Health Insurance - Medibank


 Health Insurance
   Effective April 2018

                          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
•	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 that you
   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 34 of this Guide.
•	This Guide only applies to Medibank Australian
   resident covers. The information in this Guide is
   only relevant to these covers. If you hold a cover
   other than an Australian resident cover, please
   contact us for details of the services covered
   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 covered under 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 online
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 Benefit 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 Benefit Scheme (PBS)      17
                                           Emergency department facility fees       17
Managing your Premiums               11
                                           Hospital benefits table                  18
Premium payment options              11
Premium protection                   11   Hospital Cover                           19
Premium arrears                      11   How hospital benefits are assessed       19
Premium refunds                      11   Long stay hospital patients 		            19
                                           (nursing home type patients)
Changes to your Membership           12
                                           Treatments where no Medicare             19
Categories of membership             12   benefit is payable
Adding a child dependant             12   Waiting periods                          19
Moving interstate?                   13   Mental Health Waiver                     20
Receiving treatment interstate       13   Pre-existing conditions (PEC)            20
Suspending your membership           13   Having a baby?                           21
                                           Ensuring your newborn is added
                                           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
                                           Claiming for a CPAP-type device          22
                                           Hospital benefit exclusions              23

6 | Member Guide
What’s Inside
Extras Cover                            24   Government Initiatives                       30
How extras benefits are assessed        24   Australian Government Rebate                  30
                                              on private health insurance 
Members’ Choice extras providers        24
                                              Medicare Levy Surcharge                      30
Non-Members’ Choice extras providers    24
                                              Lifetime Health Cover loading                31
Waiting periods                         24
                                              Permitted days without Hospital cover        31
Benefit replacement periods             25
                                              LHC loading exemptions                       31
Applicable limits                       25
Consultations26                              Other Important Information                  32
Prescription pharmaceuticals            26   Members’ Choice Network                      32
– non-PBS
                                              Recognised providers                         32
Appliances requiring referrals          26
Extras benefit exclusions               27
                                              Compensation and damages                     32
Ambulance Services                      28   Medibank Privacy Statement                   33
When are benefits payable?              28   Private Health Insurance                     33
                                              Code of Conduct
When are benefits not payable?          28
                                              Private Patients’ Hospital Charter           33
State Ambulance Schemes                 28
NSW and ACT members with                28   Contact Us                                   34
Hospital cover
Standalone Ambulance cover              28

Making a Claim                          29
Hospital claims                         29
Extras claims                           29
Claims documentation                    29
Time limit for submitting a claim       29

                                                                                Member Guide | 7
Welcome to Medibank
Your welcome pack                                       •	for which you have not fully served the
If you’ve just joined Medibank, you’ll receive               waiting period.
a welcome pack which includes:                          When you transfer to Medibank, we’ll use our
•	this Guide                                         nearest equivalent cover (to the cover you held
                                                        with your previous fund) to determine benefit
•	a Cover Summary, which is a summary of the         entitlements. It’s important to be aware that:
     services and treatments under your cover
                                                        •	extras benefits paid by your previous fund/s
•	a Standard Information Statement (SIS), which           will be counted towards:
   is a high-level summary and isn’t intended to
   be a comprehensive description of your cover.          – annual limits in your first calendar year
   We are required by law to give you a SIS when            of Medibank membership
   you join, and then at least once every 12 months.      – lifetime limits
   It’s important that you read the SIS with your
   Cover Summary and this Guide to fully                  – benefit replacement periods (refer to page 25).
   understand your cover.                               •	any loyalty bonus or other similar entitlements
You’ll also receive a membership card                        (e.g. increased annual limits on Extras cover for
(sometimes referred to as a policy card),                    orthodontics) built up with your previous fund/s
either with your welcome pack or shortly after.              won’t apply to your Medibank cover.
Use your membership card to make a claim                •	if you choose a Medibank Hospital cover with a
or arrange admission to hospital. You should                 lower excess, the excess of the equivalent cover
also keep it handy if you need to make                       will apply until you have served the relevant
an enquiry about your membership.                            waiting period.
Make sure you keep your card safe and advise us         •	any excess or per-day payment paid to your
immediately if it’s lost or stolen. Medibank won’t           previous fund won’t be deducted from any
accept liability for any loss to you resulting from          excess or per-day payment payable under your
the misuse of a lost or stolen membership card.              Medibank Hospital cover (where applicable).

Transferring from another                               We need a Transfer Certificate from your previous
Australian health fund                                  fund to confirm your level of cover, waiting periods
                                                        served and benefits paid. You may not be able to
Provided that you join Medibank within two
                                                        claim benefits for certain services until we have
months of leaving your previous private health
                                                        received your Transfer Certificate. We also need
insurance fund, you generally won’t need to
                                                        a Transfer Certificate to check whether a Lifetime
re-serve any waiting periods you have already
                                                        Health Cover loading applies to anyone on the
served. This means you’ll generally only need to
                                                        membership, as this can affect premiums payable
serve waiting periods for any treatments or items:
                                                        (refer to page 31).
•	that were not included under your previous cover
                                                        Where you join Medibank with a break in cover
•	that have an increased benefit (e.g. upgrading     of more than two months, you’ll be treated
     from a Limited to an Included hospital service     as a new member and all waiting periods relevant
     or increasing an annual limit on an Extras         to your cover will apply.
     cover). If you’ve served the waiting periods for
     the lower benefits on your previous equivalent
     cover, benefits will be paid at that level until
     you’ve served your new waiting periods

8 | Member Guide
Cooling off period                                    Any changes will apply regardless of whether
We give you 30 days from the date you join or         premiums have been paid in advance and
change your cover to review and make sure you’re      may include:
happy with it. If you change your mind during that    •	Closing a cover. If we close a cover that you’re on:
period, and no claims have been made, we’ll either
give you a full refund or transfer you to a more        – we may permit you to stay on the cover, but not
appropriate cover.                                        make any changes to your membership (e.g.
                                                          adding or removing a member or component
During the cooling off period, you cannot generally       of cover). If you want to make a change to your
return to a cover that Medibank has closed.               membership, you’ll need to select a new cover; or

Types of cover                                          – we may not permit you to stay on this cover and
                                                          will move you to a cover as similar as possible.
Medibank offers a range of health insurance
covers. A person may be a member of:                  • Removing a service or item from a cover.

