeon and potentially a lot longer waiting times. We all know stories of someone who's waited over 12 months for a hip replacement.
So again, you can be a private patient in a public hospital or a private hospital. It gives you more choice, more control. You can choose your own surgeon or specialist. What hospital would you like to go into? Have your own room if it's available. So your treatment's often a lot faster and you can potentially pick the time that suits you best.
Tara: Thanks, Karina. That sounds like really important things that people would need is convenience and access to care in a timely manner. Thanks a lot. Now let's talk about the different levels of hospital cover. Karina, what are the different levels of hospital cover available?

Levels of Hospital cover

Karina: Yeah, absolutely. So we've got four different tiers. We start off with our basic tier, our basic hospital cover. We've got bronze, silver and gold. So each level has different clinical categories included. So as you move up the tiers, more clinical categories are included. So gold being our highest provides cover for all clinical categories that Medicare recognises.
Tara: Fantastic. Sophie, what does Peoplecare offer?
Sophie: Thank you, Tara. So Peoplecare has six open products. They range from Basic Accident being our lowest, Basic Plus, Bronze Plus, Silver Plus Essentials, Silver Plus Grow and Silver Plus Hospital. So there are six open products. So the plus means that Peoplecare has chosen to include clinical categories that wouldn't naturally be on that product otherwise. For example, Bronze Plus has more than the standard bronze. And Peoplecare have chosen those added clinical categories. And different health funds have different pluses. They won't have the same clinical category that we have.
We also have three closed products. They are Gold Hospital, Premium Hospital Gold and Mid Hospital. So that means that we no longer sell those products, but some of our members are still on those products and can stay on those products.
Tara: Thanks so much, Sophie. With all the plus products out there in the market, it could be confusing to choose a cover. What should members look for when comparing covers?
Sophie: So the key things to check is what's included, what's restricted and what's excluded. So included means that that clinical category is included in that cover. Restricted means that there's limited benefits. So you can be admitted as a private patient in a private hospital, but there would be quite large out-of-pocket costs because we can't pay the theatre fee and we can only pay default rate of the bed fee. You can be admitted as a private patient in a public hospital, however, and excluded means that there's no cover. So that's not included in your cover at all.
Tara: Thanks so much, Sophie. So it sounds like people should really focus on what clinical categories they will need treatment for and make sure they choose the right cover for them. So, Karina, why do members choose hospital cover?

Why members choose hospital cover

Karina: Yeah, Tara, I believe that there's many reasons people can pick hospital cover. It's giving you access to the private system. So it's giving you control. Choice of doctor. You know, do your research. Select who you would like to do your surgery. You can have a look on our website under Find a Provider and look at who's participated in the Access Gap Scheme before. Choice of hospital. Is it a hospital near you? Is it a hospital that could be an hour away? You have that choice of where you go. So timings. Potentially shorter wait times. Therefore, you've got faster access for treatment for many procedures. And again, you pick a time that suits you better around family, around life, work.
Offers you financial protection. So private hospital treatment can be very expensive. Serious procedures can result in significant costs without cover. Another good point is government incentives. So if you are a high income earner, holding private hospital cover can exempt you from the additional Medicare levy surcharge. So you can look at those tiers on our website to see what income bracket you may fall into. The other is avoid or reducing further lifetime health cover loading as another big one. So there's, yeah, many, many reasons for having private hospital cover. And it's ensuring that you understand all of those rules and what's included in it.
Tara: Great. Thanks, Karina. It's also really important to understand, members, that government rebates can also help reduce the cost of your cover. So make sure you check out those government rules and what rebates you're eligible for at the Department of Health and Ageing's website.
Now let's jump into a simple example using John, who needs a joint replacement. Natalie, what should John do first if he has hospital cover?

