Phoenix Health Hospital

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Hospital Cover provides benefits to help pay towards the cost of treatment you receive whilst admitted into hospital.

When you’re admitted into hospital as a private patient you’re covered for things like your medical treatment and hospital accommodation.

Taking out Private Hospital Cover is all about providing you with choice. You have more choice and flexibility in choosing who treats you, where you’re treated, and often when you’re treated.

For more information about Hospital Cover and the benefits available on each level of cover, see the relevant product information sheet. Please read these in conjunction with the Phoenix Health Member Guide.

	Bronze Hospital	Bronze Plus Essentials Hospital	Bronze Plus Care Hospital	Silver Everyday Hospital	Silver Plus Content Hospital	Silver Plus Advantage Hospital
Hospital psychiatric services	R	R	R	R	R	R
Rehabilitation	R	R	R	R	✓	✓
Palliative care	R	R	R	R	R	✓
Bone, joint and muscle	✓	✓	✓	✓	✓	✓
Brain and nervous system	✓	✓	✓	✓	✓	✓
Breast surgery (medically necessary)	✓	✓	✓	✓	✓	✓
Chemotherapy, radiotherapy and immunotherapy for cancer	✓	✓	✓	✓	✓	✓
Diabetes management (excluding insulin pumps)	✓	✓	✓	✓	✓	✓
Digestive system	✓	✓	✓	✓	✓	✓
Ear, nose and throat	✓	✓	✓	✓	✓	✓
Eye (not cataracts)	✓	✓	✓	✓	✓	✓
Gastrointestinal endoscopy	✓	✓	✓	✓	✓	✓
Gynaecology	✓	✓	✓	✓	✓	✓
Hernia and appendix	✓	✓	✓	✓	✓	✓
Joint reconstructions	✓	✓	✓	✓	✓	✓
Kidney and bladder	✓	✓	✓	✓	✓	✓
Male reproductive system	✓	✓	✓	✓	✓	✓
Miscarriage and termination of pregnancy	✓	✓	✓	✓	✓	✓
Pain management	✓	✓	✓	✓	✓	✓
Skin	✓	✓	✓	✓	✓	✓
Tonsils, adenoids and grommets	✓	✓	✓	✓	✓	✓
Heart and vascular system	x	x	✓	✓	✓	✓
Lung and chest	x	✓	✓	✓	✓	✓
Blood	x	✓	✓	✓	✓	✓
Back, neck and spine	x	x	x	✓	✓	✓
Plastic and reconstructive surgery (medically necessary)	x	x	✓	✓	✓	✓
Dental surgery	x	✓	✓	✓	✓	✓
Podiatric surgery (provided by a registered podiatric surgeon)	x	x	x	✓	✓	✓
Implantation of hearing devices	x	x	x	✓	✓	✓
Cataracts	x	x	x	x	✓	✓
Joint replacements	x	x	x	x	✓	✓
Dialysis for chronic kidney failure	x	x	x	x	x	✓
Pregnancy and birth	x	x	x	x	✓	x
Assisted reproductive services	x	x	x	x	✓	x
Weight loss surgery	x	x	x	x	x	x
Insulin pumps	x	x	x	x	x	✓
Pain management with device	x	x	x	x	x	✓
Sleep studies	x	x	x	x	x	x

✓

Indicates where a service is covered on the corresponding level of cover

Indicates where Restricted benefits apply on the corresponding level of cover

Excluded

Exclusions & Restrictions

What is an exclusion?

When a service is excluded under your hospital cover there will be no benefit payable where the service is the primary reason for admission in a private or public hospital.

What is a restriction?

Restricted cover provides cover in a public hospital as a private patient. If you have restricted services and you are admitted to a private hospital, there will be no benefit payable for any theatre fee charges and a reduced benefit will apply towards your accommodation fees. This means you may be faced with considerable out-of-pocket costs in a private hospital.

What am I covered for, & what am I not covered for?

What does Hospital Cover include?