• a Hospital cover, Extras cover or both; or          •	Reducing or removing a benefit or benefits
                                                         under a cover.
•	a packaged cover which is made up of both
   Hospital and Extras.                               If we make a change and you choose to continue
                                                      your membership (under the new or changed
Some Hospital covers must be taken with an            cover) you’ll be bound by its terms and conditions.
Extras cover and some Extras covers must              If you do not wish to continue under the new or
be taken with a Hospital cover.                       changed cover you have the option of transferring
                                                      to a different cover or cancelling the membership.
Changes to the Terms and Conditions
of your membership                                    Medicare eligibility
All members of Medibank are subject to our Fund       Your Medicare Card indicates your eligibility
Rules, which set out the terms and conditions of      for Medicare. Holding a reciprocal (yellow)
cover, as well as the services we pay benefits for.   Medicare card or no Medicare card at all, will
We may change the Fund Rules from time to time.       affect the benefits you’re entitled to receive under
If any changes to our Fund Rules will have a          Hospital cover. As a result, you could be left with
detrimental effect on a member’s entitlement          very large out-of-pocket expenses if you receive
to benefits under their cover, we’ll provide the      hospital treatment.
Policy holder with reasonable notice in writing
before the changes are due to take effect.            If you, or any member on the membership, have
                                                      limited or no access to Medicare, you should call
                                                      us to discuss whether the cover you’ve chosen
                                                      is the most suitable. Medibank offers a range
                                                      of non-resident covers that may be better suited
                                                      to your needs.

                                                                                              Member Guide | 9
Managing your Membership
My Medibank                                      Partner authority
My Medibank is a convenient way of managing      If the Policy holder adds their partner they’ll be
your membership online. You can sign up at       given authority to manage most aspects of the Once you have signed        membership, unless the Policy holder tells us
up you’ll be able to:                            otherwise. This means Medibank may disclose
                                                 membership details to both the Policy holder
• View membership details
                                                 and their partner.
• Update contact details
                                                 Partner authority includes:
• Manage premium payments
                                                 • Making claims
•	Register bank account details to receive
                                                 • Adding or removing dependants
   benefits for extras claims by EFT
                                                 • Changing cover
• Order a replacement membership card
                                                 • Suspending and reactivating the membership
All Medibank members aged 16 years and over
can use My Medibank; however, access to some     • Changing contact and bank account details
functions may be limited to the Policy holder.
                                                 • Changing payment methods
                                                 • Requesting and receiving premium refunds
                                                 Only the Policy holder can remove themselves
                                                 or cancel the membership entirely.

                                                 Third party authority
                                                 Anyone on the membership can nominate a third
                                                 party to deal with Medibank on their behalf.
                                                 There are three ways a member can nominate
                                                 someone as their authorised third party:
                                                 • Verbally over the phone;
                                                 •	By completing a Medibank Authority
                                                    form – the form can be downloaded
                                                    at; or
                                                 • By giving Medibank a valid Power of Attorney.
                                                 A third party can be nominated for a specific
                                                 timeframe or for the duration of the membership.

10 | Member Guide
Managing your Premiums
Generally you cannot pay more than 12 months          Where you have paid in advance, the date you
in advance for any cover. However, if you join        have paid up to will be adjusted accordingly.
Standalone Ambulance cover you’ll need to pay
                                                      Premium protection doesn’t protect you
either six or 12 months in advance.
                                                      against any other changes made to the terms
                                                      and conditions of your membership.
Premium payment options
We offer a range of options for premium               Premium arrears
payments, including:
                                                      A membership is in arrears whenever the
• Financial institution direct debit                  premiums aren’t paid up to date. You won’t receive
                                                      any benefits for services provided or items
•	Credit card direct debit
                                                      purchased while your membership is in arrears.
•	Manually through direct payment. If you pay
                                                      If your premiums remain in arrears for more than
   using this method, we’ll send you a Health Cover
                                                      two consecutive months, your membership will be
   Account which has instructions on all the ways
                                                      closed and you’ll no longer be eligible to receive
   you can make a payment.
                                                      any benefits from us.

Premium protection                                    It’s your responsibility to ensure that your
                                                      premium payments are up to date.
Premiums can change from time to time subject
to approval by the Minister for Health. Where this
occurs we’ll write to the Policy holder to let them   Premium refunds
know what the new premium will be.                    If you cancel your membership, you can apply for
                                                      a refund of premiums paid in advance. Your refund
If you’ve paid your premiums in advance,
                                                      will generally be calculated from the date of
the new premium won’t apply until your next
                                                      application. An administration fee may apply.
payment is due. This is known as premium
protection. For example, if your premium
increases on 1 April and you have paid your
current premiums until 1 August, the new
premium will apply from 2 August.
However, if you make one of the following changes
your premium protection will be lost and the new
premium will apply from the date of the change:
• Change your level of cover
•	Change your membership category or state
   of membership
•	Add or remove a component of your cover
   (e.g. Hospital or Extras)
•	Reactivate your membership after a period
   of suspension.

