hospital and ancillary

Transcription

1 Your guide to hospital and ancillary The information contained in this document is current at the time of issue: October 2016 Read about what s in, what s out and what it s all about (P.S. we recommend you keep a copy of this guide)

2 Hospital What s covered You can claim benefits towards thousands of procedures, but below is a list of the most common ones. Ambulance Services Unlimited cover for medically necessary ambulance trips to the nearest hospital able to provide the level of care you require. Tas and Qld residents are covered by their state schemes. All joint reconstructions and investigations All joint replacements Cancer treatment Such as chemotherapy and radiotherapy. Colonoscopies Heart-related procedures Such as angiograms and stents, or open heart and bypass surgery. Major eye surgery Obstetrics related services Including mid-wife assisted home births. Assisted reproductive services Such as IVF and GIFT. Midwife assisted home births Brain surgery Bowel surgery Psychiatric services Rehabilitation Removal of appendix, tonsils and adenoids Renal dialysis Surgical removal of wisdom teeth (hospital charges only) Spinal fusion surgery Weight loss surgery All other in-hospital services Where Medicare pays a benefit. Male and female sterility reversal What we pay towards included services: theatre fees and hospital accommodation in a private or shared room surgically implanted prostheses up to the minimum benefit listed on the Federal Government s Prostheses List doctors fees for in-hospital medical services GapCover for participating doctors, specialists and surgeons medical fees speech processor and insulin pump replacements - benefits are paid in accordance with the minimum benefits listed on the Federal Government s Prostheses List. Just a heads up, although there are no restricted or excluded services on, there are some other procedures, charges and items that we don t pay benefits for, such as procedures that aren t covered by Medicare or listed on the Medicare Benefits Scheme (MBS). For more info see the Member Guide ahm.com.au/downloads 2

3 The daily charge explained A daily charge (also known as a co-payment) is the daily amount you pay towards the cost of treatment in hospital or day surgery. The daily charge amount depends on what level of cover you have. Hospital cover There is no daily charge on this level of cover. Hospital cover level 5 A daily charge does apply on this level of. Here s an example of what you pay if you go to hospital: Up to 1 night Pay a $250 daily charge per person on admission 2nd night Pay another $250 daily charge per person $0 Every night after that + any future hospital visits within your membership year! The daily charge cap The $250 daily charge is capped at $500 per person ($1,000 per family) each membership year. When we waive your daily charge On this cover we'll waive your $250 daily charge in the following cases: for any Child Dependant, Student Dependant or Adult Dependant on your policy who requires a hospitalisation; or hospitalisation as a result of an accident - where possible we'll waive the daily charge upfront However, due to the way we receive claims for hospitalisations relating to accidents, the hospital may require you to pay the daily charge on the day of admission. We ll then reimburse this amount, subject to eligibility for the waiver. The daily charge will only be waived for the first admission each membership year in relation to a non-compensable accident. A Child Dependant is: a child of the Principal Member who doesn t have a partner and is under 21. A Student Dependant is: a child of the Principal Member who doesn t have a partner and is over 21 and under 25 and studying full time. An Adult Dependant is: a child of the Principal Member who doesn t have a partner and is over 21 and under 25, and isn t studying full time. 3

4 There might be a gap... The benefit we pay towards medical services is based on the Medicare Benefits Schedule (MBS). If a service is listed on the MBS and included on your cover, Medicare will pay 75% of the MBS fee and we ll pay 25%. A doctor may choose to charge more than the MBS fee. This may leave you with an out-of-pocket expense you have to pay. This is the medical gap. To limit medical gaps you should check with your doctor whether they participate in GapCover before agreeing to treatment. You can search for doctors who have previously registered for GapCover at ahm.com.au/find-a-doctor What is GapCover? GapCover is designed to help reduce or remove the medical gap so that you pay less for your treatment or nothing at all. If your doctor chooses to participate in GapCover, we ll provide benefits up to an agreed fee and then you ll have to pay any difference. Under GapCover, the maximum gap that you ll have to pay is $500 per claiming provider (i.e. doctor s account). GapCover doesn t apply to diagnostic services such as blood tests, x-rays and untrasounds. Hospital waiting periods This is a set amount of time you must wait before you can receive benefits for a service included on your cover. A waiting period applies when you first join or re-join after some time without health insurance, change to a higher level of cover, get cover for additional services or increase your limits. 1 day Hospital treatment as a result of an accident that occurred after joining this cover Ambulance Services 2 months Hospital treatment (where there are no pre-existing conditions) Rehabilitation, psychiatric services and palliative care (regardless of whether the condition is pre-existing) 12 months Pre-existing conditions Speech processor and insulin pump replacements Obstetrics related services Midwife assisted home births Pre-existing condition...please explain This is any kind of condition, illness or ailment that you had the signs or symptoms of (in the opinion of ahm s appointed Medical Practitioner) in the 6 months before you joined private health insurance or changed your cover. Before any hospital visit call us on to make sure you re covered. 4

