Welcome

to Bupa
Your Important
Information Guide
Here’s what you need to know

Effective 1 July 2024

 Welcome Making sense of health insurance 12
to Bupa 4 Understanding health Using your
insurance health insurance
Your Health Insurance > Hospital cover Choosing a medical specialist
What to expect from us . . . . . . . . . . . . . . . . . . . 5 Hospital explained . . . . . . . . . . . . . . . . . . . . . . . . 12
Q&As . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Mental Health > Our support . . . . . . . . . . . . . . . . 5 Waiting periods . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Informed financial consent . . . . . . . . . . . . . . . . 21
Other Bupa Insurance offers > Hospital costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
More than just Health Insurance . . . . . . . . . . . . . 5
Ambulance Choosing a hospital
The Bupa Community >
Emergency and Non-Emergency . . . . . . . . . . . 14 Private . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Projects, tools, and programs . . . . . . . . . . . . . . 6
Ambulance services across States . . . . . . . . . . 15
Health Services > Dental, Optical & more . . . . . 6 Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

The who what where & why of Your Extras cover What should I ask before I decide? . . . . . . . . 26
Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Extras explained . . . . . . . . . . . . . . . . . . . . . . . . . 16
Private health insurance means . . . . . . . . . . . . . 8 Members First Extras Providers . . . . . . . . . . . . 17 Ambulance
Changing Bupa Cover > What to expect . . . . . 9 Special types of Extras Services . . . . . . . . . . . . 18 When can I use my Ambulance cover? . . . . . 26

Pharmacy
By your Hospital cover . . . . . . . . . . . . . . . . . . . 28

By your Extras cover . . . . . . . . . . . . . . . . . . . . . 28

Managing your
Your Bupa Health cover and accidental injuries
payments 31 Waiting periods . . . . . . . . . . . . . . . . . . . . . . . . . 29

essentials 10 Reducing your medical costs

Utilising ‘Accident Benefits’ . . . . . . . . . . . . . . . 29

The Bupa Medical Gap Scheme . . . . . . . . . . . . 31

No Gap Cardiac Services >
Stay up to date . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Advara HeartCare . . . . . . . . . . . . . . . . . . . . . . . 32

myBupa > how to self serve . . . . . . . . . . . . . . . 10 Paying your hospital expenses

Hospital > Medical >

Let’s wrap
Your Bupa card . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Prosthesis and Pharmacy . . . . . . . . . . . . . . . . . 34
Statement of Benefits . . . . . . . . . . . . . . . . . . . . 35
Our Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Member health support programs . . . . . . . . . . 11

Understanding your premium
Community rating . . . . . . . . . . . . . . . . . . . . . . 35 things up 38
Customer support – Our Team . . . . . . . . . . . . . 11 Late and overdue payments . . . . . . . . . . . . . . 35
Financial Hardship . . . . . . . . . . . . . . . . . . . . . . . 35 Fund rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Government policies and tax considerations Privacy and personal data . . . . . . . . . . . . . . . . 38
Lifetime Health Cover (LHC) . . . . . . . . . . . . . . 36
Government rebate . . . . . . . . . . . . . . . . . . . . . . 36 Health cover and overseas travel . . . . . . . . . . 38
Age-Based Discount . . . . . . . . . . . . . . . . . . . . . 36 Complaints and feedback . . . . . . . . . . . . . . . . 39
Medicare Levy and Medicare
Levy Surcharge . . . . . . . . . . . . . . . . . . . . . . . . . . 37 More information . . . . . . . . . . . . . . . . . . . . . . . . 39
2 3
Welcome to Bupa
Get more from your health insurance
Because life happens
The good. The bad. The unexpected. It’s all part of living a longer, healthier happier life.
That’s why it’s good to know Bupa is helping to look after your health insurance.
We offer a broad range of services and support to take care of your health and wellbeing. From the
everyday protection for your health, travel, car, home, pet insurance and aged care, to accredited
healthcare providers. Plus, a range of projects, tools, and programs to promote health, wellbeing, and
sustainability in the community to give you even greater value.

Health insurance
As one of Australia’s largest health insurers, we have agreements with most private overnight and
day hospitals, plus a huge Extras network so you’ll know you always have a wide range of choices.

Mental health
Support when you need it
With more of us looking to take better care of our mental health, we have extended our partnership
with THIS WAY UP to offer all members free access to an online mental health and wellbeing
treatment program.* There are a variety of evidence-based programs to choose from and best
of all they can be completed online when it suits you, without the need for a GP referral for most
programs.#
For more information visit: bupa.com.au/health-insurance/why-choose-bupa/support-for-your-
health/mental-health
*Available until 31 August 2024. #GP referral is required for the Chronic Pain Program and PTSD Program.

4 5
 Your membership
Because Health insurance doesn’t have to be complicated
This guide is designed to answer all of the most common questions we’re asked about health insurance.
Everyone is different of course, and you might have specific questions you’d like answered. Contact us
on 134 135 (+613 9487 6400 if you are overseas) or visit us in one of our Health Insurance stores.
Keep in mind that this guide doesn’t replace the Bupa Fund Rules, which outline the terms and
conditions of your cover.

Why have Private Health Insurance explained

As Australians, we’re lucky to have access to a quality, public health system . But it’s not without
its limitations . For example, it doesn’t cover all treatments and services, and can limit things like
where and when you’re treated .

The Bupa community

We’re taking care of our community with projects, tools, and programs to
promote health, wellbeing, and sustainability. We’re sharing our wealth of
knowledge through our online health resource Bupa Health Link. We’re
helping to fund breakthrough medical research that enables real health and
care improvements for all Australians through our Bupa Health Foundation.

Bupa Health Services

Whether you’re after dental care or an eye or hearing test, we’re all about
giving you the personalised health and advice you need quickly and
easily. That’s why we’ve partnered with healthcare providers who focus
on preventative health. Any claims for services under your Bupa health
insurance policy are subject to any applicable waiting periods, yearly limits,
benefit claiming restrictions, fund and policy rules.
Dental · Optical · Audiologist · Telehealth

6 7
 What if you change your existing Bupa cover?
There are a few things to keep in mind

1. You may not be able to claim new additions straight away

If your new Bupa policy covers services that your old policy didn’t, or allows you to get
more money back, there might be a waiting period that you’ll need to serve before we
will pay claims for the additional services, or you may only be able to claim the lower
amount until your waiting period is up.

2. You’ll change to the lower level of cover right away

If you have chosen to change to a lower level of cover, the lower level of benefits will
apply immediately.
Private health insurance means:
3. Your Extras limits will transfer
1 More control
All insurance policies have limits on the amount of money you can claim. It might be per
If you need to go to the hospital for a non-emergency procedure. You’ll have more choice when
month, year, by family or over an individual’s lifetime. These limits are transferred when
it comes to your hospital, your specialist and when you’d like your procedure to take place. You
you change your Bupa cover. For example, any claims you have already made that year
might also be able to request a private room.
will count towards your new yearly limit.

2 Reduced wait times

For non-emergency hospital procedures (like having your tonsils out) at a private hospital. 4. You have a 30-day cooling-off period
If you’re not privately insured, you might have to choose between being on a public hospital If you want to reverse any change to your cover, you can reverse the change within
waiting list for months (sometimes over a year+) or paying a hefty fee to go to a private 30 days, as long as you haven’t claimed. After 30 days, you can change your cover back,
hospital. but it will only apply from the day you requested to change it back. If you are going back
to a higher level of cover, you may need to wait before you can use any extra benefits.
3 The ability to claim money back
On some everyday health services that may not be covered by Medicare, such as dental and
physio from recognised providers^. Depending on your cover, you may even be able to claim
money back for services like remedial massage and acupuncture.

4 Avoiding or reducing the Lifetime Health Cover (LHC) loading

If you’re 31 or over and don’t have hospital cover. The LHC loading is a Government initiative
designed to encourage Australians to take out hospital insurance earlier in life. If you don’t
have hospital cover by 30 June following your 31st birthday, but then decide to take it out
later in life, you’ll pay a 2% loading on top of your premium for every year delayed (up to a
maximum of 70%). This extra loading remains in place for 10 years. For example, if you delayed
getting hospital cover for 3 years after you turned 31, you’ll pay an additional 6% on top of your
premium for the next 10 years. Refer to page 36 for more information.

5 Tax time
Depending on your income, you may have to pay an extra 1-1.5% tax levy, known as the
Medicare Levy Surcharge (MLS) (on top of the Australian Government’s Medicare Levy) if
you don’t have appropriate hospital cover for you and all your dependants over the whole
year. That may be similar to the cost of some of our hospital covers. The Government will also
contribute to the cost of your premium - this is known as a ‘rebate’. The amount is based on
your age and income and you can choose to get it as a reduced premium or offset in your tax
return.* Refer to page 37 for more information.
+ Source: Australian Government Institute of Health and Welfare Report: Elective surgery waiting times 2017-18. ^Extras services providers must meet certain
requirements to be recognised by Bupa and for us to pay towards the cost of your treatment. Before you book a treatment or service, it’s a good idea to check
with us so we can confirm whether we recognise the provider you’re planning to visit. Yearly limits, waiting periods, benefit claiming restrictions, fund and
policy rules apply. *Applicable rebate % and income thresholds are reviewed annually by the Australian Government. Single parents and couples (including
de-facto couples) are subject to family tiers. For families with children, the income thresholds are increased by $1500 for each Medicare Levy Surcharge
dependant child after the first child. For more information go to ato.gov.au.