                                                                                           Member Guide | 11
Changing your Membership
As your circumstances change you may need to add        Family membership – covers the Policy holder,
or remove members on your cover. The following          their partner and any of their child dependants
people can be on a Medibank membership:                 and/or student dependants.
Policy holder – this is the person who is responsible   We also provide an option for families with
for the membership. Unless approved by us,              adult dependants, where, for an additional cost,
the Policy holder must be 16 years of age or older.     some covers can be extended to also include
                                                        an adult dependant/s.
Partner – a person who lives with the Policy
holder in a marital or de facto relationship.           Not all membership categories are available
                                                        for all covers. Contact us to find out more.
Child dependant – a child of the Policy holder
or their partner who isn’t married or living in a
de facto relationship and is under the age of 21.
                                                        Adding a child dependant
                                                        To cover your child dependant from their date of
Student dependant – a child of the Policy
                                                        birth or inclusion in your family unit (e.g. through
holder or their partner isn’t married or living
                                                        marriage, adoption or fostering) you’ll need to
in a de facto relationship, has reached the age
                                                        have commenced your Medibank membership
of 21 but is under 25 and is undertaking full-time
                                                        no later than that date and add them within the
education at an approved educational institution.
                                                        timeframes below.
Adult dependant – a child of the Policy holder
                                                        •	For a single membership – two months.
or their Partner who isn’t married or living
                                                           This change must be backdated to the child’s
in a de facto relationship, has reached the age
                                                           date of birth/inclusion in the family unit and
of 21 but is under 25 and isn’t undertaking
                                                           means you’ll need to change to a family or single
full-time education.
                                                           parent family cover and pay higher premiums.
If the status of anyone on the membership                  Where a child is added outside two months,
changes, for example a student dependant ceases            they’ll have to serve all waiting periods
to be a student or defers their study, you must            applicable to the cover.
notify us immediately as it may mean they’re
                                                        •	For a couple or family membership – 12 months.
no longer eligible to remain on the membership.
                                                           This change can be backdated to the child’s date
                                                           of birth/inclusion in the family unit, or
Categories of membership
                                                           commence from the date of application or any
Adding or removing a member may mean the                   future date you choose. Where a child is added
category of your membership needs to change.               outside 12 months, their cover will commence
This type of change can also affect the premiums           from the date of application or any future date
you’ll need to pay.                                        you nominate.
We offer the following membership categories:           Where a child is added within the above
Single membership – covers the Policy holder.           timeframes and the membership commenced
                                                        no later than the child’s date of birth they’ll only
Couple membership – covers the Policy holder
                                                        have to serve the waiting periods that haven’t
and their partner.
                                                        been served by the Policy holder.
Single parent family membership – covers the
Policy holder and any of their child dependants
and/or student dependants.

12 | Member Guide
Moving interstate?                                     •	Members with both Hospital and Extras cover
Premiums and some benefits vary from state to             cannot suspend one without the other.
state. When moving interstate, you need to advise      •	Standalone Ambulance cover cannot be suspended.
us of your new address within two months so that
                                                       •	The maximum suspension periods are two
we can adjust your premiums and ensure you
                                                          years for eligible Centrelink benefits and four
receive the benefits applicable to your state.
                                                          years for overseas travel and custodial
Receiving treatment interstate
If you receive treatment interstate, Medibank          •	The minimum period between reactivation and
will pay benefits in accordance with our provider         suspension for the same reason is six months
agreements in that state (our agreement                   for overseas travel and 12 months for eligible
providers are referred to as Members’ Choice              Centrelink benefits and custodial sentencing.
providers, see pages 15 and 24 for more details).      If you’re considering suspending your
Where you receive treatment by a Non-Members’          membership for overseas travel, you should
Choice provider, benefits are payable as follows:      also note:

•	For hospital treatment, benefits are payable        •	Premiums must be paid two weeks in advance
   at the level applicable to the state in which          of your suspension date.
   treatment is provided.                              • The suspension application must be made prior
•	For extras treatment, benefits are payable            to your departure date.
   at the level of benefits applicable to your state   •	The minimum period for overseas travel
   of membership, regardless of the state in              suspension is two months. This means you must
   which the service was provided.                        be absent from Australia for at least two months
                                                          to be eligible to suspend your membership on
Suspending your membership                                this basis.
Members can apply to suspend their membership          From time to time Medibank may close covers.
if they are travelling overseas, receiving some        If your cover is closed while your membership
types of Centrelink assistance or have been given      is suspended, you may be transferred to a similar
a custodial sentence.                                  cover. The premium applicable to the new cover
If you’re considering suspending your                  will apply from the date your membership
membership you should note:                            reactivates.

•	Benefits are not payable for treatment received,    Depending on the reason for requesting a
   services provided or items purchased during         suspension, you may need to provide supporting
   a period of suspension.                             documentation.

•	You may be subject to the Medicare Levy
   Surcharge for the period you’re suspended
   (refer page 30).
•	Any period of suspension won’t count towards
   waiting periods or benefit replacement periods.
•	Any period of suspension can affect your
   entitlement to an increase in annual benefit
   limits for extras items and services.

