Member Guide
Total Page：16
File Type：pdf, Size：1020Kb
member guide effective November 2020 Member Guide | 1 Information for non-Australian residents The Hospital covers that this Guide applies to are generally not suitable for non-Australian residents, including visitors from countries with which the Australian government has Reciprocal Health Care Arrangements. If you’re a non-Australian resident, please contact us for information about health covers that may be more appropriate for you. Our Member Guide This Guide is a summary of Medibank’s Fund Rules and policies as at the date of this Guide. It’s designed to help you understand how your Medibank membership works, and should be read together with the Cover Summary you receive when joining or changing your cover. Your Cover Summary is a summary of the services and treatments provided by your particular health insurance cover. You can download a copy of your Cover Summary and our Fund Rules from medibank.com.au • Please read this Guide and your Cover Summary carefully and keep them for your reference. • If you need further information about your cover or anything in this Guide, please contact us. • We’ll send correspondence to your email address, or your postal address where you have opted out of email communication. It’s important to let us know if your contact details change. • It’s also important to contact us if you, or anyone else on the membership, are going to need treatment, to check what services and treatments we pay benefits towards and what out-of-pocket expenses you may have. Our contact details are on page 36 of this Guide. • This Guide only applies to Medibank Australian resident covers. If you hold a cover other than an Australian resident cover, please contact us for details of the services included and membership conditions. Member Guide | 3 Before you get started… Here is an explanation of some of the terms commonly used in this Guide: ‘We’, ‘us’ and ‘our’ is Medibank Private. ‘You’ is any member of Medibank to whom this Guide applies. ‘Member’ is any person on a Medibank membership. ‘Membership’ is made up of one or more members. ‘Policy holder’ is the person who is responsible for the membership. This is the person we contact when we need to communicate about the membership. To help you make the most of this Guide and understand the services and treatments under your cover, we’ve also prepared a glossary of useful terms that you can access at medibank.com.au/glossary Medibank Joining Statement By joining Medibank, you (if you are the Policy • authorise any health service provider to holder) have agreed that you: supply to Medibank any information Medibank considers necessary for the assessment of any • will ensure that all information supplied claim on the membership, and will ensure that to Medibank is true and correct members aged 16 years and over have provided • will keep your membership information the relevant consent up to date and notify us of any changes • authorise Medibank to supply to any health as soon as possible service provider any information Medibank • will ensure that all members on the membership considers necessary for the assessment of any are aware of and abide by Medibank’s Fund Rules, claim on the membership, and will ensure that the information in this Guide and Medibank’s members aged 16 years and over have provided policies, including its Privacy Policy the relevant consent • have the authority to provide the personal • will make the minimum advance premium information of other members on the membership payments required • will make, or authorise the making of, all claims • are aware that Medibank may terminate your under the membership and ensure that any claim membership in accordance with Medibank’s that includes sensitive information of a member Fund Rules. aged 16 years and over is made having first obtained the consent of that member Member Guide | 5 What’s Inside Welcome to Medibank 8 Going to Hospital 14 Your welcome pack 8 Inpatient vs outpatient 14 Transferring from another 8 Informed financial consent 14 Australian health fund Hospital accommodation benefits 14 Cooling off period 9 Choice of hospital 14 Types of cover 9 Members’ Choice hospitals 15 Changes to the terms and conditions 9 Non-Members’ Choice hospitals 15 of your membership Public hospitals 15 Medicare eligibility 9 Medicare Benefits Schedule (MBS) 15 Managing your Membership 10 and medical services My Medibank 10 Doctors’ fees and GapCover 16 Partner authority 10 Surgically implanted prostheses 16 Third party authority 10 Pharmaceutical Benefits Scheme (PBS) 17 Dependants 16 years or over 10 Emergency department facility fees 17 Hospital benefits table 18 Managing your Premiums 11 Premium payment options 11 Hospital Cover 19 Premium protection 11 How hospital benefits are assessed 19 Premium arrears 11 Long stay hospital patients 19 (nursing home type patients) Premium refunds 11 Treatments where no Medicare 19 Changes to your Membership 12 benefit is payable Categories of membership 12 Waiting periods 19 Separated couples 12 Mental Health Waiver 20 Adding a child dependant 12 Pre-existing conditions (PEC) 20 Moving interstate? 