One way to go Health cover with peace of mind - July 2019 - Onemedifund
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one way to go Health cover with peace of mind July 2019
Contents It’s your choice.......................................................... 2 New to private health cover?..................................... 3 Unravelling the maze................................................. 4 Helping you choose your cover.................................. 6 Hospital cover........................................................... 8 Extras cover............................................................ 12 Ambulance cover..................................................... 15 How do I?................................................................ 16 I want to know about............................................... 18
It’s your choice
This brochure has been designed to help you choose
the right private health cover. Following the simple
steps throughout this brochure will help you understand
the different types of health cover onemedifund offers
and will help you to make the right choice to suit your
personal needs and budget.
We want to make choosing private health cover for
you and your family as easy as possible, so if at any
time you do not completely understand the information
contained in this brochure, just pick up the phone and
call 1800 148 626 to speak to one of our customer
service specialists. They will explain everything you need
to know about health cover and help you choose the
right cover to suit your needs.
You can start your health cover over the phone or on our
website at onemedifund.com.au for immediate peace
of mind.
2 onemedifund
New to private health cover?
At onemedifund we know that
health cover can be confusing If you’re new to health cover,
and we aim to help you choose there are a few important things
the right health cover product for you need to be aware of:
you and your family.
1. Private health cover
If you have any questions, Private health cover is designed to complement
please feel free to call us on Medicare, not replace it. Private health cover
contributes towards the cost of public and
1800 148 626 between 8:30am private hospital treatment and health services
& 5pm AEST, Monday to Friday. not covered by Medicare.
For a comprehensive outline of exactly what
you’re covered for, please see the product
onemedifund health covers are descriptions on pages 8-15.
especially designed to:
• cover you against high & rising 2. Medicare Levy Surcharge
hospital, medical & other healthcare The Medicare Levy Surcharge (MLS) applies to
costs at competitive rates Australian taxpayers who do not hold private
• give you the option to select your hospital cover for the full financial year and
doctor and avoid hospital waiting lists who earn above a certain income. If you take
through access to private hospitals out either of our Hospital covers you will avoid
having to pay the MLS.
• cover your dependent children on
your family cover until the age of 18 (see page 20 for full details)
(or 25 if they’re studying full-time) at
no extra charge 3. Australian Government
Rebate on Private Health
Insurance
The Australian Government Rebate on private
health insurance was introduced as an
incentive to make Private Health Insurance
more affordable. The Rebate is income tested
and applies to all onemedifund products.
The Rebate you receive is dependent on your
household income, age, inflation (CPI) and
average health fund increases using a complex
Government formula.
(see page 20 for full details)
4. Lifetime Health Cover loading
The Lifetime Health Cover loading will increase
the standard rate for hospital cover by 2%
for each year that you are over the age of 31
as at the date that you take out a hospital
cover. There are some other exemptions if you
migrated to Australia in the last 12 months or
were overseas. Visit privatehealth.gov.au for
details.
(please see page 22 for full details)
one way to go 3
Unravelling the maze
Hospital cover
onemedifund Gold Hospital cover provides
benefits for private and public hospitals and Gold Hospital
has the option of an excess to reduce your
No excess
premium. This excess is the maximum amount
a patient pays if hospitalised in a financial year
($250 per person and $500 per family). Other or
than the excess, the benefits payable are
identical for each cover option. You can select
one of our Hospital covers as a stand alone
Gold Hospital
product or in combination with Extras cover. $250/$500 excess
See pages 8-11 for details
+
Extras cover
Extras cover provides benefits for services that Extras
are not covered by Medicare. This includes dental, (our comprehensive Extras cover)
optical, physiotherapy, chiropractic and more. It is
important to understand that it does not include or
any hospitalisation expenses. It is essential to
choose Hospital cover for this. You can select one
of our Hospital covers as a stand alone product or Economy Extras
in combination with Extras cover. (our economy Extras cover)
See pages 12-14 for details
=
Combination packages Step 1
You can mix and match any Hospital and Extra Choose your level of Hospital cover from
cover options. This is known as a ‘combination’ the options above (Gold Hospital, with or
cover. Follow these easy steps to choose your without an excess)
combination cover:
See pages 8-15 for details Step 2
Choose the level of Extras cover you
prefer (Extras or Economy Extras)
Step 3
Add them together (the rates can be
found at the back of this brochure or on
our website).
4 onemedifund
If you change
your mind
We are committed to helping you
choose the health cover that is right
for you. If for any reason you decide
that your choice was not suitable
then we will provide you with a refund
(provided no claims have been made).