                                                                                            Member Guide | 13
Going to Hospital
It’s important to be aware that Hospital cover        Hospital accommodation benefits
may not pay all of the costs associated with          The benefits we pay for hospital accommodation
hospital treatment. You may still incur out-of-       will depend on whether the hospital admission
pocket expenses above the benefits we pay.            is for an Included, Limited or Excluded service
To help understand your potential out-of-pocket       (refer to your Cover Summary), and the type of
expenses, you should contact us prior to any          hospital you’re admitted to as explained below.
hospital admission. You should also speak             •	Included services – we pay benefits towards
to your doctors and hospital to confirm any              same day and overnight hospital accommodation
out-of-pocket expenses you may incur.                    and intensive care; however, out-of-pocket
                                                         expenses may still apply.
Inpatient vs outpatient
                                                      •	Limited services (also known as Restricted
Hospital cover provides benefits when a member
                                                         services) – we pay the minimum benefits for
is treated as a private inpatient. An inpatient is
                                                         hospital accommodation set by the Australian
someone who is admitted to hospital to receive
                                                         government (also known as default benefits)
medical care or treatment. Services that are
                                                         towards same day and overnight hospital
provided where a member isn’t admitted to
                                                         accommodation and intensive care. The benefits
hospital are called outpatient services. Outpatient
                                                         we pay won’t be enough to cover all hospital
services also include things such as visits to an
                                                         costs. This means you could incur substantial
emergency department, a general practitioner
                                                         out-of-pocket expenses. For Limited services
(GP) or a specialist.
                                                         in a public hospital we’ll pay minimum shared
Under government legislation, Medibank isn’t             room benefits.
allowed to pay benefits for outpatient services.
                                                      • Excluded services – no benefits are payable.
This is why we won’t pay any benefits when a
member isn’t admitted to hospital. A rebate           Hospital accommodation benefits do not include
may be claimable from Medicare for                    other things such as TV hire, telephone calls,
outpatient services.                                  newspapers, parking and take-home items,
                                                      e.g. crutches. Medibank won’t pay benefits for
Informed financial consent                            these (or similar) items and services. The hospital
Before going to hospital it’s important to ask        should discuss any charges with you.
your doctor/s and the hospital about any
potential out-of-pocket expenses you might incur.     Choice of hospital
This information should be provided in writing        Hospital cover allows you to choose whether
before your treatment or hospital admission           you’re treated as a private patient at either
and is known as informed financial consent.           a private or public hospital. While we pay
If you’re admitted in an emergency, there may not     benefits regardless of where you’re treated
be time for the hospital or doctor/s to seek your     (if the treatment is Included or Limited under your
informed financial consent. Information about         cover) the benefits we pay and the out-of-pocket
your out-of-pocket expenses should be provided        expenses you may incur for your hospital stay
by the hospital or doctor/s as soon as possible       can vary depending on the hospital you choose.
after you receive treatment.                          When making a decision about which hospital
                                                      you’ll be treated at, you should be aware that not
                                                      all doctors have admitting rights to all hospitals
                                                      and this may affect where your doctor can treat
                                                      you. Your doctor will be able to tell you at which
                                                      hospitals they have admitting rights.

14 | Member Guide
Regardless of whether you’re treated at a            Public hospitals
Members’ Choice, non-Members’ Choice or public
                                                     All eligible Australian residents are entitled to
hospital, the hospital should seek your informed
                                                     be treated as a public patient in a public hospital.
financial consent about any out-of-pocket
                                                     If you elect to be treated as a private patient
expenses you’ll need to pay. It’s also important
                                                     in a public hospital we’ll pay the minimum benefits
to be aware that if you have a Hospital cover
                                                     for accommodation for a shared room only.
with an excess or per-day payment, it will apply
                                                     You’ll be required to pay any difference between
regardless of the type of hospital you choose
                                                     the benefit we pay and the amount the hospital
(refer to page 22 for more information about how
                                                     charges (in addition to any applicable excess
an excess and/or per-day payment will apply).
                                                     and/or per-day payment).
Members’ Choice hospitals
                                                     Medicare Benefit Schedule (MBS)
Medibank has agreements with most private            and medical services
hospitals and day surgeries in Australia. We refer
                                                     The Medicare Benefit Schedule (MBS) lists
to our agreement hospitals as Members’ Choice
                                                     all of the medical services subsidised by the
hospitals. For an Included service in a Members’
                                                     Australian government through Medicare.
Choice hospital, we’ll pay an agreed rate for your
                                                     These medical services include:
treatment, which includes the cost of a private
room (where available) or shared room and any        • doctors’ services, e.g. GPs and specialists
theatre or procedure room costs. Generally this      •	diagnostic services, e.g. blood tests,
means any out-of-pocket expenses you incur              x-rays and ultrasounds provided by
for accommodation charges will be limited               pathologists and radiologists.
to any excess and/or per-day payment
applicable to your cover.                            Each service listed in the schedule has an item
                                                     number and a corresponding fee that’s been set
By visiting a Members’ Choice hospital, you’ll       by the government. Medibank pays benefits
generally get better value for money compared        towards in-hospital medical services based on the
to a non-Members’ Choice hospital as long as the     Medicare Benefits Schedule (MBS). If a service is
service you receive is included in our agreement     listed in the MBS and Included or Limited under
with the hospital and isn’t Excluded or Limited      your cover, Medicare will pay 75% and we’ll pay
under your cover.                                    25% of the MBS fee. This means where the
Our agreements with Members’ Choice hospitals        provider charges you no more than the MBS fee,
are subject to change. You should confirm prior      you won’t have an out-of-pocket expense for those
to receiving treatment whether your hospital         inpatient medical services.
provider is part of our Members’ Choice network      Doctors and providers are not restricted to
as this may affect your out-of-pocket expenses.      charging the MBS fee and may choose to charge
To find a Members’ Choice provider,                  more for a particular service. Where this occurs
visit                            you’ll have an out-of-pocket expense unless:
                                                     •	your doctor participates in Medibank’s
Non-Members’ Choice hospitals                           GapCover; and
Non-Members’ Choice hospitals are private
                                                     • the service provided is eligible for GapCover.
hospitals and day surgeries Medibank doesn’t
have agreements with. The benefits we pay            The MBS is available at:
towards accommodation in these hospitals             Items on the MBS are subject to change from time
are generally lower than those in a Members’         to time in accordance with changes made by the
Choice hospital and you may incur significant        Department of Health.
out-of-pocket expenses (in addition to any
applicable excess and/or per-day payment).
                                                                                           Member Guide | 15
Doctors’ fees and GapCover                           •	GapCover doesn’t apply to diagnostic services
Where your doctor/s elects to charge more than          (e.g. blood tests, x-rays and ultrasounds).
the MBS fee, you’ll be left with an out-of-pocket       This means where you’re charged more than
expense you’ll need to pay. This is commonly            the MBS fee for in-hospital diagnostic services,
referred to as the ‘gap’. To help you reduce or         you’ll have an out-of-pocket expense for the
eliminate the gap, GapCover is available on all         difference between the charge and the MBS fee.
Medibank Hospital covers in relation to eligible     •	GapCover doesn’t apply to any doctors’ charges
services (excluding Public Hospital covers).            for outpatient medical services.
If your doctor/s chooses to participate in our       You should always confirm upfront with your
GapCover for the claim forming part of your          doctor/s prior to each claim forming part
treatment, we pay an amount higher than 25%          of your treatment whether they’ll participate
of the MBS fee. Where they participate,              in Medibank’s GapCover.
there are two possible scenarios:
                                                     Contact us to find out more about GapCover.