13 Having a baby? 21 Receiving treatment interstate 13 Ensuring your newborn is added Suspending your membership 13 to your membership 21 Accident waiting period waiver 21 and Accidental Injury Benefit Hospital covers with an excess 22 Hospital covers with a per-day payment 22 Travel and Accommodation benefits 22 Claiming for a CPAP-type device 23 Hospital benefit exclusions 23 6 | Member Guide What’s Inside Extras Cover 25 Government Initiatives 32 How extras benefits are assessed 25 Australian Government Rebate 32 on private health insurance Members’ Choice extras providers 25 Medicare Levy Surcharge 32 Non-Members’ Choice extras providers 25 Discounts for 18-29 olds 32 Waiting periods 25 (Young Adult Discount) Benefit replacement periods 26 Lifetime Health Cover (LHC) loading 32 Applicable limits 26 Permitted days without Hospital cover 33 Consultations 27 LHC loading exemptions 33 Prescription pharmaceuticals 27 – non-PBS Other Important Information 34 Appliances requiring referrals 27 Members’ Choice Network 34 Extras benefit exclusions 28 Recognised providers 34 Disclaimer 34 Ambulance Services 29 Compensation and damages 34 When are benefits payable? 29 Medibank Privacy Statement 35 When are benefits not payable? 29 Private Health Insurance 35 State Ambulance Schemes 29 Code of Conduct NSW and ACT members with 30 Private Patients’ Hospital Charter 35 Hospital cover Standalone Ambulance cover 30 Contact Us 36 Complaints 36 Making a Claim 31 Hospital claims 31 Medical claims 31 Extras claims 31 Claims documentation 31 Time limit for submitting a claim 31 Member Guide | 7 Welcome to Medibank Your welcome pack Where you join Medibank with a break in cover of If you’ve just joined Medibank, you’ll receive more than two months, you’ll be treated as a new a welcome pack which includes: member and all waiting periods relevant to your cover will apply. • this Guide When you transfer to Medibank, we’ll use our • a Cover Summary, which is a summary of the nearest equivalent cover (to the cover you held services and treatments under your cover with your previous fund) to determine benefit entitlements. It’s important to be aware that: • a Private Health Information Statement (PHIS), which provides general information and isn’t • extras benefits paid by your previous fund/s intended to be a comprehensive description of will be counted towards: your cover. We are required by law to give you a PHIS when you join, and then at least once – annual limits in your first calendar year every 12 months. It’s important that you read of Medibank membership the PHIS with your Cover Summary and – lifetime limits this Guide to fully understand your cover. – benefit replacement periods (refer to page 26). You’ll also receive a membership card, either with your welcome pack or shortly after. • any loyalty bonus or other similar entitlements Use your membership card to make a claim or (e.g. increased annual limits on Extras cover for arrange admission to hospital. You should also orthodontics) built up with your previous fund/s keep it handy if you need to make an enquiry won’t apply to your Medibank cover. about your membership. • if you choose a Medibank Hospital cover with a Make sure you keep your card safe and advise us lower excess, the excess of the equivalent cover immediately if it’s lost or stolen. Medibank won’t will apply until you have served the relevant accept liability for any loss to you resulting from waiting period. the misuse of a lost or stolen membership card. • any excess or per-day payment paid to your previous fund won’t be deducted from any Transferring from another excess or per-day payment payable under your Australian health fund Medibank Hospital cover (where applicable). Provided that you join Medibank within two months We need a Transfer Certificate from your previous of leaving your previous private health insurance fund to confirm your level of cover, waiting periods fund, you generally won’t need to re-serve any served and benefits paid. We’ll request a Transfer waiting periods you have already served. This Certificate on your behalf if you’ve given us means you’ll generally only need to serve waiting permission to do so. Without the Transfer periods for any treatments or items: Certificate, we cannot verify whether anyone listed • that were not included under your previous cover on your membership is required to have Lifetime Health Cover loading applied to their policy. As a • that have an increased benefit (e.g. upgrading result, if we do not receive a Transfer Certificate from a Restricted to an Included hospital service from your previous insurer, we’ll calculate and or increasing an annual limit on an Extras apply the loading to all members over 31 from their cover).