You will need to contact us within the
first 30 days of taking out your cover
or changing your level of cover for this
refund to be available.
one way to go 5
Helping you choose your cover
This table shows the most popular Hospital and Extras covers to suit each life stage.
Step 1 Step 2 Step 3
choose your life stage our suggestion view pages
Young singles Hospital cover pages
Gold $250/$500 excess 8-11
You have finished studies or have started working.
You only require cover for services you need and
don’t want to pay for services you don’t expect to
use. You need cover suited to your lifestyle
+
Extras cover pages
and budget. Economy Extras 12-14
Married no children Hospital cover pages
You are married, have settled down and are Gold - $250/$500 excess 8-11
planning for the future. Getting ahead is important
and you don’t want to neglect your health. You
need a suitably priced cover that offers more
+
Extras cover pages
comprehensive benefits. 12-14
Extras
Married planning to have children
Hospital cover pages
You are planning for a family and good health cover 8-11
Gold - No excess
+
and value for money is important. You need a
cover that sets you up for the future and provides a
good starting point for the new arrival.
(Please note a 12 month waiting period applies for pregnancy
Extras cover pages
and birth related services. Please see page 18). 12-14
Extras
Married with children Hospital cover pages
You and your family are settled into a home Gold - No excess 8-11
and protecting the health of your loved ones is
important. You want a comprehensive cover that
provides for the health needs of everyone in your
+
Extras cover pages
family. You can keep your children on your cover 12-14
until they are 18 (or 25 if they are studying full time) Extras
Older People Hospital cover pages
You are a mid-age single, or senior couple or Gold - No excess 8-11
a family whose children are now independent.
You are financially well established, leading a
comfortable lifestyle and you want a quality
+
Extras cover pages
cover at this stage of life. 12-14
Extras
Please note: Extras covers must be purchased as a combination with a Hospital Cover.
6 onemedifund
Step 4 Step 5
it’s your choice applying for your health cover
If you prefer other combinations/ Complete the enclosed
options you may choose any Application form
Hospital cover (pages 8-11) Sign up online at
and www.onemedifund.com.au
Extras cover (pages 12-13) Phone us on
1800 148 626
to suit your personal
circumstances.
one way to go 7
Hospital cover
We make selecting your Hospital cover easy!
Our Gold Hospital gives you comprehensive cover for most public and private hospital
services 365 days per year. You can choose to have no excess or a $250/$500 excess to
reduce your health fund contributions.
Gold Hospital cover
Clinical Categories Gold Hospital
Rehabilitation P
Hospital psychiatric services P
Palliative care P
Brain and nervous system P
Eye (not cataracts) P
Ear, nose and throat P
Tonsils, adenoids and grommets P
Bone, joint and muscle P
Joint reconstructions P
Kidney and bladder P
Male reproductive system P
Digestive system P
Hernia and appendix P
Gastrointestinal endoscopy P
Gynaecology P
Miscarriage and termination of pregnancy P
Chemotherapy, radiotherapy and immunotherapy for cancer P
Pain management P
Skin P
Breast surgery (medically necessary) P
Diabetes management (excluding insulin pumps) P
Heart and vascular system P
Lung and chest P
Blood P
Back, neck and spine P
Plastic and reconstructive surgery (medically necessary) P
Dental surgery P
Podiatric surgery (provided by a registered podiatric surgeon) P
Implantation of hearing devices P
Cataracts P
Joint replacements P
Dialysis for chronic kidney failure P
Pregnancy and birth P
Assisted reproductive services P
Weight loss surgery P
Insulin pumps P
Pain management with device P
Sleep studies P
Common services P
Support services P
Ambulance P
Please note: waiting periods (including those for pre-existing conditions) and excesses may apply. Please see page 18.
8 onemedifundHospital excess
• You can reduce your
contribution rate
by choosing an
excess.
• The excess is the maximum
amount you pay up front if you are
admitted to hospital in a financial year.
• Public hospital or day surgery: You pay half the
excess.
• The good news is, that no matter how many times you go to
hospital during a year, you only pay a maximum $250 excess per
person (or $500 per family) per financial year.
Key features
• Comprehensive cover for most public and private hospital services 365 days per year.
• Gold Hospital provides benefits for most public and private hospital services, subject to the
excess level chosen. onemedifund has agreements with around 560 private hospitals nationwide. A
small number of private hospitals do not have a current agreement with the fund and an out of pocket may
apply.
• All hospital cover options provide medical gap benefits (known as Access Gap) through agreements with more
than 36,000 doctors. This is designed to eliminate or reduce out of pocket costs for medical expenses. See page
19 for more information on Access Gap.