Member journey: John's joint replacement

Natalie: Yeah, thanks, Tara. So the first thing John should do is definitely go and see his GP. A GP can provide a referral to a specialist to start the process of establishing what surgery may be required and if a joint replacement is in fact needed sooner rather than later. At this stage, it's important to consider a specialist who may participate in a scheme referred to as Access Gap to assist with keeping your costs lower. So this scheme called Access Gap can help reduce out-of-pocket costs with our many agreed providers across Australia. In many cases, if a specialist does participate in Access Gap, your costs could be kept as low as a maximum of $500.
Tara: Great. Thanks, Nat. I think it's also a useful tip that members can visit our website and look for a Find a Specialist or Provider search that helps them search for providers that do participate in our Access Gap scheme. So Nat, what would be the second step that John would take in this member hospital cover journey?
Natalie: Yeah, perfect. So once they've got a referral, they can book in and go and see a specialist. They can then establish what procedure may be required. So it's important to commence discussions surrounding your procedure and what this may actually cost you. We suggest you ask whether they participate in Access Gap during this appointment or alternatively, what the costs of the procedure may actually be. And this should all be documented within what we call an Informed Financial Consent or, to put it simply, an itemised quote, to establish what the procedure will involve and how much this may actually cost you.
This Informed Consent, like any quote, should outline and break down your procedure and what your surgery may involve. You may notice that your Informed Financial Consent will show a rebate from Medicare and a rebate from your health fund. If they are not proceeding to go through the Access Gap, you should have an outline figure to show what costs may impact you personally and what part of the procedure is not covered by Medicare or Peoplecare. And look, it's really important to then establish where the procedure will take place. As each specialist will often have an agreement with specific hospitals to utilise their facilities.
Tara: Thanks, Natalie. That's some really useful information. Peoplecare has agreements with most private hospitals across Australia. What does John need to do next? I'll throw to Sophie for this one.
Sophie: Thank you, Tara. So the first thing that John will need to do is he will need to give Peoplecare a call and we will check to see if the clinical category that he's going in for, so in this particular scenario, it will be a joint replacement. We'll need to see if that's a clinical category that's included in his cover. If it is, we will then have a look to see if he's served his waiting periods, which are two months if not a pre-existing condition and 12 months if it is a pre-existing condition. Then we will check whether or not he has an excess. So depending on what level of cover you have, you'd have chosen an excess. So we'll go through that. The next thing that we'll go through is the hospital and we will check whether or not we have a full contract with that particular hospital or to see if we don't have a full hospital contract.
The last thing that we'll go through is hospital substitution programs. Yes, so it's a really good opportunity for members to understand that they can chat with their GP or specialist around what treatment they might be eligible for in the comfort of their home. Peoplecare covers medical treatment through a program called Hospital in the Home and rehabilitation treatment through a program called Rehabilitation in the Home. This means that that treatment the member would have otherwise received while staying in a hospital and that if they're eligible, they may be able to go home and receive that treatment under the care of their specialist or GP and Peoplecare can fund those services. For more information around Hospital in the Home and Rehab in the Home programs, we encourage you to give Peoplecare a call and we can discuss your options.
Tara: Sophie, what would be the next thing that John would need to consider before he goes to hospital?
Sophie: John would need to then book the procedure and plan his hospital admission. And we do have a part on our website, a going to hospital guide, which I do recommend reviewing before you do have an admission.
So the next thing that he will do is he will actually go to hospital and he will need to consider some costs that he may have. So one of those may be an excess and that will be dependent on his level of cover. Any agreed gaps, which he would have discussed with the doctors beforehand and any personal incidentals, which may be things like Foxtel, parking, Wi-Fi, those sorts of things.
Now, after the procedure, that's where the claims start to happen. So this is step six. So the hospital themselves, they will bill Peoplecare directly. And so that will be for the bed fee and theatre fee. That automatically comes through to us. Now, with doctors bills, it depends on how they're billing, depends on what steps you may need to take. So if a doctor goes through access gap or no gap, they just bill the health fund directly. But if they don't go through that scheme and they do charge larger out-of-pocket costs, you may need to do the claim in yourself. And the way to do that is by some forms that we will send through to you. It is a Medicare form and a Medicare two-way form. You can always contact us and we can assist you through that as well.
Now, in terms of other steps, you may have a GP appointment after the procedure to see how your recovery is going. So that may be an additional cost because that is outpatient. And lastly, some services such as a joint replacement, you may need things like physio ongoing as well. So if you do have extras cover, you may be able to claim those sort of services through us for your extras cover as well.
Tara: Great. Thanks, Sophie. And it is really important that members do understand that you can visit our website or call us at any time and we'll take you through those specific steps that you need to follow going to hospital. And then our hospital guide is a really handy tool for you to access prior to your hospital admission. But if in doubt and you have a specific circumstance you wish to discuss, please make sure you give us a call.

Key terminology

Tara: So now we're going to jump to unpacking some common terms that are used in hospital cover and try and help you with any of that confusing terminology. Karina, over to you to explain a little bit more about excess.
Karina: Yeah, thanks, Tara. So an excess is an amount you contribute when admitted to hospital. So on our open hospital products, we have a $500 or $750 excess. The higher excess generally means lower premiums. For an overnight stay, you would pay, for example, $500 if you had a $500 excess. If it was just a day admission, we only charge half the excess. But $500 would be the maximum that you would pay within a financial year, regardless of how many admissions that you have. Another great thing with us is that we do not charge any excess for children under the age of 21.
Tara: Great. Thanks, Karina. Over to you, Natalie, just to explain a little bit further around waiting periods.
Natalie: So it's really critical to understand your waiting periods if you are new to a health fund or changing your level of cover. So this can be the difference between getting a benefit for a service or paying for the service in full yourself. So waiting periods are the time which must pass before any claims can be made through Peoplecare Health. Waits differ from service to service. So checking in with your customer service team can prevent any confusion. If you are unsure about your wait, please reach out and we can go through your cover in more detail, including any waits which apply more specifically to your services.
Tara: Thanks, Natalie. Sophie, you touched on a scheme called Access Gap a little earlier. Could you explain Access Gap a little bit further for us?
Sophie: Yeah, of course. So Access Gap is a scheme that some doctors participate in. Not all doctors, however, do participate. But if they do, it means the maximum that they can charge you out of pocket is generally $500. It is $800, however, with obstetrics. And then you pay that to them and they send the rest of the bill directly through to us and Medicare. It does mean that as a fund, we do pay a little bit more than the scheduled fee to the doctor. So that's why it is an incentive for them to go through it.
Tara: Great. Sounds like a great incentive. And a reminder to members to jump on our website to have a look for find a specialist for those that participate in Access Gap or give us a call and we can help you find someone who participates in our Access Gap program.