8 9
Your Bupa essentials
Connect with us to make the most of your membership.
There are a few quick steps to complete to make sure you get the most out of your new Bupa policy.

It’s our way of saying thanks

for doing life with Bupa
With Life Rewards, the more life we share,
myBupa the more rewarding it gets. Member-only
offers, discounted eGift Cards, dining
myBupa.com.au is our member self service area. discounts, and competitions are just the
It helps you easily manage and understand your Health beginning. Thanks for sharing life with
Insurance online. Once you register, simply log in using your Bupa, we can never say that enough.
secure log-in details to: Visit bupa.com.au/liferewards
• Access your policy documents and tax information. to find out more

• Submit an Extras claim and see your claim history.

• Update your personal details.
• Access exclusive health tools and discounts.
• Put Bupa in your pocket with the myBupa App.
Access our Member Health Support Programs and Services
At Bupa we’re here to help you not just when • Mind Care Choices Program
you are in need. That’s why we’ve developed
• Parent and Baby Wellbeing Program
a range of health support programs and
services to help find a healthier you. • Recovery Support Program
Your Bupa card
These programs and services are designed • The COACH Program
Your new Bupa card will arrive soon after you join and:
to help support you and your family’s health • Chemotherapy Choices Program
• Contains your membership number and a list of the people who are covered by your policy. and wellbeing at no extra cost to you. It’s all
part of our commitment to helping you live • Dialysis Choices Program
• The ability to make eligible on-the-spot claims when you have received a treatment or service
from many of our recognised Extras providers, such as a dental or physio. a longer, healthier, happier, life*. • Palliative Care Choices Program
• Unique identification if you’re admitted to hospital. • Bupa Health Coaching Program • Aged Care Support Line
• Dietitian Health Coaching Service • Advance care planning
Tap fast. Claim quick
• With just one tap you can claim with iPhone, Apple Watch or Android phone.1 • Osteoarthritis Healthy Weight For Life • Advara HeartCare Partnership
Program
• Add a digital membership card today, simply follow the steps at bupa.com.au/card • Kids Helpline@School program
• Rehab Choices Program
1 Digital cards may be used at HICAPS and selected Healthpoint terminals, and are compatible with Apple iOS 11 or later and Android Lollipop 5.0 or later.

*Fund, policy, waiting periods and program eligibility rules apply.

We’re never far away

Stay up to date
You can update small changes to your membership
Click the links below to
(like new contact details or payment information) online at
visit Bupa online bupaaustralia
myBupa.com.au. But bigger changes, like adding or removing
people from your cover, or moving interstate, can affect the cost
myBupa.com.au BupaAustralia and level of cover – including things like ambulance services.
So it’s always best to speak to us to make sure your cover is still
BupaAustralia +61 134 135 right for you, and we’ll clarify exactly what your cover includes.
• Call us on 134 135 • Apple iMessage
BupaAustralia bupa • Find a local Bupa Health Insurance • WhatsApp
store at bupa.com.au/find-a-centre

10 11
 Pre-existing conditions It’s better to know before you go
A pre-existing condition is any condition, ailment If you’re in hospital for a pre-booked admission, it
or illness that you had signs or symptoms of is important that you make sure that the hospital
during the six months before you joined or or specialist tells you the costs that you’re
upgraded to a higher level of cover with us. It is expected to pay yourself, after we’ve paid our
not necessary that you or your doctor knew what part. The hospital should make sure they get your
your condition was or that the condition had consent for these costs before you’re admitted.
been diagnosed. As always, if you’ve got any questions, please just
get in touch.
Keep in mind that a doctor appointed by us will
decide whether your condition is pre-existing.
That said, the appointed doctor must consider Multiple Treatments during a hospital
your treating doctors’ opinions on the signs and admission
symptoms of your condition, although they’re not You’ll note that when you undergo more than
bound to agree with them. one type of hospital treatment during a hospital
admission, we will generally only cover hospital
Planning for a baby treatment including accommodation, theatre fees
If you’re thinking about starting a family we and prosthesis for procedures related to treatment
recommend that you check in advance whether covered by your policy that are performed as part
your current level of cover includes pregnancy of your admission. We will also cover hospital
and birth services. This is because there’s a treatment as required under legislation relating to
12-month waiting period for this. the payment of benefits for Associated Treatments
for Complications, Associated Unplanned
No waiting periods apply to a newborn baby, Treatments, Common Treatments and Support
provided your little one has been added to your Treatments (as discussed further below).
level of cover within 90 days of their birth.
In circumstances where a member receives hospital
treatment during an admission to hospital for which
What’s covered and what’s not?
Bupa pays the entire treatment using a bundled
The five types of costs you might encounter payment mechanism (e.g. using a single Diagnosis

Making sense
Different waiting periods apply during your hospital stay: Related Group) and we cannot allocate the cost
to different hospital services*: • Hospital costs between the treatment that is covered and the

of your health • Medical costs component that is not covered, Bupa may pay
Service/Treatment Waiting period
the full bundled payment (less any excess or co
• Prostheses costs
payments the customer needs to contribute) on an

insurance
Emergency ambulance^ • Pharmacy costs ex-gratia basis.
and treatment after 1 day
• Emergency Ambulance costs
accidents Otherwise, you’ll be responsible for all expenses related
Learn more about Accidents that occurred
The next few pages will help you understand
the type of costs you might encounter during
to the treatment which is excluded on your policy.

Hospital cover after joining Bupa

None your hospital stay (assuming you are covered by Associated Treatments for
your policy for the treatment you’re receiving Complications and Associated
in hospital and that you have served all relevant
Hospital cover Palliative care,
rehabilitation and waiting periods).
Unplanned Treatments
2 months If you have a hospital treatment that’s covered
hospital psychiatric
Hospital waiting periods services* Medical costs before you go to hospital under your policy, we’ll also cover any associated
When you first take out or upgrade health cover treatments for complications, if any should
In the lead-up to a hospital admission, customers happen during your admission. We’ll do the same
there’s a period of time before you can make a All other treatments will generally need appointments with their GP
claim on your new level of cover. This is common 2 months for any associated unplanned treatments, as long
included in your cover and/or specialist(s). There may also be a need for
across the health insurance industry and is known as it is deemed both medically necessary and
tests such as blood tests, x-rays, etc. Under the urgent at the time by the medical practitioner
as a waiting period. Pre-existing conditions 12 months Private Health Insurance Act, we’re not allowed giving the unplanned treatment.
To claim you need to have finished any waiting to cover these appointments through health
periods that apply. You can’t claim for services Pregnancy and birth insurance, so please check with your GP and
12 months Common Treatments and support
which are not included on your level of cover. (obstetrics) relevant specialist for the exact costs, as these
Treatments
You also can’t claim for services that took place *Existing members: If you need to discuss how you’re covered for urgent mental
will be your out-of-pocket costs to pay.
during your waiting period, even after you have health treatment in-hospital, please contact us. Policy rules and exclusions apply. If you have a hospital treatment that’s covered
completed them. ^A 1 day waiting period applies for emergency, non-emergency and on-the-spot under your policy, we’ll also cover specific
treatment for selected products, where ambulance is included.
Medicare Benefits Schedule items that are related
to treatments covered under your policy.
12 13
Hospital costs Scheme is designed to eliminate or minimise the Your ambulance cover depends on your cover type#:
amount you’ll have to pay in cases like this. Go to
Charges related to your hospital admission such
pages 30 and 31 for more information. Cover type
as the operating theatre, nursing and allied health
services including accommodation and meals. • Remember, you might have to see multiple
specialists for one procedure.
• How you’re covered for hospital costs when you’re
admitted as an ‘inpatient’ depends on your choice
of hospital. See page 23 for more details. Check
Emergency ambulance Selected basic, bronze Gold tier and selected Corporate Silver Plus Gold Ultimate
with your doctor whether your treatment will costs and silver tier hospital
covers, and most Extras
silver tier Hospital
covers, Corporate
Extensive Hospital^,
Corporate Gold
Health Cover
require you to be admitted to hospital.
The costs associated with transport services (via air covers^ Hospital cover and Comprehensive
• Depending on your level of cover, we might also or road) from the place where you are treated, to
pay some of the costs for a partner, immediate Corporate Choice Extras Hospital^ and Premium
the emergency department of a receiving hospital. and Emergency Only Ambulance Cover*
family member, carer or next of kin to stay in
hospital with you. Ambulance Cover^
• If a treatment is listed as having ‘restricted cover’
Emergency or non-emergency –
What’s included per calendar year
on your policy information, we pay less toward what’s the difference?
your hospital costs. This means you may have Unlimited Emergency Unlimited Emergency Unlimited Emergency Unlimited Emergency
large hospital out of pocket expenses. You can Emergency Ambulance Cover Ambulance Cover Ambulance Cover Ambulance Cover
read more about restricted cover on page 33. This means an unplanned event where you’ve been
injured or you have a medical emergency where Up to $5,000 in Or, we’ll refund the
Prostheses costs your life may be at risk or where you need medical Non Emergency costs of an Ambulance
treatment right away. Ambulance per person* subscription from our
The cost of items that are surgically implanted
recognised provider in
in hospital. For example, artificial hips or cardiac A 1 day waiting period applies for emergency, non- your state (VIC, SA, and
devices like pacemakers. emergency and on-the-spot treatment for selected
NT only).
products, where ambulance is included.
• You’re covered for all prostheses on the Australian
#
Only claimable at Bupa recognised ambulance providers.
Government’s Prostheses List, up to the value For more information about what we define ^A 1 day waiting period applies for emergency, non-emergency and on-the-spot treatment for selected products, where ambulance is included.
stated on the list. as an emergency, read our fund rules at *Premium Ambulance has a 1-day waiting period for emergency ambulance and on the spot treatment and a 1-month waiting period for non-emergency ambulance

