What you're covered for

What is covered

Hospital expenses	Members First and Network private and licensed day hospital facilities If you choose to be treated at a Members First or Network private hospital, including licensed day hospital facilities, you will be fully covered for hospital accommodation and theatre fees. Find a Members First or Participating private hospital Non-Network  and Fixed-Fee private hospitals If you choose to be treated in a non-Network private hospital, you will be covered for your accommodation and theatre fees at the Government default benefit. You will be required to pay the difference between the hospital charge and the default benefit.   There are a small number of ‘fixed fee’ hospitals that charge a fixed daily fee for a maximum number of days per stay.   At Fixed Fee hospitals, you may have to pay a co-payment. Public hospitals You will be fully covered for shared ward hospital accommodation, same day services, accident and emergency and outpatient medical and post-operative services in public hospitals. Other Inpatient Expenses Cover for Pharmacy You will also be covered for supplied pharmaceuticals approved by the Pharmaceutical Benefits Scheme and provided as part of your in-hospital treatment  Cover for Prostheses If your doctor chooses a ‘No Gap’ prosthesis you will not have any out-of-pocket expense where the prosthesis item is implanted as part of hospital treatment. If the prosthesis item used is listed as a ‘Known Gap’ prosthesis you’ll have to pay any gap charged by the hospital.
Medical expenses	Cover for your in-patient medical expenses We cover you for 100% of the Medicare Benefits Schedule (MBS) fee for services provided by doctors including surgeons, anaesthetists, pathologists or radiologists whilst in hospital.   Cover for your out-patient medical expenses Your OSHC provides a benefit of 100% of the MBS fee for out of hospital medical services. This includes services from General Practitioners (GPs), medical specialists, medical imaging providers (x-rays and ultrasounds), pathology providers, and more.
Emergency Ambulance services	Emergency Ambulance Services Your OSHC covers 100% of the charge of transport by or under arrangement with an approved ambulance service when medically necessary for admission to hospital or for Emergency Treatment. It does not cover general ambulance, including transportation between hospitals.
Outpatient Pharmacy benefit	Outpatient Pharmacy benefit For selected pharmacy items prescribed as a hospital outpatient or by a doctor or specialist, we’ll cover the balance of the item cost up to $50 per script item after you pay the Pharmaceutical Benefit Scheme (PBS) patient co-payment fee.   You can claim up to $300 per calendar year for a single membership or $600 per calendar year for a family membership.

What is not covered?

Treatment During a Waiting Period	A waiting period is the time between when you joined us and when you are covered for a service or treatment. If you receive a service or treatment during this time, you are not eligible to receive a benefit payment from us, regardless of when you submit the claim. If you’re changing from another OSHC provider to Bupa Australia, you’ll continue to be covered for all benefit entitlements that you had on your old cover, including any waiting periods that you have served. This is referred to as ‘continuity of cover’. You are not covered for: Treatment you receive within the waiting period, where that treatment is for any pre-existing ailment, illness, or condition, unless classified as Emergency Treatment. Treatment you receive within the waiting period, of any secondary condition or disability that directly arises from the pre-existing ailment, illness, or condition. Treatment for a pregnancy related condition within the waiting period, unless classified as Emergency Treatment
Exclusions	Exclusions for specific procedures or services means you will not be covered and may have significant out-of-pocket costs should you require treatment for the excluded service. For the duration of your cover you will not receive benefits for: Assisted reproductive services (including but not limited to IVF) Elective cosmetic surgery Treatment where compensation, damages or benefits may be claimed from another source Treatment for a student’s child who is over 18 years of age. Treatment for services not covered under the Medicare Benefits Schedule, for example health screening services and medical check-ups relating to visa applications or employment. Any treatment or service rendered outside of Australia. This includes: treatment arranged before you arrived in Australia; treatment while travelling to or from Australia; expenses for treatment outside of Australia; or transportation into or out of Australia in any circumstance.
Services and situations not covered by health funds	There are some hospital services you will not be covered for, or will have limited cover for, under OSHC. These are generally not covered under any health fund's hospital cover:   A person who has been in hospital for more than 35 days and is classified as a nursing home type patient may receive limited benefits. In such cases patients are required by law to make a personal contribution towards their care Hospital treatment provided by a practitioner not authorised by a hospital to provide that treatment If you choose to use your own allied health provider rather than the hospital's practitioner for services that form part of your in-hospital treatment (e.g. chiropractors, dieticians or psychologists)
Medical Gap	For doctors who charge you an amount above the MBS Fee, your OSHC will cover 100% of the MBS fee and you will need to pay any amount above this benefit, called the ‘Medical Gap’ or ‘Gap’.

What are the waiting periods?

	Waiting Period
Pre-existing ailments, illnesses or conditions of a psychiatric nature	2 months
All other pre-existing ailments, illnesses or conditions	12 months
Pregnancy related services (including childbirth)*	12 months