• All services eligible for Medicare benefits are eligible for hospital benefits under these health products.
• All hospital cover options include national coverage for ambulance services.
We cover most public hospital stays, unless they charge over the Commonwealth default rate. Please contact us before you go
into hospital for more details.
Hospital substitution programs*
Our hospital substitution programs allow you to recover where you’re most comfortable – all you need is a referral from your
treating doctor.
Hospital @ Home allows you to have services you would usually receive in hospital (like wound care or IV antibiotics) at home.
If the healthcare services you need can be provided at home, you may be able to avoid a hospital stay altogether.
Rehab @ Home allows you to recover in the comfort of your own home with short term therapy for joint replacements,
fractures, spinal conditions, stroke, respiratory conditions, cardiac conditions and mobility problems. We offer physiotherapy,
occupational therapy and more.
Like all hospital services, there is a 2 month waiting period for these services. Please note, anything that is a
pre-existing condition has a 12-month waiting period except for rehabilitation, hospital psychiatric services, palliative care
and ambulance. See page 18 for more information.
*Hospital substitution programs Hospital @ Home and Rehab @ Home can ONLY substitute hospital treatments you are covered for.
Exclusions and restrictions may apply.
Health programs
These programs are designed to help you keep your health on track.
My Health Online gives you access to a range of health and wellbeing tools through our My Health Online web portal. You can
store health information and share it with your doctor, keep a calendar of healthcare appointments, access a health library and
more.
Health Risk Assessment helps you discover more about your health. The online questionnaire gives you a health report
showing where you are doing well and where we may be able to help.
Strive for Health has been developed to assist contributors with chronic conditions manage their health with the help of expert
telephone or face to face support at home.
The Healthy Weight for Life program is a program that can assist with heart disease, diabetes and osteoarthritis management
with strategies to help you maximise your overall health, strength and quality of life. Healthy Weight for Life can help you with
weight loss, strength exercises and education to improve your health.
one way to go 9Hospital cover
What we will pay benefits towards: What we will not pay benefits towards:
Gold Hospital • services incurred before waiting periods have
been served (see page 18).
• public or private hospital bed - shared or
private room (if available) • any treatment for which Medicare does not
pay a benefit, including cosmetic surgery
• same-day surgery
• services that are provided outside the
• theatre fees
Commonwealth of Australia
• special unit accommodation
• services where an entitlement exists or may
• in-hospital psychiatric treatment exist under any compensation, third party or
• in-hospital rehabilitation treatment other insurance
• in-hospital pharmacy • a claim for a service that is submitted more
• surgical prostheses, up to the benefit listed than 2 years after the date of service
on the Government’s Prostheses List (refer to • Doctors’ fees (including GPs, specialists,
page 11) radiology, pathology etc.) for services that are
• ambulance services Australia wide (refer to not part of a hospital admission. Services are
page 15) not covered until the contributor is admitted
to hospital (visits to hospital Emergency
• emergency ambulance treatment and
departments and for diagnostic services are
transport to hospital via road, air and sea
not covered).
• non-emergency road and air ambulance
• outpatient services other than where included
transport
in an agreement between the fund and the
• emergency ambulance treatment without hospital
transport
• take home drugs and some high cost drugs
• emergency ambulance transport between or drugs that are not deemed to be related to
private hospitals the reason for your admission to hospital
• hospital substitution options (refer to page 9) • prostheses items that are not included on the
• health programs (refer to page 9) Commonwealth Government approved list
• ambulance subscriptions, fees and state-
based ambulance levies
• ambulance costs that are covered under
Government legislation or other compensable
sources
• transport provided by a non-recognised state
ambulance provider
• some medical devices and consumables
• experimental treatments
• incidental fees (e.g. Foxtel, newspapers)
10 onemedifundOther Important
Information
What should you do?
• Before you have any surgery, check your
level of cover with the fund.
• If your surgery requires a prosthesis,
ask your surgeon which will be best for
you and which ‘no gap’ prostheses are
available.
• If the surgeon recommends a prosthesis
and a gap is payable, ask why this is
being recommended.
• Ask the surgeon to explain the cost of
the surgery, including the prosthesis. If
there are any gaps for you to pay ask for
a written cost estimate.
• Contact the fund again to confirm if your
surgery will involve any gap payments.
Waiting periods
Please refer to page 18 for information about
waiting periods for this cover.
Pre-existing conditions
Please refer to page 18 for information about pre-
existing conditions.