5 Extras With there s plenty of extras to go round. No waiting periods on most extras No time to wait? That s ok. We ve waved goodbye to waiting periods on most things like routine dental and therapies. Unlimited emergency ambulance Includes emergency transport to hospital due to a sudden or unexpected event (1 day waiting period applies). Excludes transport covered by a state scheme or ambulance subscription and nonemergency transport eg. transport from hospital to home. Tas and Qld residents are covered by their state schemes. 100% back on optical Frames, prescription lenses and contact lenses included. For scripted sight correcting products only. Extras Waiting Periods Like hospital cover, waiting periods on extras are the set amount of time you must wait before you can receive benefits for a service included in your cover. If you switch to us from another private health insurer, we ll generally recognise any waiting periods you ve already served for comparable extras. Included extras Annual limits apply and reset every financial year. Service Item number Benefit Annual Limit Waiting Period General Dentistry (most common listed) 80% of actual charge up to Comprehensive examination $28.80 Periodic examination $28.00 X-ray (one film) $21.60 Panoramic x-ray $44.80 Topical fluoride application $18.40 Clean and polish $25.60 $800 per person $1,600 per family Continued on the next page... Scale and clean $ These services have a combined limit of 2 services per person per financial year 2 Maximum 2 services per person per financial year 3 These services have a combined limit of 3 services per person per financial year 5

6 Service Item number Benefit Annual Limit Waiting Period Mouth guard (custom made) $75.20 Non-surgical extraction 311 $64.80 Surgical extraction 324 $ Metallic restoration 1 surface/3 surfaces Adhesive filling (front) 1 surface/3 surfaces Adhesive filling (back) 1 surface/3 surfaces 511/ / / 533 $56.00/ $83.20 $61.60/ $88.00 $65.60/ $ combined general dentistry limit from the previous page. Occlusal splint $ Preparation of one root canal 415 $ Filling of one root canal 417 $ High Cost Dentistry 60% of actual charge up to Specialist root planing (per tooth) 222S $8.40 Specialist surgical removal or a tooth (e.g. wisdom tooth) Specialist preparation of one root canal 324S $ S $ Full crown - metallic 618 $ Full crown - veneered 615 $ Bridge pontic - indirect 643 $ Full denture - upper/lower 5 711/712 $ Partial denture - upper/lower 5 727/728 $ $800 per person $1,600 per family 12 months Specialist occlusal splint 1 965S $ Orthodontics Specialist full upper and lower banding (benefits vary depending on item numbers and we pay lower benefits for services provided by a general dentist.) 60% of actual charge up to 831B $ Maximum of 1 service per person per financial year 5 One complete set per person every 3 financial years 6

7 Service Benefit Annual Limit Waiting Period Therapies 100% of charge up to Physiotherapy Physiotherapy, Occupational therapy, Hand therapy and One-on-one Hydrotherapy (service must be provided by an ahm recognised physiotherapist) Chiropractic $45 $600 per person $1,200 per family Initial consultation $40 Chiropractic x-rays $90 $500 per person $1,000 per family Natural therapies Acupuncture, Alexander Technique, Biochemistry, Bowen Therapy, Feldenkrais, Herbalism, Homeopathy, Kinesiology, Naturopathy, One-onone Pilates, Orthoptist, Osteopathy, Reflexology, Remedial Massage, Rolfing $45 $600 per person $1,200 per family Psychology and Hypnotherapy (service must be provided by an ahm recognised psychologist) Phychology $70 Hynotherapy $70 $400 per person $800 per family Group phychology $15 Speech therapy Initial consultation $50 $300 per person $600 per family Optical 100% of charge up to Single vision glasses, bifocal glasses, multi-focal glasses, contact lenses, disposable contacts (only payable on scripted sight correcting products) $300 $300 per person $600 per family 7

8 Service Item number Benefit Annual Limit Waiting Period Pharmacy 100% of charge up to General items such as hormonal implants, contraceptives for medical reasons, preventative/travel vaccines (excludes PBS scripts, over the counter medicines, vitamin and herbal medicines) Preventive Treatments (e.g. Nicobate patches, Hepatitis A/B injections, flu and travel vaccines) 100% of balance above general patient PBS amount. Up to $50 per item prescribed. Up to $30 per item $650 per person $1,300 per family Dietitian & Nutritionist 100% of charge up to Initial consultation $40 $300 per person $600 per family Podiatry and associated services 100% of charge up to Podiatry, biomechanical assessment and cast $40 $400 per person $800 per family Orthotics/Orthopaedic shoes (Purchase must be from an ahm recognised podiatrist or orthopaedic supplier. Excludes sporthotics and formthotics.) $200 $200 per person $400 per family 12 months Hearing Aids (account must be paid in full before we pay a benefit) 100% of charge up to Per hearing aid $600 $600 per person every 3 financial years $1,200 per family Repeair $100 every 3 financial years 12 months 8

9 Got questions? We re here to help Now that you ve read this guide make sure to save a copy. You can find out more information in our Member Guide - it s full of health insurance goodness, download a copy at ahm.com.au/downloads Monday to Friday Chat at ahm.com.au Call or ask anytime ahm by Medibank is a business of Medibank Private Ltd ABN ahm by Medibank, ahm Health Insurance and ahm are references to Medibank Private Ltd trading as ahm by Medibank. The information contained in this document is current at the time of issue: October MAHM