HCF Cover FAQs
Types of health cover
There's 3 types of health insurance: hospital, extras and ambulance only (not available to residents of Qld and TAS due to state schemes). Your level of health insurance will depend on the services you want to be covered for and the amount you're willing to pay. Watch this video on how to choose the right cover for you.
What's hospital cover?
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.
HCF hospital cover includes (for treatments listed on your cover):
- 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.
What's extras 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
- Orthodontics
- Dentures, crowns and bridges
- Optical
- 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.
Watch this video to find out how you can save with 100% back on a range of popular extras services*.
*100% back from providers in our No-Gap network is available on selected covers. Waiting periods and annual limits apply. See hcf.com.au/100back
What's not covered or included?
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.
What's ambulance cover?
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.
Interstate
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.
Who's covered?
Please make sure 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.
- Policyholder
- Partner listed on the policy
- Dependants listed on the policy.
Only the policyholder can determine who's covered under a membership.
The dependants listed on your membership are automatically covered at no extra cost under your family cover until the day before they turn 22.
If your dependants are full-time students, rely on you for maintenance and support, and aren't married or in a de facto relationship, 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 31 or stop full-time study (whichever comes first).
If your dependants aren't full-time students but rely on you for maintenance and support, and aren't married or in a de facto relationship, you can also continue to cover them until they turn 31 with Extended Family Cover which is only available on some levels of HCF cover. Otherwise, your adult dependants 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.
- Policyholder
- 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.
- Policyholder
- Partner listed on the policy.
- Policyholder
Dependants
Until what age can dependants stay on their family's health cover?
To make healthcare more affordable for our members, we've implemented government reforms that let dependants stay covered on their family’s health cover for longer. You can now keep dependants on your family’s health cover until they turn 31.
Does my health insurance cover my dependants?
If they're listed on your policy, your dependants 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 31 or cease full time study (whichever comes first).
If your dependants aren't full-time students, but rely on you for maintenance and support and are unmarried or not in a de facto relationship, you can continue to cover them until they turn 31 with Extended Family Cover. This is available on some levels of HCF health cover and will add a loading to your premium.
Extended Family Cover is not available on the following covers: Healthmate Ultimate Gold, HealthClub Silver Plus, Healthmate Advanced Silver Plus, Healthmate Starter Silver Plus, Healthmate Essentials Silver Plus,Top Hospital Gold, Healthy First Hospital Silver Plus, HealthStart Hospital Silver Plus, Premier Extras, Healthcover Extras, Smart Extras, HCF Ambulance Cover, HCF My Future Basic Plus, HCF Future Care Basic Plus, Fit & Free Silver Plus and Young Singles & Couples Basic Plus.
I've just finished school, and am starting my first job. Does our family health insurance cover me?
If you're under 22, you don't need to do anything. You're covered under your family's health cover.
If you're between 22 and 30, you may be eligible to be covered with Extended Family Cover for an additional loading on top of your family's current premium.
I'm still living at home but just finished studying at university full-time – what do I need to know?
If you're under 31 and primarily reliant on your parents, you can be covered with Extended Family Cover at an additional loading on top of your family's current premium.
Extended Family Cover is only available on some levels of HCF health cover and will add a loading to your premium. If you're not eligible for Extended Family Cover we can help you choose your own health cover to suit your needs and budget, get in touch with us on 13 13 34 or visit your nearest branch.
I'm still studying at university – can I stay on my family's health cover?
If you're single, under 31 and studying full-time, you can continue to be covered on your family’s health cover as a student dependant.
HCF No-Gap or Known-Gap scheme
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.
Find an HCF participating doctor
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).
Before having hospital treatment
- 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.
Participating hospitals
What's a participating hospital?
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.
How do I find a participating hospital?
What's a non-participating private hospital?
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.
What's the difference between public and private hospitals?
Public hospitals
Pros
- 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.
Cons
- You have little say over who treats you
- You have little control over when you get treated for elective procedures
Private hospitals
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).
Pregnancy cover
What are 'pregnancy and birth-related services'?
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.
What sort of cover do I need if I want to cover the birth?
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.
To check your cover, view your product summary at online member services, or call us on 13 13 34.
We're having a baby – when do I need to add my baby to my membership so he or she is covered?
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
I'm travelling interstate - does my private health insurance cover me outside my state?
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.
Does my private health insurance cover me if I'm sick when travelling overseas?
No – your HCF insurance only covers you in Australia.
HCF offers travel insurance. You can find more information here.