Hospital Cover provides benefits towards services you receive when you are admitted into hospital as an in-patient for treatment, such as:

Day surgery
Overnight accommdation
Theatre fees
Intensive care unit
Medicare recognised procedures
Private room [where available]
Specialist Surgeons, Anaesthetists and Assisting or Attending Doctors fees
In – Hospital Pharmacy
In – Hospital Pathology
In – Hospital medical supplies

You are covered as a private patient in a private hospital, or as a private patient in a public hospital – where you elect to be treated as a private patient. The choice is yours.

Where you elect to be covered as a private patient in a public hospital, you will be eligible for accommodation benefits paid at a shared ward rate. This means should you be given a private room, you may end up with out of pocket expenses.

What treatments are covered under your membership will depend on the level of cover you have selected, so you should always refer to your individual cover information sheet to find out what you are specifically covered for. We recommend contacting us prior to a hospital admission so we can confirm your eligibility for benefits.

Is there anything that my Hospital Cover won’t cover?

Private Hospital Cover can only provide benefits towards services received when you are admitted into hospital, or where the fund has arrangements with providers for services such as Chronic Disease Management and Obstetric programs. There are some services that your hospital cover does not provide benefits for:

Treatment received while not admitted into hospital – i.e. outpatient services, GP and Specialists visits,
Treatment received in the Emergency Department of a hospital, including emergency department facility fees,
Treatment that does not have a Medicare item number,
Services rendered in conjunction with a hospital stay where an Extras item number is raised – for example, where you are admitted into hospital for dental surgery (ie. wisdom teeth removal) and a dental item number is billed. The hospital stay and any medical and theatre items will be paid under Hospital Cover, but a relevant level of Extras cover is required to receive any benefit on the Dental items billed, and
Pharmaceuticals and medications provided on discharge from hospital

What is an Excess and Co-Payment?

What is an Excess?

An Excess is an amount you agree to pay towards your treatment if you are hospitalised, usually to reduce the premium of your cover without compromising what you are covered for.

The Excess is payable on admission to hospital once per person, per calendar year, regardless of how many times you may need to go to Hospital and does not apply to dependant children on a policy.

Excess example: You have Phoenix Health Bronze Plus Essentials Hospital with a $750 Excess
On admission to hospital you pay your $750 excess to the hospital for your first admission.
If you are re-admitted in the same calendar year, you will not have to pay your excess again.

What is a Co-Payment?

A Co-payment is an amount in addition to your nominated Excess, that is payable by you every time you are admitted to hospital for a minimum of one night (ie. not day surgery).

Co-Payments do not apply to day admissions or to dependant children listed on a policy.

Here’s an example of how the co-payments work:

Co-payment example: You have a hospital cover with a $250 excess and $300 co-payment
On admission to hospital you pay your $250 excess and where you stay for a minimum of one night, you will also be required to pay your $300 co-payment.
If you’re re-admitted in the same calendar year (again for a minimum of one night), you will not have to pay your excess, however you will still be required to pay your $300 co-payment.
If you’re admitted again before the end of the calendar year and stay overnight you’ll continue to be required to pay your $300 co-payment each time for each admission.

Before going to hospital

Access Gap Cover Scheme

Phoenix Health members with private hospital cover can eliminate or reduce out-of-pocket expenses for in-patient hospital treatment where the doctor participates in our Access Gap Cover Scheme. We currently have agreements with over 36,000 doctors who participate in the Access Gap Scheme. It is each doctor’s choice to participate.

Before booking any treatment, you should ask your doctor to explain the costs involved for your hospital admission, any fees or gaps you may be charged, including anaesthetist and assistant surgeons. If there are any gaps for you to pay, ask for a written cost estimate. This is known as Informed Financial Consent.

Doctor & Hospital Search

Looking for a doctor that participates in the Access Gap Cover Scheme? Or want to check out what hospitals we have agreements with?

You can quickly search for a doctor or specialist by visiting our search tool.

Going to Hospital?