Medicare Benefits Schedule &
Access Gap
Please refer to page 19 for more information.
one way to go 11Extras cover
We make selecting your Extras cover easy...
Choosing an Extras cover is easy. We have 2 different levels to suit your needs and
budget – Extras and Economy Extras. Here is a summary of what we cover. Please
note: Extras cover can only be purchased in combination with a Hospital Cover. To get
the full product information please contact us or download a cover description from
www.onemedifund.com.au.
Please keep in mind that each service has a limit and waiting periods may apply.
What we will pay benefits towards:
Service Extras Economy Extras
Annual limit Annual limit
(as at July 2019) Benefit Benefit
per person / family per person / family
General dental Basic restoration (fillings)
Diagnostic services
Set benefits
Oral surgery No annual limit 75% of cost $550
per item*
Periodontics
Endodontics
High cost $1,000
dental
Crowns & bridges
($1,500 loyalty limit) O O
$650
Dentures Set benefits ($800 loyalty limit) O O
per item*
Implants $1,000 O O
Lifetime Limit $2,100 ($2,600
Orthodontics
loyalty limit) O O
Optical Glasses / frames & contact
$275 100% of cost $180
lenses
100% of cost
$500 per eye
Laser eye surgery
$1,000 every 2 financial years O O
Prescriptions only
Pharmacy
Note: Benefit applies after $65 per script $50 per script
the maximum PBS amount 100% of cost 75% of cost
$500 / $1,000 $500 / $1,000
($40.30 as at 1/1/19) has
been deducted
Initial consult
Physiotherapy
$60
and other Physiotherapy 75% of cost $350 / $700
Standard consult
therapy
$40
$550 / $1,100
Initial consult
$60
Occupational therapy
Standard consults O O
$40
Hydrotherapy 80% of cost to $20 $200 / $400 O O
Overall physio limit $550 / $1,100 $350 / $700
Please note: each service has a limit and waiting periods may apply.
Loyalty limits apply after 5 years of continuous cover on Extras.
*For set benefits, contact the fund for details.
12 onemedifundService Extras Economy Extras
Annual limit Annual limit
continued Benefit Benefit
per person / family per person / family
Complementary Chiropractic x-rays 80% of cost $115 / $230
therapies Chiropractic
Remedial massage
Osteopathy
Myotherapy
Initial consult
$40 75% of cost $350 / $700
Chinese Herbal medicine $435 / $870
Standard consult
(consultation only) $30
Acupuncture
Podiatry
Dietetics O O
Orthotics
(Custom made or heat 80% of cost $250 / $500 O O
moulded. Limit each 2 years)
Overall complementary
$750 / $1,500 $350 / $700
therapies limit
Additional Pre / Post-natal classes 80% of cost $150 O O
benefits 80% of cost up to $45
Home nursing
per visit / $90 per day
$1,000 O O
Hearing aids $80% of cost $1,500 per 5 years O O
80% to $120 (initial) $500 / single
Psychology
or $80 (subsequent) or $650 / family O O
Allergy treatment 80% of cost $100 O O
Surgical equipment / 50% of cost to $400.
health aids Loyalty benefits apply –
$400
(sub-limits apply.
80% up to $1,000 after 5
($1,000 loyalty limit) O O
years cover. Contact the
Contact us for more info) fund for details.
$150 / single $100 / single or
Health management programs 100% of cost 75% of cost
or $300 / family $200 / family
Travel expenses Up to $100 / single and $200
(for in-patient services)
20c/km
/ family O O
Speech therapy 80% of cost $800 O O
Ambulance National ambulance cover 100% of cost No annual limits 100% of cost No annual limits
Please note: each service has a limit and waiting periods may apply.
one way to go 13Extras cover
What isn’t covered: Other important information
• Treatment you have not been charged for Annual limits are for a financial year (1 July – 30
• Services not recognised by onemedifund June) and are per person unless stated otherwise.
• Services from providers that are not Optical benefits (glasses and contact lenses)
recognised by onemedifund are paid only when prescribed by a registered
• Services provided outside of Australia optometrist. Benefits will only be paid where sight
• Services that can be claimed through correction is necessary. No benefit is payable for
compensation, third party or sports club non-prescription sunglasses.
cover
Pharmacy benefits apply after the standard
• Claims submitted more than 2 years after Pharmaceutical Benefit Scheme (PBS) amount has
the service date been deducted. The PBS amount changes every
• Non-prescription contacts, glasses and year on 1 January and is $40.30 as at
sunglasses 1/1/19. This means that you will pay the first
• Claims with a benefit less than $5 $40.30 yourself and then onemedifund pay
• Services provided by family members, a percentage of the balance depending
relatives, business partners or yourself on the level of your Extras cover.