 Scenario 1 ‘No Gap’                                 Surgically implanted prostheses
 Your doctor participates in GapCover and            If you need to be hospitalised for a procedure
 charges you no out-of-pocket for the claim          requiring a surgically implanted prosthesis
 forming part of your treatment you receive          (e.g. a pacemaker or cardiac stent), we’ll pay
 as an inpatient.                                    the minimum benefit set out in the government’s
                                                     Prostheses List. The Prostheses List includes
                                                     over 10,000 items together with a minimum
                                                     benefit and, in some cases, a maximum benefit
                                                     that can be charged for each item.
 Scenario 2 ‘Known Gap’
                                                     You’ll have an out-of-pocket expense where
 Your doctor participates in GapCover and            (in consultation with your doctor) you choose
 charges you a limited out-of-pocket of no more      a prosthesis that:
 than $500 for the claim forming part of your
 treatment you receive as an inpatient.              •	is included in the government’s list but costs
                                                        more than the minimum benefit. In that case
                                                        you’ll have to pay the difference between
If your doctor/s chooses not to participate in
                                                        the minimum benefit we’ll pay and the cost
Medibank’s GapCover, the amount we pay will be
                                                        of the item; or
limited to 25% of the MBS fee. This means that
where the doctor elects to charge more than the      •	isn’t included in the government’s list at all.
MBS fee you’ll need to pay the gap yourself, which      In that case, we won’t pay any benefits and you’ll
could result in very large out-of-pocket expenses.      be responsible for the full cost of the item.
It’s important to be aware that:                     Your doctor should discuss your prosthesis
                                                     options with you and seek your informed financial
•	It’s entirely up to your doctor whether they’ll
                                                     consent regarding additional costs you may
   participate in GapCover.
                                                     have to pay.
•	Doctors can decide to participate in
                                                     Benefits are not payable for any prosthesis associated
   GapCover on a per claim, per treatment,
                                                     with an Excluded service under your cover.
   and per patient basis.
                                                     The Prostheses List is available at
•	If you’re being treated by more than one doctor
   (e.g. surgeon and anaesthetist), participation
   is at each individual doctor’s discretion.
•	GapCover doesn’t eliminate amounts that you
   have agreed to pay under the terms of your
   policy, e.g. excess and/or per-day payment.

16 | Member Guide
Pharmaceutical Benefit Scheme (PBS)                Emergency department facility fees
The Pharmaceutical Benefit Scheme (PBS) is         Some private and public hospitals charge an
funded by the government and makes subsidised      Emergency Department facility fee to outpatients.
prescription medicines available to Australian     Unless benefits are specifically provided under
residents. Residents eligible for the PBS          your cover (refer to your Cover Summary),
contribute to the cost of subsidised medicines     Medibank won’t pay towards those fees.
by paying a co-payment for each item set by the    Additionally, if you’re treated in an Emergency
government.                                        Department and you’re not admitted to hospital,
                                                   you’ll be an outpatient and we won’t pay any
Government legislation prevents health insurers
                                                   benefits for treatment you receive.
from paying benefits for medications covered
by the PBS unless provided under an agreement
with the hospital.
This means Medibank will only pay benefits
towards PBS medications where:
•	you’re admitted to a Members’ Choice hospital
   for an Included service (refer to your Cover
•	the pharmaceutical is directly related to the
   treatment of the condition for which you’re
   admitted; and
•	the pharmaceutical isn’t prescribed for
   cosmetic purposes.
No benefits are payable for PBS pharmaceuticals
that do not meet the above requirements,
including pharmaceuticals provided on discharge
from hospital and pharmaceuticals provided
at a non-Members’ Choice hospital.
Under Hospital cover, benefits are not payable
for non-PBS pharmaceuticals.
Further details about the PBS are available at

                                                                                      Member Guide | 17
Hospital benefits table
We’ve prepared this table to help you understand what benefits Medibank pays under Hospital
covers (for Included and Limited services) and where potential out-of-pocket expenses may arise.
Medibank doesn’t pay any benefits for Excluded services (refer to your Cover Summary).