This is what we know and where we can really help you out. As soon as you find out you’ll need a hospital admission contact us so you can be confident in what to expect. We’ll talk you through minimising doctor’s fees and any other out-of-pocket costs as well as check your cover and discuss any pre or post-hospital support programs that we may have available for you.

Let us help you, so you can focus on what’s important; we’re here for you

What do I need to ask my Doctor?

Before any treatment, we recommend you ask your doctor these 3 questions;

Will you participate in the Phoenix Health Fund Access Gap Cover scheme for my procedure?
Will I have any out-of-pocket expenses, and if so, please provide a written estimate of how much?
Will any assisting doctors also use Access Gap Cover and if so, how can I obtain a quote for their services?

Waiting Periods for Hospital Cover

What is a Waiting Period?

A waiting period is the time you’ll need to wait before you can claim a benefit on your membership, and will apply whether you’re taking out private health insurance for the first time, switching to Phoenix Health from another fund, or you’re a current Phoenix Health member changing your level of cover.

Click here for everything you need to know about Waiting Periods, including what happens if you’re new to private health insurance, transferring from another fund or you’re already a Phoenix Health member.

What are the Waiting Periods?

Hospital Cover Waiting Periods

Pre-existing conditions Excluding Hospital Psychiatric services, Rehabilitation and Palliative care	12 months
Pregnancy and birth	12 months
Hospital Psychiatric services, Rehabilitation and Palliative care Regardless of whether they are pre-existing or not	2 months
All other conditions requiring a hospital admission, that are not considered pre-existing
Hospital Care programs
Hospital treatment as a result of an accident	No waiting period

Ambulance Cover

Ambulance

1 day

For all the information you need to know about Waiting Periods, including what happens if you’re new to private health insurance, transferring from another fund or a current Phoenix Health member changing your level of cover, click here.

Looking for information about Extras Cover? Click here.

What is an Accident?

An accident for the purpose of Accident Cover means an unplanned or unforeseen event that has occurred in Australia resulting in bodily injury that requires immediate hospital treatment. The accident has happened by chance and was caused by an unintentional and external source and cannot be attributed to medical causes.

Where a member hasn’t completed serving their hospital waiting periods (or holds a level of cover that has exclusions) and is hospitalised as a result of an accident, we’ll waive the standard waiting period for that condition and benefits will be payable for their admission in a private hospital, regardless of whether the service they require is excluded on their level of cover or not. Any excesses applicable will not be waived as a part of Accident Cover.

For more information about Accident Cover, click here.

What is a Pre-Existing Condition?

A pre-existing condition is any illness or ailment that, in the opinion of a Medical Practitioner, existed at any point in the 6 months prior to taking out or upgrading your cover.

If you require hospitalisation within the first 12 months of taking out hospital cover or upgrading your level of hospital cover, and have served the general 2 month waiting period, the fund may request a Pre-Existing Condition Assessment Form to be completed by your regular GP and Specialist. This information would then be assessed by an independent Medical Practitioner appointed by the fund who will determine if the condition is pre-existing or not and as such whether or not a benefit will be paid or not.

For more information about Pre-Existing Conditions click here.

What is the Psychiatric Upgrade Waiver?

To improve access to mental health treatment in Australia, the Government have introduced mandatory Psychiatric Hospital upgrade waiver rules. Where a cover has restrictions or exclusions for hospital psychiatric services and you have served your initial 2 month waiting period, you have the option to upgrade to a cover that provides full hospital psychiatric cover, without having to serve any additional waiting periods on the upgrade for that treatment. This psychiatric upgrade waiver is available once per person, per insured lifetime and is transferrable between funds and is detailed on a Transfer Certificate.
The waiver does not apply to any excess that may apply on upgrading cover. All other waiting periods still apply.

For more information about the Psychiatric Upgrade Waiver, click here.

Hospital Care Programs

Health Management Programs

At Phoenix Health, looking after your health and wellbeing is about more than supporting you while you’re unwell. This is why we offer a range of Health Management Programs with all Phoenix Health Hospital covers with no additional or out-of-pocket cost to eligible members.

Click here to learn more.

Hospital Cover