• Goods or services primarily used for sport, Complementary therapies benefits
recreation or entertainment are payable on fund recognised services and the
provider must be registered or recognised by the
Registered providers fund or registered with Medicare or the Australian
It is a requirement that any Extras provider is Regional Health Group.
registered with Medicare or the Australian Regional Loyalty limits apply after 5 years of continuous
Health Group, and recognised by the fund before cover on Extras.
benefits will be paid. Our aim is to ensure the safety
Please contact the fund on 1800 148 626
and appropriateness of treatment to our contributors
before you have your treatment so we can
and we will only pay benefits for providers who are
tell you how much you will get back.
deemed to have met the fund’s recognition criteria.
We reserve the right to refuse payment for services
rendered by a provider who does not satisfy the fund
criteria. If you wish to ensure that the provider you
are attending is covered by the fund you can search
for registered providers on our website
www.onemedifund.com.au or contact us prior
to treatment.
14 onemedifundAmbulance cover
Ambulance cover provides
benefits for ambulance
treatment and/or transport
should you suffer a
sudden illness or accident.
Ambulance cover is
included in all onemedifund
Hospital, Extras and
Combination covers.
What we cover:
• 100% of the cost
• Air, land or sea ambulance
• Unlimited distance within Australia
• No annual limit
• No waiting period
What is not covered:
• Ambulance subscriptions or state-based
levies
• Costs that are covered under Government
legislation or as part of a compensation claim
• Ambulance services that are not medically
necessary
one way to go 15How do I... onemedifund will automatically reduce your contributions
to take out your nominated Rebate amount once
you submit your rebate application form. For more
information see pages 20-21.
Commence health cover with Nominate or change my Rebate Tier
onemedifund
You can nominate or change your rebate tier at any
Starting onemedifund health cover is easy! Simply choose time, simply:
the best level of cover for you, either Hospital only, or a
• visit www.onemedifund.com.au/rebate
Combination cover (recommended), then choose how
you’d like to sign up. • complete our Rebate Tier Nomination Form,
available on our website, and return it to
Online www.onemedifund.com.au Locked Bag 25, Wollongong NSW 2500
Phone 1800 148 626 • call us on 1800 148 626 or email
Email send a completed application form to info@onemedifund.com.au
info@onemedifund.com.au
Fax send a completed application form to Find a registered healthcare provider
1300 673 406
To find out whether your Hospital, Access Gap doctor
Mail send a completed application form or Extras provider is recognised by onemedifund,
addressed to: go to www.onemedifund.com.au/find-a-provider,
onemedifund
email us at info@onemedifund.com.au or call us on
Locked Bag 25, Wollongong NSW 2500
1800 148 626.
Transfer from another health fund Make an Extras claim
Transferring from another health fund is easier than you
Claiming is easy, simply choose the option that best
think. It takes around 5 minutes and you can switch over
suits you and we can pay your benefit straight into your
the phone, online or by sending in your application form.
nominated account.
You won’t have any waiting periods that you have
Electronic – Upon commencing health cover, all
already served with your previous health fund provided
onemedifund contributors are given a HICAPS card,
that you had an equivalent or higher level of cover with
which they can use to claim their benefit EFTPOS style
that fund.
at the time of treatment. On-the-spot claiming is available
To switch, simply start your onemedifund cover from at any Extras providers around Australia who are using
the same day you cease your previous cover. We the HICAPS system, including dentists, physiotherapists,
will request a Transfer Certificate on your behalf and optical dispensers, chiropractors, osteopaths, occupational
recognise the waiting periods you have already served. therapists, psychologists and podiatrists.
If you have used all of your annual limits with your Simply swipe your onemedifund contributor card at a
previous fund, you may have to wait for the new financial participating provider and your claim is paid immediately.
year for these limits to be reset.
Please note: You must treat your HICAPS card like you
would a credit card and sign only for services provided.
Change or upgrade my cover Make sure that you maintain personal control over your
You can change or upgrade your cover to one that card at all times. Additional cards are available for other
better suits your needs at any time. Simply log in to members of your family upon request. Please report any
Online Services on our website, lost or stolen cards to onemedifund immediately.
www.onemedifund.com.au, email us at Online You can claim for a range of Extras benefits at
info@onemedifund.com.au or call us on www.onemedifund.com.au/contributors/os.
1800 148 626. See page 17 for a full list of services.