                                                Members’                       Non-Members’
                                                                                                      Public Hospital
                                              Choice Hospital                  Choice Hospital

                                   • Medibank will pay the cost of shared     •	Medibank will pay the minimum
                                      or private room accommodation              hospital benefit set by the Australian
                                      in hospital or same day facility.          government for shared room only.
                      Included     • Your potential out-of-pocket             •	Your potential out-of-pocket expense
                       service        expense is limited to any hospital         will be any charge above the minimum
                                      excess and/or per-day payment              benefit set by the government and
 and Intensive
                                      applicable to your cover.                  any excess and/or per-day payment
 Care Unit (ICU)
                                                                                 applicable to your cover.
                                   • Medibank will pay the minimum hospital benefit set by the Australian government.
                       Limited     •	Your potential out-of-pocket expense is any charge above the minimum
                       service        benefit set by the Australian government in addition to any excess and/
                                      or per-day payment applicable to your cover.

                                   •	Medibank will pay costs as per our       • Medibank will pay no benefits.
                                     agreement with the hospital.              • Your potential out-of-pocket
                      Included     •	Your potential out-of-pocket                expense will be any charge raised
                       service        expense is limited to any hospital          by the hospital and any excess and/
                                      excess and/or per-day payment               or per-day payment applicable
 Theatre fees
                                      applicable to your cover.                   to your cover.

                                   • Medibank will pay no benefits.
                       service     •	Your potential out-of-pocket expense will be any charge raised by the hospital
                                      and any excess and/or per-day payment applicable to your cover.

                                   •	Medibank will pay the minimum benefit set out in the government’s Prostheses List.
                                   • Your potential out-of-pocket expense – if the prosthesis is:
 Surgically            Included     – included in the Prostheses List and costs up to the minimum
 implanted            or Limited      benefit – no out-of-pocket expense.
 prostheses             service     – included in the Prostheses List and costs more than the minimum
                                      benefit – any charge above the minimum benefit.
                                    – not included in the Prostheses List – the full cost of the prosthesis.

                                   • Medibank will pay 25% of the MBS fee.
                                   •	Your potential out-of-pocket expense – where your doctor/s charges more
 In-hospital           Included       than the MBS fee and:
 doctors’ medical     or Limited    – participates in Medibank’s GapCover – either no out-of-pocket expense
 services               service       or limited out-of-pocket expense of no more than $500 per doctor.
                                    – doesn’t participate in Medibank’s GapCover – any difference between
                                      the MBS fee and the amount the doctor charges.

 In-hospital                       • Medibank will pay 25% of the MBS fee.
 diagnostics                       •	Your potential out-of-pocket expense – any difference between the MBS
                      or Limited
 (e.g. bloods                         fee and the amount you’re charged.
 tests, scans etc.)

18 | Member Guide
Hospital Cover
Hospital cover pays benefits towards hospital          Treatments where no Medicare
accommodation, intensive care and medical              benefit is payable
services that you receive when you’re treated          Hospital cover benefits are generally payable
in hospital as a private inpatient.                    only for treatment for which a Medicare benefit
                                                       is payable. However, under some Hospital covers
How hospital benefits are assessed                     we pay limited benefits towards the following
In assessing benefits for hospital charges,            treatments when provided to a hospital inpatient,
Medibank takes the following into account:             even though no Medicare benefit is payable (refer
•	The cover you held at the date the service was      to your Cover Summary):
   provided. This includes whether the service         •	Surgical removal of wisdom teeth. We’ll pay
   was Included or Limited and any excess                 benefits towards hospital accommodation
   and/or per-day payment applicable to your              charges. We don’t pay any benefits towards the
   cover (refer to your Cover Summary)                    dentist’s fees under Hospital cover. This means
•	The type of hospital to which you were admitted        you could incur out-of-pocket expenses for
   (Members’ Choice, non-Members’ Choice                  those charges. Some benefits (up to applicable
   or public hospital)                                    limits) may be claimable for the dentist’s fees
                                                          if you hold an appropriate level of Extras cover.
•	Whether all relevant waiting periods had been
   served by the member requiring treatment            •	Podiatric surgery. We pay limited benefits
                                                          towards hospital accommodation charges for
•	Whether a Medicare benefit is payable                  podiatric surgery performed by an accredited
   for the treatment                                      podiatrist. This means you could incur
• Whether the premiums were paid up to date               significant out-of-pocket expenses.

•	Any legislative requirements governing              Waiting periods
   hospital treatment
                                                       A waiting period is a set amount of time each
•	Whether any other exclusions or assessing           member must wait before they can receive
   rules apply.                                        benefits under their cover. No benefits are payable
Benefits for certain same day procedures               for items and services obtained while serving
specified by the Department of Health may not          a waiting period.
be payable unless your doctor certifies your           It’s important to know that waiting periods apply
need to be admitted to hospital.                       when each member:

Long stay hospital patients                            •	first takes out cover, is added to an existing
(nursing home type patients)                              membership, or changes cover prior to serving
                                                          all applicable waiting periods
If you’re admitted to hospital as an inpatient for
a period of continuous hospitalisation exceeding       •	resumes cover after a break of two months or
35 days, you’ll be regarded as a long stay or             more (having previously held cover with another
nursing home type patient. If your doctor doesn’t         Australian health fund)
certify your need for ongoing acute care after         •	changes their cover to include new or upgraded
35 days, we’ll pay a lower benefit towards the daily      services or items, or to reduce their excess or
accommodation hospital charge and you’ll need             per-day payment.
to pay the difference as an out-of-pocket expense.
These charges could be significant depending           Check your Cover Summary for waiting periods
on your length of stay.                                that apply.