bupa.com.au/fundrules
Medical costs Ambulance services across states
The fees charged by a surgeon, physician, or Non-Emergency When it comes to ambulance services, each state is different. You should consider what you’ve
other medical specialist whilst being treated as an This is when you need to use an ambulance but chosen to be covered for, the state you live in and whether you need cover interstate. The below table
inpatient in the hospital. don’t need treatment straight away, or your life is compares your options.
not at risk.
• We make arrangements directly with specialists,
separate from our arrangements with hospitals. A 1-day waiting period applies to non-emergency
State you normally live in Options at home Options while interstate
This means your specialists will bill separately, and ambulance on corporate hospital covers where ACT
in addition to, what the hospital bills for your stay. non-emergency is included. Premium Ambulance Private cover
has a 1-month waiting period for non-emergency NSW
How fees for medical treatments are set ambulance cover.
VIC
• The Australian Government recommends the fees
For example:
for medical services. However, a doctor can charge NT Private cover OR a state ambulance subscription
more than this. • Transport from a hospital to your home or nursing
home. Country WA
Find out more about how the Australian Healthcare
• Transport to a hospital, your home, or nursing
system works at Metro WA & Norfolk Island Private cover
home for ongoing treatment, like dialysis or
bupa.com.au/healthcare-system
chemotherapy. SA Private cover OR a SA Ambulance subscription
How medical costs are covered • Where you’ve been admitted to one hospital and
TAS The State Government The State Government covers
need to be taken to another (the hospital should
• Medicare has a list of medical services that the covers you at home you, except for in QLD and SA
include this in the cost of your procedure).
government will either pay some or all of the cost
of, called the Medicare Benefit Schedule. Each has QLD The State Government covers you everywhere in Australia
a fee that the government thinks is appropriate * NSW/ACT Hospital Cover - Through the cost of
to charge for that service, which is the amount your Hospital Cover, Bupa collects a levy which
It’s worth noting that some states:
Medicare will pay for that service. contributes towards a NSW/ACT State Ambulance
Scheme. As a part of this scheme, you are provided Offer free or subsidised ambulance services to pension and concession card holders. Check your State
• Medicare and Bupa both pay a portion of the
fee for medical services set by the Australian with uncapped emergency transportation when Government website for more details.
Government (75% and 25% respectively). provided by NSW/ACT Ambulance within the State.
Have agreements with other states to cover their residents, and vice versa. What’s covered under
However, your specialist may choose to charge these agreements varies, so if you travel interstate frequently, it might be worth considering private
more than the set fee. This means you would have
cover or a subscription.
a ‘gap’ to pay yourself. The Bupa Medical Gap

14 15
 What are Extras? There are great advantages in visiting a
Members First provider:
Not everything that keeps you healthy • You’ll know how much you can claim and how much
is covered by Medicare. That’s why you’ll be out-of-pocket. Depending on your cover,
you’ll get from 50% – 100% of the cost back on most
Extras cover can be a big help. Extras
dental, physio, chiro and podiatry consultations, up to
cover is all about covering some of
your yearly limits.1
the costs that aren’t hospital related.
• You can usually expect to claim more money back
Some of the most common services
than if you go to a provider who doesn’t have an
and treatments that people make agreement with Bupa.
extras claims for include:
• You may be on a level of cover where you can be sure
of the percentage you’ll get back at any recognised
provider. Check your Private Health Insurance
Statement (PHIS) to see if this applies to you.

Members First Ultimate and Members First

Platinum Network
In addition to Members First providers, we have Members
First Ultimate and Members First Platinum providers which
help to provide more value when it comes to dental care.
Dental check-ups Physiotherapy,
Get 100% back on up to two check-up and cleans per year,
and cleans chiropractic,
claimable outside of your yearly limits2 and 100% back on
occupational therapy
and podiatry general dental fillings, up to yearly limits at Members First
Ultimate providers.3

With Members First Platinum, you could get 100% back on

up to two check-up and cleans per year, claimable up to
your yearly limits.4

Find out more at

bupa.com.au/health-insurance/dental-partners

Note: Some of these benefits depend on your level of

Extras cover. Yearly limits, waiting periods and our Fund
Rules apply.
Optical products, Health aids and To read our Fund Rules visit bupa.com.au/fundrules
such as prescription appliances, such
glasses and contact as asthma pumps/ Making a claim is really simple. At these providers you
lenses nebulisers, blood can usually make your claim on the spot by swiping your
pressure monitors and Bupa card or Digital card if an electronic claiming terminal
hearing aids is available.

Providers of extras services have to

be recognised by Bupa in order for

Your
us to pay towards the cost of your 1
Yearly limits, waiting periods, benefit claiming restrictions, fund and policy rules apply.

treatment5. The following information 2

Members First Ultimate Providers are not available in all areas. You can receive 100% back on dental check-up
and cleans (select dental items only) once every 6 months at Members First Ultimate Providers. Waiting
is important for you to understand periods, benefit claiming restrictions, policy and fund rules apply. Excludes orthodontics and in-hospital
treatments. Available on all eligible extras products which includes General Dental (excluding FLEXtras and
what is required for a claim, and how Your Choice Extras 60 where general dental is not included). If you choose or require any additional dental

Extras
services, any health insurance benefits will also be subject to your yearly limits.
your choice of provider can affect 3
Members First Ultimate Providers are not available in all areas. You can receive 100% back on direct
restorations or fillings (select dental items only), up to yearly limits, at Members First Ultimate Providers.
what we will pay. Waiting periods, benefit claiming restrictions, policy and fund rules apply. Benefits are payable up to yearly
limits or on available remaining limits in relation to your product. Some out of pocket costs may apply if a
claim exceeds your yearly limits. Excludes orthodontics and in-hospital treatments. Available on all eligible

cover
extras products which includes General Dental (excluding Simple Start – Basic Plus, OSHC Extras, FLEXtras and
Members First Extras providers Your Choice Extras 60 where General Dental is not included). If you choose or require any additional dental
services, an out-of-pocket cost may apply.
We have agreements with a network 4
At Members First Platinum providers you can receive 100% back on dental check-up and cleans (select dental
items only) once every 6 months, up to yearly limits. Available on eligible packaged or combined hospital and
of dental practitioners, chiropractors, extras products which include general dental (excluding Freedom 50 Extras, Freedom 60 Extras, Freedom 60

explained
Boost, Extras Saver, Corporate Benefit 60 Flex, FLEXtras products and Your Choice Extras 60 where General
podiatrists and physiotherapists dental in not included. Waiting periods, benefit claiming restrictions, yearly limits, policy and fund rules apply.
5
Extras service providers must meet certain requirements to be recognised by Bupa and for us to pay towards
across Australia. We call them our the cost of your treatment. Before you book a treatment or service, it’s a good idea to check with us so we
can confirm whether we recognise the provider you’re planning to visit. Yearly limits, waiting periods, benefit
‘Members First’ providers. claiming restrictions, fund and policy rules apply.