Mail Simply complete a claim form, attach all
accounts and/or receipts and post them to:
Apply for the Australian Government
onemedifund
Rebate on Private Health Insurance Locked Bag 25, Wollongong NSW 2500
You may be able to reduce your regular health fund Fax Complete a claim form, attach copies of all
contributions by completing the Australian Government accounts and/or receipts and fax them to
Rebate on Private Health Insurance form included on the 1300 673 406
onemedifund application form. Alternatively, email us at Email Complete a claim form online or scan your
info@onemedifund.com.au, call us on 1800 148 626 completed claim form and a copy of all
to request the form, or download it from our website, accounts and/or receipts and email them to
www.onemedifund.com.au. info@onemedifund.com.au
16 onemedifundMake a medical claim Claim online
Access Gap – Your doctor should advise you of any Claiming online is easy! You can claim up to a
amounts payable before your admission to hospital. maximum of $200 a day for a range of Extras services
Your doctor will usually send the claim directly to at www.onemedifund.com.au/contributors/os,
onemedifund for payment and you will receive an including:
advice of the benefits we have paid. • Dental
Electronic – onemedifund participates in the • Optical (glasses & contact lenses)
Australian Government electronic claiming system for • Chiropractic
doctors and hospitals known as ECLIPSE. Where the
• Physiotherapist
ECLIPSE service is used, there is no need to submit a
• Podiatry
claim form to onemedifund
• Occupational therapy
Claim Form – Simply complete a claim form, attach
• Speech therapy
the Medicare Benefits Statement and send them to
onemedifund using one of the following methods:
Mail onemedifund All you need to do is log in to online services and fill in
Locked Bag 25, Wollongong NSW 2500 the details from your receipts. Your claim is processed
Fax 1300 673 406 automatically and your benefit is paid straight into your
account. You don’t even need to send in your receipts
Email info@onemedifund.com.au
for certain claims under $200 (but you do need to keep
all your receipts as we may ask for them later to check
Make a hospital claim some of the information). Claims that are over $200
The hospital should check your level of cover can still be completed online, but before payment is
and benefits with onemedifund and advise you of made you will need to send in or upload a scanned
any amounts payable before your admission. On copy of your receipts.
discharge, you should check the account carefully to
ensure that all details are correct. The hospital will send Make a contribution payment
the claim directly to onemedifund for payment, and you
Direct debit is the most efficient way for you to pay
will receive an advice of the benefits we have paid.
your contributions and ensures that your cover is
always current and benefit entitlements are maintained.
Use Online Services onemedifund does not charge any additional fees for
Using our Online Services is an easy, convenient, cost- this service. All you need to do is complete and return
effective way of managing your health cover 24 hours a the Direct Debit Request Authority included with the
day, 7 days a week. application form. This will ensure automatic deductions
from your bank account.
You can use our secure Online Services to: You can also pay your contributions by BPAY. Our
BPAY Biller Code is 4899159. Please contact us for
• choose the cover that’s right for you your Customer Reference Number.
• commence cover with onemedifund
• claim online (see next column)
• view or change your contributor details
• view your claims history
• download forms and brochures
• order a HICAPS card
• find a healthcare provider (hospital, Access
Gap doctor or Extras provider where you can
use your HICAPS card)
• print your annual tax statement
• complete a Health Risk Assessment (if you
hold Hospital cover)
one way to go 17I want to know about...
Waiting periods and continuity of cover
Waiting periods are established to protect all contributors by encouraging people to maintain their health cover. A
waiting period is a length of time applied to each new health cover and also applies when cover is upgraded. During
this period, benefits are not payable.
onemedifund will recognise served waiting periods for people transferring within 2 months from another health fund
or from another onemedifund product provided that equivalent or a higher level of cover was held. To be eligible, the
transferring health cover must be paid up-to-date, all waiting periods from the previous fund must have been served
or partially served and a clearance certificate provided.
Months Service
Ambulance
Accidents requiring hospitalisation
0
Transferring equivalent cover from another fund or parent’s cover
Note: previous cover must be financial at the time of transfer and waiting periods must
be served. The balance of partially served waits will apply.
General dental, pharmacy, physiotherapy and complementary therapies
Rehabilitation psychiatric services and palliative care (even for pre-existing
2 conditions)
Health programs
Hospital substitution programs
Optical
6
Health management programs
Pregnancy and birth
High-cost dentistry
Assisted reproductive services
Pre/post-natal services
12*
Pre-existing conditions (*except rehabilitation, psychiatric services and palliative
care): any ailment, illness, or condition that you had signs or symptoms of (in the
opinion of a medical practitioner appointed by the health insurer) that existed during
the 6 months prior to you commencing or upgrading hospital cover. It is not necessary
that you or your doctor knew what your condition was or that the condition had been
diagnosed. A condition can still be classed as pre-existing even if you had not seen
your doctor about it before commencing or upgrading hospital cover
Note: this waiting period applies to hospital cover only
Laser eye surgery
24
Hearing aids
If you transfer to onemedifund from another fund where you had similar or higher cover and you have finished your
waiting periods, you will not have those waiting periods again. This means you can claim straight away for the
services you were already covered for.