                                                                                             Member Guide | 19
Mental Health Waiver                                   •	they have held their cover for less than
The Mental Health Waiver allows members who               12 months; or
have served their two month waiting period for         •	they have changed their cover to include
Limited in-hospital psychiatric treatment to upgrade      a new or upgraded service and they haven’t
to a cover with Included in-hospital psychiatric          been covered for that service for 12 months.
treatment and elect to have the two month waiting
                                                       Medibank’s Medical Practitioner is the only
period for those higher benefits waived.
                                                       person authorised to determine if an ailment,
Members can elect to use their waiver at the point     illness or condition is pre-existing. To have a
of upgrading or after upgrading, prior to serving      determination made, the member will be required
the two month waiting period for Included              to provide two PEC certificates completed by their
psychiatric treatment. Members need to have held       treating practitioners (e.g. their GP and their
Hospital cover without a break of more than two        admitting specialist).
months to be eligible to use the waiver.
                                                       Medibank won’t pay for the member or a provider
The waiver only applies to the two month waiting       to supply this information.
period for the higher Included benefits for in-
                                                       Medibank will apply the PEC waiting period if:
hospital psychiatric treatment. All other
applicable waiting periods will continue to apply.     •	the member doesn’t authorise the release
                                                          of medical or paramedical evidence relating
Members will only be able to use the Mental
                                                          to their claim; or
Health Waiver once in their lifetime.
                                                       •	despite the member’s authorisation, their
Pre-existing conditions (PEC)                             provider doesn’t release that evidence.
Most hospital treatments have a two month              We need up to 10 working days after receiving all
waiting period, unless we determine the condition      required information to make a PEC assessment.
to be pre-existing. Treatment of a pre-existing        Members should allow time for a determination
condition (PEC) has a 12 month waiting period.         to be made before agreeing to a hospital
The only hospital treatments that aren’t subject       admission date. However, it’s important to be
to the PEC waiting period are psychiatric care,        aware that a condition requiring hospitalisation
rehabilitation and palliative care (a two month        will still be assessed for a PEC (and the 12 month
waiting period applies to these services).             waiting period may still apply), even where a
Obstetrics-related services are also not subject       member is admitted to hospital in an emergency.
to PEC, as they always have a 12 month waiting
                                                       If a member:
period (refer to page 21).
                                                       •	is admitted to hospital and chooses to be treated
                                                          as a private patient
 What is a PEC?
                                                       •	has been covered for the required service
 An ailment, illness or condition that, in the            or treatment for less than 12 months; and
 opinion of a Medical Practitioner appointed
 by Medibank, the signs or symptoms of which           •	our Medical Practitioner determines
 existed at any time in the six month period              (either prior or subsequent to the admission)
 prior to the day on which the member became              the member’s condition to be a PEC.
 insured under the policy or changed their cover.      Medibank won’t pay any benefits. This means the
                                                       member will be required to pay all hospital and
The PEC waiting period will apply even if an           medical charges.
ailment, illness or condition was not diagnosed        Medibank reserves the right to apply, or not to
before the date of commencing membership               apply, the PEC waiting period to individual claims.
or changing cover.                                     This means we can refuse or reduce benefits on
Where a member requires hospital treatment,            later claims even if the PEC waiting period hasn’t
their condition will be assessed for a PEC if:         been applied to any earlier claims for that ailment,
                                                       illness or condition.
                                                       You can download the PEC certificates
20 | Member Guide
Having a baby?                                             Accident waiting period waiver
If you’re considering having a baby we recommend           and Accidental Injury Benefit
you contact us to ensure your cover includes
obstetrics-related services. This is because there          What is an accident?
is a 12 month waiting period for those services
that the mother will need to have served before             An unforeseen event, occurring by chance and
the baby is born.                                           caused by an external force or object, resulting
                                                            in involuntary injury to the body requiring
This waiting period applies regardless of the               immediate treatment.
baby’s due date or whether the member was
pregnant at the time of taking out or upgrading             Accident doesn’t include any unforeseen
their cover to include obstetrics-related services.         conditions the onset of which is due to medical
                                                            causes, nor does it include pre-existing
                                                            conditions, falling pregnant or accidents arising
 What are obstetrics-related services?                      from surgical procedures. Condition means a
 Services and treatment provided in hospital                state of health for which treatment is sought.
 that deal with the care of women during
 pregnancy, childbirth and following delivery.             Accident waiting period waiver
                                                           Where a one day or two month waiting period
In addition, once the baby is born, it’s important to
                                                           applies to a Limited or Included service or
ensure they’re added to your cover from birth, in
                                                           treatment on your hospital cover (refer to your
case they require hospital treatment immediately.
                                                           Cover Summary), it may be waived for claims
Ensuring your newborn is added to your                     resulting from an accident. All other waiting
membership                                                 periods will continue to apply.
Generally, a healthy newborn isn’t separately              Accidental Injury Benefit
admitted to hospital as an inpatient (this is because      (also known as Accident override)
the baby comes under the mother’s admission).              Under some Hospital covers, benefits are payable
Because the baby isn’t an inpatient, it’s important to     for services which would normally be Excluded or
be aware that any treatment, tests or doctor’s visits      Limited, where treatment is required for injuries
(e.g. a pre-release check-up by a paediatrician) are       sustained in an accident. This is known as Accidental
outpatient services, for which Medibank doesn’t            Injury Benefit (refer to your Cover Summary
pay any benefits. This means you’ll only be eligible       to check if Accidental Injury Benefit applies).
to claim a Medicare rebate for those services
and may have out-of-pocket expenses.                       The following conditions apply to Accidental Injury
                                                           Benefit on all applicable covers:
In some cases a newborn may need to be admitted
to hospital in their own right, for example where          •	It’s limited to hospital treatment and doesn’t
they require treatment in a special care nursery or           give you coverage for any services or items
an intensive care unit. This type of admission can            under any level of Extras cover you may hold.
be very expensive. To ensure your newborn will be          •	It only applies to treatment for which a Medicare
entitled to receive benefits in the event they need           benefit is payable.
these services, we strongly advise you to add them
                                                           •	It doesn’t apply to Standalone Ambulance cover.
to your membership from their date of birth. If a
newborn isn’t added within Medibank’s required             Some Hospital covers have additional eligibility
timeframes (refer page 12), you’ll be responsible          requirements (e.g. you must see a medical
for any costs associated with their admission.             practitioner within seven days of the Accident
                                                           occurring). Please see your Cover Summary
You should also be aware that if you’re expecting a
                                                           for details.
multiple birth (e.g. twins) your second or subsequent
babies will always be separately admitted to hospital      To make a claim under Accidental Injury Benefit,
as inpatients. This means that an accommodation            you’ll need to submit the Accident form for
charge will be raised by the hospital, so it’s important   assessment. The form can be downloaded at
to make sure they’re added to your membership.   
Contact us to add your baby to your membership.                                                 Member Guide | 21
Hospital covers with an excess
                                                       What is a per-day payment?
Medibank offers a range of Hospital covers, some
of which have an excess. The SIS sent to you in        A daily amount that a member contributes towards
your welcome pack will confirm whether you’ve          their accommodation costs when admitted to
chosen a cover with an excess and how much that        hospital, separate to any excess applicable.
excess is. Alternatively, you can contact us to        The amount payable is determined by the cover
check whether an excess applies to your cover.         held and is payable directly to the hospital.