16 17
Special types of Extras Using your health insurance Claiming for Extras
You can make a claim for a treatment or service provided in Australia if it’s covered by your policy and
services Making an Extras claim the provider is recognised by Bupa. For example, you might purchase a pair of glasses, but we might
not recognise the provider, so you won’t be able to make a claim. Extras providers must meet certain
Health aids and appliances requirements to be recognised by Bupa – we do this because we are focused on the health and care of
These are items that help you return to a normal
Claiming on the spot
our members.
lifestyle, help to recover from (or prevent further) with your Bupa card
injury or improve a health condition. Before you book a treatment or buy a health appliance, it’s a good idea to check with us and get an
Electronic claiming is the fastest way to make
estimate via myBupa. We can confirm that we recognise the provider and what your cover includes.
If you need to make a claim for these: your health insurance claims
• You may need a referral letter from your doctor Many Bupa recognised providers around Australia
or specialist to explain the medical need for your
Knowing your claim limits
item. provide this service, such as dental practitioners,
Claim limits are the maximum that we’ll pay for specific treatments and services. This is common for
• The provider or manufacturer of the item must be physiotherapists, chiropractors, podiatrists,
most types of insurance. Other health insurers might set the same or different limits to us.
recognised by Bupa. remedial massage therapists, optical outlets
• Items such as orthotics, compression garments and more. After your treatment, swipe or tap If you move between health funds, your use of limits usually moves with you. For example, most funds
and surgical shoes need to be custom-made to fit, your Bupa card and the claim will be processed have a lifetime limit on orthodontics, so if you have claimed your lifetime limit at your old fund, Bupa
not be an ‘off-the-shelf’ product that is just altered would recognise this and you wouldn’t be able to make a further claim.
automatically. If your claim is accepted, there are
for you.
no forms for you to complete and you’ll only pay Here are some of the most common limits that might apply to your policy:
Please note that in certain products Custom-made the balance of the account.
foot orthotics are paid under Podiatry. For more
information on your cover details please refer to This is the maximum amount you can claim for a service from 1 January to 31 December.
PHIS and fund rules. Claiming online Yearly limit If you haven’t claimed up to your yearly limit, this doesn’t ‘roll over’ to the next year – it

You can’t make a claim for health aids or appliances

with myBupa resets on 1 January.
purchased overseas. Log in to myBupa.com.au and enter the details
This is a limit within a limit. It applies to a very specific service, per person, per year. For
You cannot claim benefits for hire and repair of found on your receipt via the ‘make a claim’
example, if you have Gold Ultimate Health Cover, there’s a yearly limit of $1,000 for natural
health aids and appliances within 12 months of section. We’ll transfer the payment directly
therapies.
purchasing the item, within 12 months of a repair, to your bank account, so have your BSB and
or on items where hire and repair are deemed Sub limit A sub limit applies to massage therapy of $250 per person, so once you have reached that
account number ready.
inappropriate. We will not pay for replacements limit for massage therapy, you can no longer claim for massage therapy that year. However,
or new models of aids or appliances that function you could make up to $750 more in claims for other permitted natural therapies, like
correctly or are still under warranty. If a faulty or acupuncture.
Claiming by post
defective aid or appliance is under warranty you
may contact the manufacturer for it to be repaired For some types of Extras services, there are limits to the number of times that benefits are
or replaced (subject to the terms of the warranty). Claim forms are available to print from our
Benefit payable for the same service. These are based on usual benefit claiming restrictions.
You can claim online with myBupa or by completing website or you can pick one up in a Bupa store.
claiming For example, you can only claim a scale and clean from your dentist or oral health
a form and submitting it in store or by mail. Fill out a claim form, attach your invoice and
restrictions practitioner once every six months. This is called a benefit claiming restrictions. These
Some of these requirements apply to just some receipt and post to:
limits apply from the date you receive the service, not from the time you submit the claim.
types of health aids and appliances, but not to all. If Bupa
you’re thinking of claiming for an item, ask us before This is the maximum amount that each person covered by your Bupa membership can
you purchase so you know where you stand.
GPO Box 990
Adelaide SA 5001 Person limit claim in a calendar year. If you’re on a policy with a family member, then you’ll have your
own individual limits.
Health Management
Claiming in a Bupa Health
Depending on your Extras cover, you might be This is the maximum amount that can be claimed collectively, by everyone covered by
able to claim some of the cost of health-related Insurance store your membership within the calendar year, for a specific type of Extras service. Remember,
programs. For more information on your cover Drop into your nearest store and we’ll help you these limits apply in addition to your individual per person limits. Also, the membership
details please refer to PHIS and fund rules. We call claim through myBupa. All benefits payments Membership limit might not be high enough for all your family members to claim their individual limits.
this Health Management. are by EFT only and are subject to standard limit
For example, you may have a person limit of $500 for chiropractic services, but a
There are specific requirements before you can start processing times. If you’re unable to use myBupa, membership limit of $1,000. This means that only two family members can maximise the
making a claim for any of these programs. complete a claim form, provide your receipts, and $500 person limit even if you have four people listed on your policy.
we’ll transfer the payment directly to your bank
For more information, visit
account within 48 hours. Health insurers usually have a lifetime limit for orthodontics. This applies to an individual.
bupa.com.au/health-management, or call us.
Lifetime limit If you have reached this limit, you can’t make any further claims for this at Bupa again. It
doesn’t reset, even if you leave Bupa and start your cover again with us.

You can find information about limits in your policy information available at myBupa.com.au

18 19
Restrictions on making claims Choosing your provider
You need to have finished any waiting periods We all have different priorities when it comes to
that apply and cannot claim for services that took choosing a healthcare provider. Your choice could
place during your waiting periods, even after be based on location, recommendations, cost, or
you have completed them. If you’re new to Bupa other factors that are important to you.
and Extras cover, it’s good to be on top of what
waiting periods apply to you and when they will The amount you’ll pay for each
end. treatment can depend on:
1. How much the provider charges for the service
1. You can’t claim twice 2. Any agreements between the provider and
If you’ve made a claim with Medicare or another Bupa
insurance policy, such as Work Cover or travel 3. The amount you can claim back, determined
insurance, then you can’t claim the cost under by your level of cover
your Extras cover. There are some exceptions,
We understand that factors other than cost
such as hearing aids and breast prostheses, so
can be important to you, such as familiarity
check with us if you’re not sure. or location. If your dental practitioner, chiro,
• The Australian Government sets a fee for the Attending a private hospital that Bupa has
podiatrist or physio isn’t in our Members First
2. You can’t claim for multiple services cost of a medical service. Medicare pay 75% and an agreement with could help to reduce your
network, you can still make a claim, as long as
of the same kind from the same they are Bupa recognised and the service is Bupa pay 25% of that set fee. Some specialists hospital and medical costs.
provider on the same day included on your level of cover*. However, you will choose to only charge that set fee. However,
may have a larger out-of-pocket expense when your specialist may choose to charge more than Ask your specialist:
This rule only applies to therapy services. For
you get the bill. the fee. This means you would have a ‘gap’ to “Do you use the Bupa Medical Gap Scheme?”
example, if you went to see an acupuncturist
pay yourself.
and then received a massage from the same You can visit bupa.com.au/find-a-provider If not, ask them what you will have to pay.
provider on the same day, you can’t claim to check whether or not your current provider • The Bupa Medical Gap Scheme is designed
for both services as they are both ‘natural has an agreement with Bupa or to find a Members to minimise or eliminate the amount you’ll “Will any other specialists be involved in my
therapy’ treatments. However, if we recognised First provider or Optical Partner. have to pay in cases like this. We do this by treatment?”
that provider as both an acupuncturist and paying more than the set fee, and we have an
Sometimes you’ll also need the services of
a chiropractor and they provided you with Choosing a medical arrangement with the specialist on a fixed cost
for your treatment. Go to pages 30 and 31 to
specialists like a pathologist, radiologist or
acupuncture and a chiropractic treatment on
the same day, then we would recognise both
specialist find out more.
assistant surgeon. If so, ask if they use the Bupa
Medical Gap Scheme, or if they are In-Hospital
treatments, as they are different types of If you have private health cover, you have more Pathology and Radiology contracted providers
services. choice as to which specialist treats you. It’s Questions to ask when choosing your that have ‘no gap’ arrangements with Bupa.
important that you feel informed before you specialist
3. T
 here are benefit claiming restrictions make this decision. As with your choice of You are entitled to be fully informed about your Informed financial consent
hospital, your decision may be based on factors
for our Extras services specialist and any associated costs before you If your hospital stay involves any out-of-pocket
such as cost, reputation, how often they’ve
We have rules about what you can claim, based start your treatment. Here are some questions hospital charges, the hospital (whether private
conducted your surgery, their location and how
on usual benefit claiming restrictions. It means comfortable you feel with them. You can search that could help you make your decision. or public) must disclose the cost and obtain your
that specific services may have a limit to the for a specialist at bupa.com.au/find-a-provider. agreement in writing before your admission.
number of times they can be claimed within a You should also discuss with your GP whether the Once you’ve had your initial
recommended specialist is appropriate for your If your doctors’ fees include any out-of-pocket
certain time frame. For example, we generally consultation with your GP, ask Bupa:
needs. charges, your specialist should disclose the
only pay for a dental check-up claim every six “Can you provide me with a list of specialists cost and obtain your agreement before your
months. Another example, you can only claim a who use the Bupa Medical Gap Scheme?”
Medical costs admission to hospital. They should provide advice
CPAP machine once every two years.
These are the fees charged by a doctor, “Can these specialists treat me in a hospital on fees charged not only by themselves but also
If you’re not sure if you’re covered for a service,
surgeon, or specialist when they are treating that has an agreement with Bupa, and which by other specialists or surgeons as well as by
or if your dental condition means you need
you in hospital. The level of cover we provide for hospitals are they?” anaesthetists, assistant surgeons, pathologists
treatment outside these rules, please contact us.
medical costs depends on what fee the specialist and radiologists.
4. You have up to two years to decides to charge and whether they use the Bupa Ask your GP: Find a no gap radiology provider for services in
submit a claim Medical Gap Scheme. “Can you refer me to a specialist who uses the hospital at bupa.com.au/no-gap-radiology
We allow customers two years from the date of • We make arrangements directly with specialists, Bupa Medical Gap Scheme?”
Find a no gap pathology provider for services in
service to submit any claims for benefits to be separate to our agreements with hospitals. “Can you refer me to a specialist who can hospital at bupa.com.au/no-gap-pathology
paid. The two-year claim rule is in place as it is This means you will be billed by your specialist treat me in a hospital that has an agreement
consistent with Medicare’s claim rules. separately and in addition to your hospital bill.
with Bupa?”
We may cover some or all of this.