Getting value from your Hospital cover

Tara: So now we're going to look at value. And I think it's important that members understand the value they can get out of their hospital cover. So what are some simple ways members can get more value out of their hospital cover? Karina, I'll throw to you for this one.
Karina: Yeah, so Tara, I think in regards to getting value, the biggest thing is being aware of your cover. Have that power yourself. Ask for a cover description. We can email or post that out to you. Have a look what's included so you know what you can and what you can't claim. Ask about costs up front in regards to any surgery that you need to have done. Get that informed financial consent so that there's no surprises afterwards. It gives you the chance to then to maybe try and negotiate the out-of-pocket expenses with your doctor. They may not participate in the Access Gap scheme, but with that conversation, they may be able to reduce any out-of-pocket expenses. Double checking that the hospital that you're choosing that we are fully contracted with.
So consider specialists who are with the Access Gap scheme. That's one of the biggest things. You can ask the surgeon, ask the anaesthetist if they are willing to participate in that scheme for you. As we've mentioned before, you can look on our website under Find a Provider to see who has participated in it previously. They do work on a day-to-day basis, patient-to-patient basis, so they may do it for one and not the next, but it's a good question to ask all the time.
Another Peoplecare benefit is no excess for children under the age of 21. All of our levels of cover include 100% ambulance, whether that be land, sea and air, and that is with state-based providers and medically necessary. The exception is for the Northern Territory in regards to state-based. We offer a 10% discount when hospital and extras are combined. So that's a good one. And then we also offer age-based discount on some of our products. So that is a government-supported reduction of up to 10% for Australians aged between 18 and 29. So there's some great tips just for being with Peoplecare.
Tara: Okay, so with a little planning, it sounds like it's really important that members are aware of what their cover covers them for and that they are accessing a cover that suits them. Sophie, how can members tell if their cover still suits them in their life stage?
Sophie: Thanks, Tara. That is a great question. So there are a few different things to consider on whether or not that your cover does still suit you. So the first question that you would be asking is, does the cover have the clinical categories for the treatments that you may need coming up in the future? Are you comfortable with the excess? As Karina mentioned earlier, our open products have the excess option of $500 or $750 excess. And as she mentioned, the $750 does reduce your premium. However, when you do go into hospital for that admission, it is a larger outlay. And the last question to be asking yourself is, have your health needs changed?
And that brings on to a good time to review. So one time that you might want to review is whether or not you want to start or grow a family. And the reason for that is we have one open product that has pregnancy and birth as a clinical category included. Another time might be after a hospital claim. We all know that our health needs changed from years that we go through. So what you may have needed 10 years ago may be different to now and it may be different to 10 years in the future. So we always do recommend that you do a cover review to make sure that you are on the right level of cover for both yourself and your family.
Tara: Excellent. Thanks so much, Sophie. I think reviewing cover regularly helps ensure you're getting the right protection that's right for you and your family, depending on your life stage. So be sure to give our team a call.

Key takeaways & close

Tara: So a key takeaway from today is hospital cover does not need to be complicated. We are here to help you. Three things that are really important to remember is know what you are covered for. And if you need help reviewing a cover, reach out. Ask questions about your treatment from your GP and your specialist and allow time for planning for a hospital admission. And reach out to our team if you need any help.
The best place to get help is to call Peoplecare and our wonderful customer service consultants, member advocates and member experience specialists are here to help you. Speak with a team member about your cover, about the hospital admission you're needing or a hospital admission you may need in the future. Or visit our wonderful website at www.peoplecare.com.au.
I would like to take the time to express my gratitude and great thanks to our wonderful panellists today, Natalie, Karina and Sophie. And thank you all to our members for taking the time and joining us. We hope you feel much more confident about your hospital cover and know that we're here to help. Reach out with any questions. Just give us a buzz. 1800 808 690. We hope to be talking to you soon. Take care and goodbye for now.