Claiming for Hospital Services

Hospital or medical claims can be confusing, particularly when Medicare is involved, but we’re here to help you every step of the way.

Teachers Health Fund will pay benefits for any treatments received as an in-patient during your hospital stay, depending on your level of Hospital cover. Teachers Health Fund will not pay for visits to your specialist before or after your hospital admission.

Hospital Bills

You will need to pay any excess payments for hospital admissions direct to the hospital. You may need to make this payment when you are admitted or the hospital may bill you at a later date - just ask the hospital if you’re unsure. Hospitals will usually bill the remainder of your account directly to Teachers Health Fund.

Doctor and Specialist Bills

If your doctor or specialist is participating in the Access Gap Cover (AGC) scheme they will generally send any AGC bills direct to Teachers Health Fund for payment. If the bill is sent to you instead, please forward it to us (do not take it to Medicare) and we will forward your claim to Medicare on your behalf and pay your doctor or specialist directly.

If your doctor or specialist is NOT participating in the Access Gap Cover (ACG) scheme, please take your bill directly to Medicare who will process the claim before we can pay any benefits.

For visits to your specialist before and after you go to hospital:
Medicare pays 85% of the Medicare Benefits Schedule for treatments incurred before and/or after you go to hospital - you will need to pay the remainder of the account.

For treatment in hospital:
Medicare pays 75% and Teachers Health Fund pays 25% of the Medicare Benefits Schedule for any in-hospital treatments.

Doctors and specialists may, at their discretion, charge above the Medicare Benefits Schedule (MBS) fee for a service. The difference between these fees and the MBS fee for the service is referred to as 'the gap', which you will need to pay as your out-of-pocket expense.