20 21
 1 Know what you’re covered for
The amount that we will pay is determined by your level of cover (your policy), the
agreement that Bupa has with the hospital you go to, and whether or not you’ve served the
relevant waiting periods.

2 Choose whether or not to go public or private

If you have private hospital cover with Bupa, the choice is yours. You might make your
decision based on location, familiarity, or a range of other factors.

3 Check your hospital options

Benefit Members Network Network Non- Public hospital

First Overnight Fixed Fee agreement
Overnight & Day Hospitals hospitals
& Day Hospitals Private Public
hospitals patient patient

Choice of
X X
hospital

Choice of
X
specialist

Reduce waiting
X X
time

Covered for
Most Limited Limited by
hospital costs
Medicare

Private room
guarantee X X X X X
(overnight)*

Choosing Cover for extra

services and
benefits
Some X X X X

a hospital Explore our hospital network at bupa.com.au/help/hospital-cover/finding-the-right-hospital

*‘Private room or money back guarantee’ means that, at our Members First hospitals, you’ll receive a private room when you book and request one at least 24 hours before
the overnight admission. If a private room is not available, you’ll receive $50 back, per night, from the hospital. You’ll also receive a complimentary daily newspaper and
complimentary local calls. Applies to overnight admissions only. Excludes ‘nursing home type patients’, emergency care same-day or occasions where a private room is
medically inappropriate.

22 23
Choosing a private hospital
Private hospitals do vary in cost and the services they provide. If cost is an issue, make sure you
choose a hospital that has an agreement with Bupa.
Provided your cover includes private hospital cover for the treatment you need, and you’ve served
your waiting periods, use the table below to help you choose a hospital. These costs and benefits are
based on you being admitted to that hospital as an inpatient.

Hospital costs and benefits by hospital type

Type of Type of Cost to you Member benefits Important to note

Cost to you Member benefits Important to note
hospital hospital

Members Low – in most Our ‘private room or To take advantage of Network Low – In most
First instances you’ll money back guarantee’ the ‘private room or Day instances you’ll be
be covered for for an overnight stay.* money back guarantee’,* hospital covered for your
hospital costs. Plus, complimentary you’ll need to book and hospital costs.
Any excess or daily newspaper, local request a private room in
co-payments as phone calls and free- a Members First hospital Non- High – These None. You will be If you attend one of these
per your policy to-air TV. If pregnancy at least 24 hours before agreement hospitals haven’t responsible for the cost hospitals, you are likely
will still apply. and birth services are admission. hospital entered into any of your stay and may be to encounter significant
included in your cover, agreement with charged directly for your expenses.
you get: breast-feeding Bupa, meaning hospital accommodation,
and parenting education You will not be able to
we only cover surgically implanted
classes postnatal clinics use the Bupa Medical
a portion of the prostheses and personal
for up to 8 weeks after Gap Scheme at these
cost. expenses such as TV hire.
you leave hospital parental hospitals to lower your
Some of these hospitals
support services. medical costs. This means
bill Bupa directly for the
the costs for you to pay
set amount we pay.
could be higher at these
Network Low – in most You will be covered for The ‘private room or
If your specialist/s charge hospitals. Make sure you
hospitals instances you’ll a private room if you money back guarantee’
more than what we pay ask for cost estimates
be covered for request one and where does not apply.*
(with Medicare), you’re from the hospital and your
hospital costs. one is available. You’ll also
likely to have some medical treating specialist/s.
receive complimentary
costs to pay yourself.
local phone calls and free-
to-air TV.
Network Hospitals near you at bupa.com.au/find-a-provider
*‘Private room or money back guarantee’ means that at our Members First hospitals, you’ll receive a private room when you book and request a private room at least 24
Network Medium – You You will be covered for At some of these hospitals, hours before the overnight admission. If a private room is not available, you’ll receive $50 back per night from the hospital. You’ll also get a free daily newspaper and free
local calls. Applies to overnight admissions only. Excludes ‘nursing home type patients’, emergency care same-day or where a private room is medically inappropriate.
hospital may be charged a private room if you a fixed fee applies to
with a fixed a fixed daily fee request one and where all services offered. At
fee and generally be one is available. You’ll also others, a fixed fee applies
covered for your receive complimentary to either a psychiatric or
There’s
hospital costs local phone calls and free- rehabilitation service only.
only a small
(this fee does not to-air TV. This fee is capped at a
number of
apply if you are maximum number of days
these.
on Gold Ultimate per overnight stay. The
Health Cover). fixed daily fee charged by
the hospital is in addition to
any excess or co-payment
you may need to make.

Please note: You may still experience out-of-pocket costs for specialist fees. To help reduce your medical costs, consider the Bupa Medical Gap Scheme.
Visit bupa.com.au/medicalgapscheme for more.

24 25
Choosing a public hospital How do I pay my ambulance costs?
If you receive an invoice for ambulance services, and you’re covered for ambulance, the table below
As a Bupa member attending a public hospital, you can choose to be treated as a public patient or as
will show you what to do. If you need to send the invoice to us, check page 18 for how to claim.
a private patient. Each has its pros and cons.
State you Recognised State What do I need to do?
Public patient in a public hospital normally provider subscription
live in available
Pros • All costs relating to your admission will be covered by Medicare, including
prosthesis and all medical costs. VIC Ambulance Victoria If it is included in your subscription –
send it to them to pay it.
Cons • You won’t be able to choose who treats you or when you’re treated. SA SA Ambulance
• You will be subject to public waitlists which can be lengthy – sometimes over a Service If it is not included in your subscription
year long. – send the invoice to us.
NT St John Ambulance
• Your procedure may be postponed if more urgent cases come up.
Country WA St John Ambulance If included in your subscription, send
• You are less likely to get a private room.*
it to ‘St John’s Ambulance’ to pay it. If
it is not included in your subscription –
Private patient in a public hospital send the invoice to us.
Pros • You’ll get your choice of your doctor, if they are available. Metro WA & St John Ambulance X Send the invoice to us.
• We’ll pay the cost of you staying in a shared room. (This amount is set by the Norfolk Island
Australian Government). ACT ACT Ambulance X Send the invoice to us. We’ll either
• If a private room* is available and you choose to stay in it, Bupa may cover some of Service organise it with your State Government
the additional cost of this, depending on your level of cover. If this won’t cover all or pay it ourselves.
your costs, the hospital should let you know the amount you will need to pay.
NSW Ambulance Service X Send the invoice to us. We’ll either
• We’ll contribute to the cost of prostheses and specialists as we would if you were
of NSW organise it with your State Government
treated in a private hospital.
or pay it ourselves.
Cons • You may still be subject to public hospital waiting lists.
TAS Tasmanian N/A If you have the service in QLD or SA –
• Depending on your illness or condition, you may get the same doctor who would Ambulance Service send the invoice to us.
have been allocated to you if you were a public patient.
Otherwise, send it to the Tasmanian
• You’ll be responsible for personal expenses such as TV and telephone calls.
Government for payment.
• You may experience out of pocket expenses.
QLD QLD Ambulance N/A There’s nothing for you to pay.
*A private room in a public hospital is a room in a hospital which is purpose built and suitable for no one other than a single admitted adult patient; holds one single sized
bed; and has a dedicated ensuite.
Service Send the invoice to the Queensland
Government to pay.
Things to remember before choosing What should I ask the hospital before I
public decide?
1. The choice is yours If you need to be admitted “What are the benefits to me if I choose to use
to a public hospital, the hospital will provide my private cover?”
you with a form where you will elect to be
“Will there be any difference to my care if I use
admitted as a private or a public patient.
my private cover?”
The hospital must clearly explain what both
options mean for you. “Can I choose my doctor?”