On the other hand, if your previous cover had lower limits or benefits than your new one, you will have waiting
periods before you can claim more than you were covered for before.
For more information on waiting periods, Transfer Certificates or continuity of cover please call 1800 148 626 or
email info@onemedifund.com.au.
18 onemedifundMedicare Benefits Schedule & Excess options
Access Gap
Choosing an excess allows you to reduce your
The Medicare Benefit Schedule (MBS) is a list of fees standard contribution rate. In these circumstances,
for medical services issued by the Commonwealth if you are admitted to hospital, you agree to pay
Government. If you have private health cover and are an amount up front towards the cost of your
admitted to hospital as a private patient, Medicare pays hospitalisation.
a benefit of 75% of the MBS and the remaining 25% is For each Hospital product a per person excess applies
paid by onemedifund. together with an annual maximum each financial year
If a doctor raises a charge that is above the MBS, this (1 July – 30 June). As a special feature, the excess
amount is known as a ‘medical gap’. onemedifund has payable for day only treatment or for any public hospital
arrangements with more than 30,000 doctors Australia admission, is only half of the standard per person
wide where additional benefits are payable by the excess.
fund to reduce or eliminate ‘medical gaps’ faced by If you are admitted to hospital, the following excess is
contributors. This scheme is known as ‘Access Gap’. payable:
The Access Gap scheme aims to reduce your out-of-
pocket costs for doctors’ bills while you’re in hospital. If Day Overnight Maximum Maximum
your doctor chooses to participate, you will have: surgery admission excess per excess per
or public in private person per family per
• No gap hospital hospital financial financial
or admission year year
• Known gap – where you will be told your $125 $250 $250 $500
exact out-of-pocket costs before you are
admitted to hospital
• The most excess an individual contributor will
Before admission to hospital you should ask your
pay in a financial year is $250
doctor/s to inform you of all medical fees that may
• The most excess a family will pay in a financial
be charged and whether he/she participates in our
year is $500
‘Access Gap’ scheme. If the doctor/s elects not to
• Excesses apply to hospital services only
participate in the ‘Access Gap’ scheme and charges
a fee above the MBS, this additional amount will need
to be paid by you. Before any hospital treatment you
should confirm all charges with your doctor/s. We can
help you identify whether your doctor participates in the
‘Access Gap’ scheme. Call us on 1800 148 626.
one way to go 19I want to know about...
Australian Government Rebate on Medicare Levy Surcharge
Private Health Insurance
The Medicare Levy Surcharge (MLS) applies to
The Australian Government Rebate on Private Health Australian taxpayers who do not have private hospital
Insurance was introduced as a financial incentive cover and who earn above a certain income ($90,000
to help Australians afford private health cover. The for singles and $180,000 for couples and families in
Rebate is income tested and applies to the standard the 2018/19 financial year). The surcharge aims to
contribution of all onemedifund products. The Rebate encourage individuals to take out private hospital cover
is not available for the Lifetime Health Cover loading and, where possible, to use the private system to
portion of your contributions (if applicable). reduce the demand on the public system.
The surcharge is calculated between 1% and 1.5%,
The amount of Rebate you are entitled to depends
dependent on your household income (see the table
on your taxable household income for Medicare Levy
on the next page). It is in addition to the Medicare Levy
Surcharge purposes, the age of the oldest person on
of 2%, which is paid by most Australian taxpayers. The
your health cover, inflation (CPI) and average health
MLS is imposed on individuals earning over the income
fund industry increases using a complex Government
threshold who do not have an appropriate level of
formula. If you would like to claim your Rebate up front
hospital cover. You do not have to pay the surcharge if
as a reduced contribution, you will need to register for
your household income is below the income threshold
the Rebate and nominate a Tier. If you don’t nominate
or if you are a ‘prescribed person’ under the Income
a Tier, or if you choose the wrong Tier, the Australian
Tax Assessment Act 1936.
Tax Office will reconcile any differences when you lodge
your annual tax return. All onemedifund hospital covers exempt you from
the MLS if you hold it for the full financial year.