The Hospitals Contribution Fund of Australia Ltd ABN 68 000 026 746 AFSL 241414 (HCF) arranges this insurance as agent for AWP Australia Pty Ltd ABN 52 097 227 177 AFSL 245631 trading as Allianz Global Assistance (AGA). AGA arranges and manages travel insurance as agent for the insurer Allianz Australia Insurance Limited ABN 15 000 122 850 AFSL 234708 (Allianz). Terms, conditions, exclusions, limits and applicable sub-limits apply. HCF, Allianz and AGA do not provide any advice on this insurance based on any consideration of your objectives, financial situation or needs. Because of that, you should consider whether the advice is appropriate for you. Before making a decision please consider the Product Disclosure Statement, the Financial Services Guide and Target Market Determination (TMD). The TMD is available at allianzpartners.com.au/policies. If you purchase a policy, HCF and AGA receive a commission which is a percentage of your premium - ask us for more details before we provide you with services.
Can I suspend or cancel my policy while I'm overseas?
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.
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.
Do I have to suspend or cancel my health insurance policy when I go overseas for a period of time?
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.
Won't the premium payments I save by suspending or cancelling my policy be enough to pay my MLS liability?
Not necessarily. Contact your accountant or tax agent for advice on this.
What if I take out travel insurance for the period I'm overseas and suspend or cancel my hospital cover?
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.
What if I take out medical insurance with an overseas fund while I'm overseas but cancel my cover in Australia during this time?
Having cover with an overseas fund isn't considered having hospital cover during the period of suspension or cancellation.
What if I cancel or suspend cover for myself but retain the cover for my family?
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.
What if I take out travel insurance while I'm overseas and maintain my hospital cover?
By maintaining your hospital cover in Australia, you won't be liable for the MLS while you're overseas.
Dental Surgery
In-patient dental surgery, like dental implants or wisdom teeth removal, can be claimed on both your hospital cover (for things like accommodation and operating theatre fees) as well as on your extras cover (your dental surgeon’s fees).
You must hold eligible extras cover if you want to claim benefits for dentist or dental surgeon’s fees performed in hospital. Depending on your annual limit you may still have out-of-pocket costs, however this cost will be higher if you don’t hold eligible extras cover.
For more information on dental implant surgery or wisdom teeth extraction call us on 13 13 34.
Prostheses
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.
Insulin pumps
I'm about to start insulin pump therapy as an outpatient – can I claim for this?
HCF members who’ve held one of the HCF covers listed below for 12 months may claim insulin pump benefits.
- Fit and Free Silver Plus
- HCF Corporate Gold
- HCF Hospital Gold
- Healthclub Silver Plus
- Healthmate Advanced Silver Plus
- Healthmate Essentials Silver Plus
- Healthmate Starter Silver Plus
- Healthmate Ultimate Gold
- HealthStart Hospital Silver Plus
- Healthy First Silver Plus
- Hospital Advanced Savings Silver Plus
- Mid Hospital Silver Plus
- Top Advanced Hospital Gold
- Top Advanced Shared Gold
- Top Hospital Gold
- Young Singles and Couples Basic Plus
If this is the first time you're having insulin pump therapy and you're being treated as an outpatient, we'll pay up to 100% of the amount listed on the Australian Government Prescribed List when we receive your completed insulin pump claim form and supplier invoice.
Am I eligible to claim a replacement insulin pump?
You’re eligible if:
- it’s been at least 5 years since you received your current pump
- you've been on any of the below HCF covers for at least 12 months
- you’ve held a health insurance product that covers insulin pumps and hospital treatment for diabetes with HCF or another private health fund continuously since the date you received your current pump (if you held a different type of cover but meet the other criteria, we may still pay 50% of the amount listed on the Australian Government Prescribed List).
Eligible HCF covers include:
- Fit and Free Silver Plus
- HCF Corporate Gold
- HCF Hospital Gold
- Healthclub Silver Plus
- Healthmate Advanced Silver Plus
- Healthmate Essentials Silver Plus
- Healthmate Starter Silver Plus
- Healthmate Ultimate Gold
- HealthStart Hospital Silver Plus
- Healthy First Silver Plus
- Hospital Advanced Savings Silver Plus
- Mid Hospital Silver Plus
- Top Advanced Hospital Gold
- Top Advanced Shared Gold
- Top Hospital Gold
- Young Singles and Couples Basic Plus
If you're eligible, you can claim up to 100% of the insulin pump price listed on the Australian Government Prescribed List. This means you might have no out-of-pocket expense.
The 5 year period imposed by HCF doesn't reflect the manufacturer’s warranty period and is the reasonable life expectancy of an insulin pump. If you need to replace your insulin pump before the 5 year period but after at least 4 years since the date you received your current pump, a pro-rata benefit may be offered depending on your circumstances and provided the pump isn't under the manufacturer's warranty.
Please note that we don't replace damaged, lost, or stolen pumps or pay for consumables for insulin pumps, which are available through the National Diabetes Services Scheme.
How do I claim for a replacement insulin pump?
Complete the insulin pump claim form and send it via email to clinicalreviewemail@hcf.com.au.