2. Once you’re admitted, the choice is made “Can you ensure I will have a private room for my
Once you decide whether to be a private entire stay?”
or public patient, it applies to your whole
admission. It generally can’t be changed, When can I use my Ambulance cover?
except in unforeseen circumstances. 1. When you can’t claim the costs from another
source. For example, when your State
Keep in mind Government doesn’t cover you and you can’t
A hospital should not ask you to charge your stay claim from a subscription or Government levy.
to your private cover after you’ve already elected See page 35 for more information.
to be a public patient. There is no need for you to 2. If your ambulance service was provided by our
do this. If you were to do so, you may have out of recognised provider in the state you had that
pocket costs for your treatment. service. These are listed in the table opposite.
26 27
 What do I need to do if I have an
accident?
We’ll waive the waiting period for treatment you
need due to an accident, if you:
We do not cover: • Get medical advice or treatment from a
• Items not approved by the TGA. registered medical practitioner within 72 hours
• Over-the-counter or non-prescription of the accident.
pharmacy items. • Submit an ‘Accident Injury Report Form’
• Compounded medications, which are available at bupa.com.au/accident-report
mixed from the individual ingredients • Continue to hold a policy which covers the
to the strength and dosage required accident-related treatment.
for an individual except in exceptional • Have all the treatment you need within 180 days
circumstances. of the accident.
• Performance or body-enhancing
medication (e.g. anabolic steroids). Here’s an example
• Medication provided by a hospital that Say you recently joined Bupa, or upgraded
isn’t intrinsic to your care. your cover, and your new policy covers hip
• Any items on Bupa’s Exclusions List. replacements. If you fell and needed a hip
replacement, we’d waive the waiting period and
If you’re not sure, contact us. you’d be covered for the surgery.

Accident Inclusion means upgraded

Pharmacy you’re not in hospital or once you’ve left hospital,
as well as unopened medication provided to you cover
when you are discharged from hospital.
The cost of prescribed medication provided to
you, or purchased by you, for treatment of your Accidental injuries We understand that no one sees an accident
Pharmaceuticals must be approved by the coming, so you might not have thought to include
condition. This includes pharmaceuticals listed
Therapeutic Goods Administration (TGA), some things on your cover. That’s why, on some
on the Australian Government’s Pharmaceutical Waiting periods and accidents
category S4 or S8 medicines (prescription only or policies, we’ll cover you in a private hospital for
Benefits Scheme Schedule (PBS), and, in some Accidents are just that – accidents. That’s why,
controlled drugs), and not on Bupa’s exclusion list. treatments that are excluded or restricted on your
cases, non-PBS ‘High-Cost Drugs’. if you have an accident shortly after you’ve cover if you need them because of an accident.
Pharmaceuticals listed on the PBS might be To make a claim for your medication you’ll joined Bupa or upgraded your cover, we’ll cover We call this Accident Inclusion. Check your policy
covered in one of two ways: you immediately for accidents you’ve sustained
need an official pharmacy receipt with the information to see if this is included in your cover.
(limited to what’s covered in your policy). What
following information:
By your Hospital cover costs we cover depends on what’s included in
• Drug name. Utilising our ‘Accident Benefit’
your policy.
This is medication you take in hospital (not • Date dispensed (or its supply date). On some covers, our Accident Benefit can help
discharge medications) required to treat and • Strength. reduce the costs you pay. In hospital, to claim
manage the condition for which you are in We consider something an accident if:
• Quantity. back your excess or co-payment if you are
hospital. In most cases, these medications are • It was unforeseen and occurred by chance.
• Confirmation the medication was not subsidised by admitted for related treatment. On Extras that will
fully covered by our hospital agreement – this just the Australian Government’s Pharmaceutical Benefits • It happened because of an external force, but aid your recovery – even if you’ve already reached
means that the hospital will bill Bupa directly and Scheme (PBS). wasn’t intentional. your limit. How the limits apply varies between
you won’t have to make a claim. • Pharmacist’s name, address and prescription number. • It happened in Australia. products, so check your policy information.
• If you’re at a private hospital with a Bupa agreement, • Customer’s name and address.
we pay some of the cost of medications that are not What’s not considered an accident? Utilising our ‘Accidents Happen Refund’
on the PBS (known as High-Cost Drugs), if they are You can make a claim with myBupa or by
provided to you in hospital and are approved by the completing a form and submitting it in-store • A sudden illness. On some covers, when requiring hospital
Therapeutic Goods Administration (TGA) for the or by mail. • Surgical procedures. treatment as the result of an accident, Bupa
treatment of your specific condition. will refund you the hospital excess you paid for
The amount Bupa will pay for medication will • Injuries due to alcohol or drug use, or drugs
• To be eligible, all waiting periods must be served and that admission. So check your policy for more
depend on your level of cover, and we only not prescribed by a registered practitioner.
your membership payments must be up to date at information.
cover for the medication cost that exceeds the • Pregnancy and birth.
the time you receive the medication.
PBS co-payment, which is an amount set by the
Australian Government. • Aggravation of an existing condition.
By your Extras cover • Damage to teeth caused by eating.
Visit Pharmacy Cover FAQs for more information.
Many types of Extras cover include cover for
pharmacy. This is medication you purchase when

28 29
 Managing and
reducing your
medical costs
The Bupa Medical
Gap Scheme
The Bupa Medical Gap Scheme is all about How does it work?
reducing the medical costs you need to pay for We pay more, so that you pay less.
treatment when you’re admitted to hospital. If
your specialist uses our scheme, you’ll never Where a doctor or specialist has signed up to
pay more than $500 out-of-pocket on medical the Bupa Medical Gap Scheme, and agrees to
costs for in-hospital treatment. use it for your treatment, the costs you pay are
reduced. Your doctor or specialist agrees to
Each doctor involved in your treatment can only charge up to a certain fee. We then pay
choose to use the Bupa Medical Gap Scheme a much higher amount than what we normally
for your admission in a Public Hospital, or would.
a Private Hospital with which Bupa has an
agreement. What can I expect if my doctor uses
The ‘gap’ is the amount you’ll need to pay the Bupa Medical Gap Scheme?
yourself if your doctor or specialist charges You will usually have multiple doctors or
more than what Bupa and Medicare will pay specialists involved in your treatment.
(Health funds pay 25% of this fee, and Medicare
pays 75%). The Bupa Medical Gap Scheme If each doctor involved in your treatment
reduces or eliminates this difference, or ‘gap’. chooses to use the Bupa Medical Gap Scheme
Bupa provides two different arrangements – for your treatment:
either ‘no gap’ or a ‘known gap’. In a Public Hospital:
If you have a pre-booked admission, you will
No Gap
never have to pay more than $500 per doctor
If your specialist is registered with the Bupa while you’re in hospital. If you are admitted
Medical Gap Scheme with no gap, they’ll any other way such as through the Emergency
bill Bupa directly and you won’t have to pay Department, your doctor will bill Bupa directly
anything for your specialist’s services provided and you will pay nothing while you’re in that
in hospital. The Bupa Medical Gap Scheme, it is hospital.
an opt-in service, so you will need to ask your
specialist if they will participate in the Bupa In a Private Hospital with which Bupa has an
Medical Gap Scheme for your treatment. agreement:
You’ll never have to pay more than $500 for
Known Gap medical treatment per doctor – we may even
If your specialist is registered with the Bupa pay for the full cost while you’re in that hospital.
Medical Gap Scheme with a known gap, they’ll
bill Bupa directly, but they’re able to charge What happens if my doctor doesn’t
you a gap up to a maximum of $500 for your use the Bupa Medical Gap Scheme?
specialist services provided in hospital. The specialist or doctor can decide what to
charge you and you’ll need to pay any ‘gap’ (or
amount above what we pay) in costs yourself.
Find Members First, Network Hospitals and
Medical Gap Scheme providers at
bupa.com.au/find-a-provider