Most people choose to claim their Rebate up front as
a lower contribution, but if you would prefer to claim
your Rebate as a lump sum through your tax at the
end of the financial year, you can elect to pay the full
contribution rate.
If you’re unsure which Rebate Tier you should
nominate, please contact your tax agent, financial
advisor, the Australian Taxation Office or visit
www.health.gov.au.
A table to help you determine your Rebate Tier is on
the next page.
20 onemedifundStep 1: Income threshold Step 2: Age & Rebate amount Medicare Levy
(for 2019/20 financial year) (age of the oldest person on your cover) Surcharge
(this will apply if
you don’t have
Under 65 yrs 65-69 yrs 70+ yrs private hospital
cover)
Single $90,000 or less
Base Tier 25.059% 29.236% 33.413% 0%
Family* $180,000 or less
Single $90,001 – 105,000
Tier 1 16.706% 20.883% 25.059% 1%
Family* $180,001 – 210,000
Single $105,001 – 140,000
Tier 2 8.352% 12.529% 16.706% 1.25%
Family* $210,001 – 280,000
Single $140,001 or more
Tier 3 0% 0% 0% 1.5%
Family* $280,001 or more
* If you are a family with children, the income threshold for each tier is increased by $1,500 for every child after your first.
Family includes couples.
For the most up-to-date information, visit www.onemedifund.com.au/rebate.
one way to go 21I want to know about...
Lifetime Health Cover entitlement to seek assistance from an external dispute
resolution body, such as the Private Health Insurance
Lifetime Health Cover (LHC) commenced on 1 July
Ombudsman (PHIO).
2000 as a Commonwealth Government initiative to
encourage adoption of hospital cover at a young age.
LHC recognises the length of time a person has had Privacy Policy
private hospital cover with a registered health fund. If you onemedifund complies with the requirements of the
start your cover earlier in life and maintain your Hospital Privacy Act 1988 and Australian Privacy Principles.
cover you will pay a lower contribution rate each year If you would like a copy of our full Privacy Policy, visit
compared to someone who starts their cover at a later www.onemedifund.com.au/policies.
age.
Complaints Handling
The main points to remember are:
onemedifund is committed to the efficient and fair
• People who purchase Hospital cover for resolution of all complaints and has a policy to ensure
the first time after 1 July following their 31st this. If you have a complaint about onemedifund
birthday will pay a Lifetime Health Cover
please contact us on 1800 148 626 and our
loading. There are some other exemptions if
staff will help to resolve your issue. Failing this, an
you migrated to Australia in the last 12 months
or were overseas. Visit privatehealth.gov.au escalation process is also available.
for details. If your complaint is not resolved you are entitled to
• This loading is based on the person’s Lifetime seek the services of the Private Health Insurance
Health Cover age. Ombudsman (PHIO). PHIO provides free independent
• The loading is 2% for each year the person’s services to private health fund contributors. PHIO
Lifetime Health Cover age is over 30 years old. (www.ombudsman.gov.au) can be contacted on
• Once you take out Hospital cover, your loading 1300 362 072, on email at
is locked in at the same rate, rather than phio.info@ombudsman.gov.au, or sent mail to:
increasing 2% each year. Private Health Insurance Ombudsman
• The loading only applies to Hospital cover. Commonwealth Ombudsman
• The maximum loading is 70% which applies to GPO Box 442
those 65 years or over. Canberra, ACT 2601
• Lifetime Health Cover loadings revert to 0%
If you would like a copy of our Complaints
after 10 years continuous hospital coverage.
Handling Policy, you can download it from
• The Australian Government Rebate is not
www.onemedifund.com.au/policies.
available for the LHC loading portion of your
contributions.
Code of Conduct
This Code was developed by Private Healthcare Australia
(PHA) and Members Health Funds Alliance (representing
restricted and regional health funds). As well as
promoting improved standards and clarity of information
(including privacy) given to contributors, it aims to solve
problems between contributors and onemedifund
through internal dispute resolution. The Code also
ensures that funds inform their contributors of their
22 onemedifundone way to go 23
Need more information? Just call our friendly staff on 1800 148 626. We look forward to assisting you with any enquiry! The information in this brochure is subject to change. For the most up- to-date information, visit www.onemedifund.com.au. Please read this brochure carefully and retain for future reference.
1800 148 626
1300 673 406
info@onemedifund.com.au
www.onemedifund.com.au
Locked Bag 25, Wollongong NSW 2500
National Health Benefits Australia Pty Ltd (trading as onemedifund).
A registered private health insurer. ABN 67 122 255 396
0619 v3.2You can also read