30 31
 Bupa will cover treatment as required under the
No Gap cardiac Potential ‘out-of-pocket’ costs legislation relating to the payment of benefits for
Associated Treatments for Complications, Associated
services 1. Excesses Unplanned Treatments, Common Treatments and
An excess is a one-off payment you make each Support Treatments. In circumstances where a member
Bupa has partnered with Advara
calendar year if you need to go to hospital. You pay receives hospital treatment during an admission to
HeartCare, Australia’s largest
this before you are admitted to hospital and before hospital for which Bupa pays the entire treatment using
group of private cardiologists, a bundled payment mechanism (e.g. using a single
we will cover the rest of the hospital costs that your
to help achieve better health policy includes. You will have agreed on this amount Diagnosis Related Group) and we cannot allocate the
outcomes for patients with when you chose your level of cover and can find it cost between the treatment that is covered and the
heart disease. in your policy information, available by logging in to component that is not covered, Bupa may pay the full
myBupa.com.au bundled payment (less any excess or co payments the
As a Bupa member, you’ll have
customer needs to contribute) on an ex-gratia basis.
no out-of-pocket expenses for An excess is paid once per person per year. Where
services from an Advara HeartCare there is more than one person required to pay an
cardiologist when you’re admitted excess on the policy, the excess is paid a maximum of 6. What is restricted cover?
to hospital for a procedure related two times in a year. This applies even if you change The Australian Government sets an amount to charge
your cover. The exception is when you change your for hospital costs, which is called the ‘minimum
to heart disease.
cover to a policy with a higher excess. In that case, benefit’. If your policy says you have ‘restricted
Find out more about Advara you’d only pay the difference between the lower and cover’ for a type of treatment, it means we will only
HeartCare at bupa.com.au/health- higher excess if you were to be admitted to hospital pay the minimum benefit for your hospital costs. In
programs/advara-heartcare- again that year. If conditions apply. most cases, if you were to stay in a shared room in a
partnership public hospital, you’d be covered but there may be an
Excesses are still payable If you have transferred from
amount for you to pay. For a private room or a private
a different health fund, regardless of whether you have
hospital, the hospital may charge even more, leaving a
already paid an excess to your old insurer in the same
significant amount for you to pay.
calendar year.
Visit myBupa.com.au
2. Co-payments This example shows what someone with restricted
A co-payment is where you pay a set amount each cover might pay in hospital costs. The actual amount
day that you are in hospital, up to the first five days, depends on a number of factors, including your choice
for each time you are admitted to hospital. Only some of hospital. Your hospital must let you know the
Bupa members have co-payments. If you do, you will specific amount before you are admitted – this is called
have agreed to this amount when you first choose your ‘Informed Financial Consent’.
level of cover and can find it in your policy information,
The amount we pay for other costs you may incur
available by logging into myBupa.com.au
in hospital (like medical costs), is not lower under
restricted cover. See page 23 for more details.
3. A daily, fixed fee
Log in to myBupa.com.au to access your policy
This is a fee charged by a small number of private
information, which shows the services this applies to.
hospitals that you may have to pay. If they do charge
one, they should tell you when you make a booking.
This is in addition to any excess or co-payment you 7. T
 hings your hospital policy
may have to pay. It may be charged by the hospital doesn’t cover
and is not related to your health insurance. It might This varies, but here are some common examples:
influence your choice of hospital.
Type of service Covered by
4. A ‘gap’ for specialist fees
GP visits, blood tests,
The Australian Government sets an amount for the X-rays and MRIs, when you Medicare
cost of specialist medical services. Medicare and Bupa are not admitted to hospital
both pay a portion of this. However, your specialist may
choose to charge more than the set fee. This means Non-emergency ambulance Check page 14 for
transport^ more details
you would have a ‘gap’ to pay yourself.
Go to pages 30 and 31 for more information. Services and treatments
specifically excluded from You
5. Exclusions your cover

Sometimes specific services or treatments are Cosmetic surgery You

excluded under your level of cover. In these cases,
subject to what is set out below, you’ll be responsible For example, travel
Services covered by
for all expenses related to your hospital admission for insurance or worker’s
another source
compensation.
that procedure or service.
^For more information on your cover details please refer to PHIS and fund rules.

32 33
Paying your These forms are available at any Medicare centre or
via the Department of Human Services website. If
Check your Statement of The only exceptions to this are:
• Due to different healthcare costs, insurance
hospital expenses you can’t get to a Medicare centre, contact either
Bupa or Medicare and ask for the relevant forms to
Benefits premiums can vary between different States
be sent to you. Remember, you might have to see After your hospital and medical claims have and Territories.
multiple specialists for one procedure. been processed, your statement will be available • Aged-Based Discount on Hospital cover.
in myBupa, showing what’s been paid on your • The Australian Government’s Lifetime Health
Paying your hospital costs behalf. This is known as your Statement of Cover (LHC) initiative.
Benefits. Please check that these details are
If you’re admitted to a they will send the bill directly to us, so there’s very little paperwork • The Australian Government Rebate.
correct and contact us straight away if you have
private hospital that has for you. Where applicable, the hospital may ask you to pay any
any questions. Find out more on page 36.
an agreement with Bupa excess, a co-payment or a daily, fixed fee when you’re admitted.
Your Statement may include costs for specialists
If you’re admitted to a you may be asked to pay the whole amount up front. In this case,
you haven’t seen in person, but who have Late and overdue payments
non-agreement hospital you can submit a claim form to Bupa to be reimbursed for some of If your health insurance premiums are late or
still performed a service for you, such as a
these fees. You’re likely to have to pay a significant amount yourself overdue, you’ll be affected if you try to make
pathologist.
if you visit one of these hospitals. a claim after the date that your membership
Sometimes we will also include a cheque made
If you’re admitted to a the hospital also sends the bill directly to Bupa. is paid to.
out to your specialist with your Statement. You
public hospital as a private should simply forward this on to the specialist When your payments are overdue by less than
patient (usually to the hospital or to their clinic). two months, we’ll accept any outstanding
If you’re admitted to a Medicare will usually fully cover your costs. payments and you’ll be able to claim as usual
once the arrears have been paid.
public hospital as a public
patient
Understanding your
When you’re overdue for more than two months,
Paying your medical costs
premium it’s at our discretion whether or not to accept
payment and allow your membership to continue.
If your specialist uses our They’ll send the bill to us directly. You won’t see the paperwork until Community rating
If your payments are late or overdue for a period
Medical Gap Scheme you receive your Statement of Benefits. If you have to pay a known Private health insurance is ‘community rated’, of more than two months, you might need to
gap (up to $500), the specialist will bill you for the fee directly. which means that every Australian resident can take out a new policy and reserve your waiting
buy the same health cover at the same price, periods.
If your specialist doesn’t use Your doctor may submit the claim to Medicare and Bupa on your
regardless of their age, gender, ethnicity or
our Medical Gap Scheme behalf and ask you to just pay the gap. If not, you can choose to pay Depending on how long the gap in your policy
medical condition. This is different from other
upfront and then claim using a Medicare Claim Form and Medicare is you may be charged:
types of insurance such as life or disability
two-way claim form. This means Medicare will liaise with Bupa on
insurance, which are ‘risk rated’. • the additional Medicare Levy Surcharge (MLS)
The specialist or doctor can your behalf to ensure your claim is processed.
decide what to charge you and Under these rules, no health fund can refuse to as part of your tax return, in addition to the
Alternatively, you can choose not to pay upfront. You will still need Medicare Levy; or,
you’ll need to pay any ‘gap’ insure you or deny you buying a health insurance
to complete the process above to receive benefits payable by Bupa
(or amount above what we policy based on your health or how likely you • more for your cover through Lifetime Health
and Medicare. You will need to forward any cheques or EFT payment
and Medicare pay) yourself. are to make a claim. This means that health Cover Loading.
you receive to your doctor or specialist as payment toward your
The ‘gap’ is the amount over funds can’t charge some people more than
medical costs, along with any gap payments outstanding. For more on these Government considerations,
the Medicare Benefit Schedule other people.
see page 36.
(MBS) fee. Health funds and
Medicare together pay 100% of
the fee. Health funds pay 25% of Financial Hardship
this fee, and Medicare pays 75%. If you’re struggling to make your payments,
please contact us to discuss your situation.
Paying your prosthesis and pharmacy costs
bupa.com.au/help/payments/behind-in-
If the prosthesis is on the and you’re admitted to a private hospital with a Bupa agreement,
payments
Australian Government’s then the hospital will bill Bupa directly.
Prostheses List
If the medication is on the and it’s essential to your care and you have taken it or it has been
Australian Government’s opened for you in hospital, you will be covered and the hospital
Pharmaceutical Benefits will bill Bupa directly. Also, if you’re at a private hospital with a
Scheme (PBS) Bupa agreement, we pay some of the cost of medications that are
not on the PBS (known as High Cost Drugs). See page 17 for more
information.

34 35
Government policies and Medicare Levy and Medicare Levy An example comparison
Surcharge
tax considerations To have access to Australia’s public health
insurance system (Medicare), most Australian No private Bupa Basic Plus
Lifetime Health Cover (LHC) Age-based discount Starter Hospital*
residents pay a Medicare Levy of 2% of their Health Cover
Lifetime Health Cover (LHC) is an Australian If you’re aged 18–29, you are entitled to receive taxable income. Non-Australian residents You pay You pay
Government initiative to encourage Australian an age-based discount on your domestic
generally don’t pay the Medicare Levy as
residents with full access to Medicare to take out Hospital cover. The discount is calculated at 2%
they don’t access Medicare benefits. $970 $1,124.52*
Hospital cover earlier in life and to keep it. for each year you’re aged under 30, when you
to cover the per year
first purchase your domestic Hospital cover. The If you’re single and earn over $97,000 per
If you don’t have hospital cover before 30 June Medicare Levy
maximum discount is 10% for 18 to 25 year olds. annum, or a couple, single parent or family You get
following your 31st birthday and then decide to Surcharge
take our Hospital cover, you’ll pay an additional Continuity of the age-based discounts and earn over $194,000 per annum and don’t • Cover for some common
hospital procedures
2% on top of your Hospital cover premium have appropriate hospital cover for you and
• Private hospital room,
If you currently have health insurance with all your dependants over the whole year, you
every year you delay – up to a maximum of where available
another fund, we’ll verify your level of discount
70%. This extra cost will remain in place until may be charged the additional Medicare Levy • Taking up this cover you
once we’ve received a clearance certificate from would have access to the
you’ve had appropriate private hospital cover for Surcharge (MLS) as part of your tax return, in Accident Inclusion feature
your old health insurer – but don’t worry, we’ll You get where in the event of
10 continuous years. addition to the Medicare Levy.
manage this process behind the scenes, so there’s nothing more an Accident, we’ll cover
you in a private hospital
To avoid the LHC loading you’ll need to take out no need for you to do a thing. You could choose to pay the Medicare Levy for treatments that are
excluded or restricted on
Hospital cover by 30 June following your 31st Surcharge as part of your tax return.
How does it work? your cover.
birthday and maintain your cover.
The younger you are when you purchase Hospital
After you take out cover, your LHC loading won’t
cover, the more discount you may be entitled to. *Based on Basic Plus Starter Hospital $750 Excess from 1 April 2024
be affected if there are short gaps in your cover $1,124.52 yearly. For singles living in NSW with Australian Government
Here’s an example of how it might work:
(for example, if you switch health insurers). You Rebate and earning $97,001 to $113,000. Assumes no LHC loading and
no age-based discount. For singles with an adjusted taxable income of
just need to make sure those gaps don’t add up • If you’re a single aged between 18 and 25, you $99,000 p.a. under the age of 65, on a Tier 1 rebate in NSW.
to be more than 1,094 days (3 years minus a day) may be entitled to the full 10% discount on your
or the loading will apply. These are known as domestic Hospital cover, until you turn 41.
‘permitted days without cover’. • If you’re a couple aged 25 and 29, you may be
eligible to receive the applicable discount for
Government rebate your age. The discount for a couple’s policy will Can you avoid paying the MLS?
Depending on your age and income, the be applied as an average to the total premium.
Check the table below to see if you are liable to pay the MLS and the amount it would be if you didn’t
Australian Government contributes an amount The partner aged 25 may be eligible for a 10%
have private hospital cover.
(known as a ‘rebate’) towards the cost of your discount on their domestic Hospital cover, while
private health insurance premium. If you’re the partner aged 29 may be eligible for a 2%
eligible, it may reduce the cost of your premiums. discount, resulting in a 6% average discount Medicare Levy
Tier Single Family
each year they hold domestic Hospital cover Surcharge rate^
You can choose to receive the rebate as a until they turn 41.
reduction to your premium to lower your upfront
• When a person turns 41 this discount will
costs, or it can be calculated when you lodge Base $97,000 or less $194,000 or less 0%
gradually start to decrease by 2% each year.
your tax return.
The rebate percentages change yearly from
1 April. The Australian Government announced Tier 1 $97,001–$113,000 $194,001–$226,000 1%
that, from 1 April 2014 and every year thereafter,
the rebate will be linked to the Consumer Price
Index (CPI) growth or the industry average health Tier 2 $113,001–$151,000 $226,001–$302,000 1.25%
insurance premium increase, whichever is less.

Tier 3 $151,001 or more $302,001 or more 1.5%

^Applicable rebate % and income thresholds are reviewed annually by the Australian Government. Single parents and couples (including de-facto couples) are subject
to family tiers. For families with children, the income thresholds are increased by $1,500 for each Medicare Levy Surcharge dependant child after the first child. For more
information go to ato.gov.au.

36 37
Let’s wrap Complaints and feedback
way we handle personal information, or doesn’t provide If you’re travelling outside of Australia
us with the information we require, we may be unable
for any reason, you can suspend your
to provide you with our products and services. If you have any concerns, or you don’t understand

things up
membership: a decision we’ve made, we’d like to hear from you.
We may use your personal (including health)
• For a minimum of two months. To find out how to contact us, or to understand how
information to contact you to advise you of health
• For a maximum of two years at a time. we’ll manage your complaint, you can read our full
management programs, products and services. When
complaints and feedback process at bupa.com.au/
Fund rules you take out cover with us, you consent to us using
your personal information to contact you (by phone,
• If you re-suspend a two-year suspension, you can
only do this up to a maximum of six years. complaints-feedback
Everything we do is governed by our Fund Rules. email, SMS or post) about products and services that • Up to two suspensions per calendar year.
These are available online at bupa.com.au/fundrules may be of interest to you. If you do not wish to receive The Private Health Insurance Code
• At least one month of active, paid cover must occur
this information, you may opt out by contacting us.
between each suspension period. of Conduct
Privacy and personal data Private Healthcare Australia’s Code of Conduct (the

Your privacy is important to us.

Health cover and To be eligible for a suspension, Code) was developed by the private health insurance
industry. It aims to enhance industry standards of
you must:
This statement summarises how we handle your overseas travel • Have held your cover for at least twelve months.
practice and service. As a signatory to the Code, we
undertake to do a number of things that will benefit
personal information. When you travel overseas you’re not covered by your
• Be up to date in your payments at the time you want you as a member. These include:
For full information about our information handling private health cover or Medicare. To provide assistance
to suspend (to at least one day after the date you
to Australian residents travelling abroad, the Australian • Working to enhance our service standards.
practices, please refer to our Information Handling want the suspension to kick in).
Policy (available at bupa.com.au/info-handling-policy). Government has signed Reciprocal Health Care • Providing information to you in plain language.
Agreements with a number of countries. • Apply for a suspension before you want the
When you join Bupa, you agree to the handling of your suspension period to begin (we can’t do it • Helping you make better informed decisions about
personal information as set out in this document. These agreements offer Australian residents retrospectively). our products.
assistance with the cost of medically necessary • Letting you know how to resolve any concerns that
• Notify us via phone on 134 135 or visit your nearest
Information Policy treatment while travelling in:
Bupa store you may have.
We’ll only collect personal information that we require • Notify us of your return to Australia within 30 days • Protecting the privacy of your information in line
to provide, manage and administer our products and of arriving. with the privacy legislation and our Information
services and to operate an efficient and sustainable Handling Policy.
Belgium Finland Ireland Italy You can change your recommencement date, as long
business.
as you notify us in advance. We’re proud to be a signatory to the Code and we’re
We are required to collect certain information from committed to continually reviewing our operations to
you to comply with the Private Health Insurance If your suspension period is less than four months, ensure compliance.
Act 2007 (Cth). We may also collect information your direct debit arrangement will continue when your
Malta New Zealand Norway The Netherlands policy resumes. A copy of the code is available at
about you from health service providers for the
bupa.com.au/code-of-conduct
purposes of administering or verifying any claim, If your period of suspension is more than four months,
and from your employer, broker or agent if you are you need to notify Bupa if you would like your
on a corporate health plan or have joined through direct debit payment arrangements to start again –
a broker or agent. We may disclose your personal Slovenia Sweden United Kingdom otherwise you will receive a renewal notice requesting
information to our related entities, and to third membership payment.
parties including healthcare providers, Government
These agreements aren’t a substitute for travel insurance. Even if you’re travelling
and regulatory bodies, other private health insurers,
and any persons or entities engaged by us or acting
to a Reciprocal Health Care Agreement country, travel insurance with cover for
medical treatment is still important to have.
Things to consider More Information
on our behalf. If we send your information outside If we don’t hear from you and you don’t resume your
To find out more about Australia’s healthcare system
of Australia, we will require that the recipient of the cover within 30 days of when you return, the policy will
Suspending your membership when you visit bupa.com.au/healthcare-guide today.
information complies with privacy laws and contractual be reinstated and ultimately cancelled if no premiums
go overseas are received.
obligations to maintain the security of the data. If you
are on a corporate health plan, we may disclose your Suspending your membership means that you won’t be
covered for any service or treatment for the duration of
If you return from suspension within two years and Bupa health cover
information to your employer to verify your eligibility to
be on that corporate plan. your suspension.
you’ve made a payment on your membership, your new
premium won’t incur the Lifetime Health Cover (LHC)
made easy
The policy-holder is responsible for ensuring that loading. After you resume your membership, any period Unsure of any words? Visit our Bupa Glossary at:
each person on their policy is aware that we handle for which it is not paid will be classed as absent days, bupa.com.au/glossary
their personal information as set out here and in our so it’s important to keep your membership active.
To see our fund rules, visit: bupa.com.au/fundrules
Information Handling Policy. Each person on a policy While you’re on suspension you’ll be considered as
aged 15 or over may complete a ‘Keeping your personal To find out more about what the Australian
not holding an appropriate level of Hospital cover. At
information confidential’ form to specify who should Government Rebate on private health insurance
the end of the financial year, if your income is over
receive information about their health claims. You means for you, visit: bupa.com.au/rebate
the thresholds set for the Medicare Levy Surcharge,
are entitled to reasonable access to your personal you may need to pay the surcharge in addition to the
information within a reasonable time frame. We reserve Medicare Levy, for the period of your suspension.
the right to charge a fee for collating such information. For more information, speak to your tax advisor.
If you or any insured person does not consent to the

38 39
We’re here
to help
We get that there’s a lot of info to take
in when it comes to health insurance
but that’s what we’re here for.

Get in touch whenever you need to

and we’ll answer any questions you
might have.

Bupa Health Insurance

Give us a call us on 134 135,

visit bupa.com.au or head into a
Bupa Health Insurance store.

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Bupa HI Pty Ltd

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Effective 1 July 2024

11880-07-24