 What is an excess?                                   If your cover has a per-day payment, it will apply:

 An amount that you must contribute towards           •	per day per hospital admission, including
 your hospital treatment. It’s deducted from             same day admissions and overnight admissions
 the benefits we pay when you make a hospital         •	only where the Policy holder or partner is
 claim, separate to any per-day payment                  hospitalised – it won’t apply to hospital admissions
 applicable. Some hospitals may require you              for child dependants, student dependants or
 to pay this amount at the time of admission.            adult dependants on family memberships
                                                      •	regardless of the type of hospital you’re
If your cover has an excess, the excess will apply:      admitted to (Members’ Choice, non-Members’
•	per hospital admission, including same day            Choice or public hospital).
   admissions and overnight admissions
                                                      Claiming for a CPAP-type device
•	only where the Policy holder or partner
   is hospitalised – it won’t apply to hospital       Benefits are payable under some of our Hospital
   admissions for child dependants, student           covers for CPAP-type devices (refer to your Cover
   dependants or adult dependants on family           Summary to see if you’re entitled to benefits).
•	regardless of the type of hospital you’re           What is a CPAP-type device?
   admitted to (e.g. Members’ Choice, non-             These devices include Continuous Positive
   Members’ Choice or public hospital).                Airway Pressure (CPAP) and Bi-level Positive
For most covers the excess will apply per member       Airway Pressure (BiPAP) or similar devices,
per calendar year. For some other covers the           as approved by Medibank.
excess will apply to each episode of hospital
treatment up to an annual maximum. Refer to your      Benefits for a CPAP-type device are only
Cover Summary for details.                            payable when:
Where a member is re-admitted to hospital for         •	the member has served the 12 month
the same or a related condition within seven days        waiting period
of discharge, the excess won’t be applied to the
                                                      •	the member has undergone an overnight
second admission, even if the admissions stretch
                                                         investigation for sleep apnoea (sleep study) for
across two calendar years.
                                                         which a Medicare benefit is payable
Hospital covers with a per-day payment                •	the member has been prescribed
Medibank offers a range of Hospital covers, some         or recommended CPAP therapy (the member
of which have a per-day payment (also known as           must supply either a letter from a Medical
co-payment). You can check your Cover Summary,           Practitioner or the results of the study itself); and
SIS or contact us to check whether a per-day          •	the device is purchased or hired within
payment applies to your cover.                           12 months of undergoing the study.
                                                      If the CPAP-type device costs more than the
                                                      benefit we pay, you’ll be responsible for paying the
                                                      remaining amount. A benefit replacement period
                                                      of five years applies (refer to page 25 for details
                                                      about benefit replacement periods).
22 | Member Guide
Hospital benefit exclusions                             •	for surgically implanted prostheses and other
Benefits are not payable:                                  items not included on the government’s
                                                           Prostheses List, or for any charge that exceeds
• for any treatments or services that are:                 the minimum benefit set out in the government’s
  – E xcluded under your cover (refer to your             Prostheses List
    Cover Summary)                                      •	for items such as newspapers, TV hire, etc.
  – subject to a PEC or other waiting period              not covered by Medibank’s agreement (if any)
    or benefit replacement period                          with the hospital

  – rendered while premiums are in arrears             •	for the cost of treatment as an outpatient
    or the membership is suspended                         (unless specifically approved by Medibank)

  – rendered, or items purchased, outside              •	accident and emergency department fees,
    Australia (including medical appliances,               unless included under your cover (refer to your
    pharmaceuticals and other items purchased              Cover Summary)
    by mail order or over the Internet direct from      •	for charges by a doctor in excess of the MBS fee,
    a supplier outside Australia) or prior to joining      unless they participate in Medibank’s GapCover
  – provided in an aged care service                 •	for same-day procedures determined by the
• for any claims:                                          Australian government as not requiring
                                                           hospitalisation where the doctor hasn’t provided
  – submitted more than two years after the               suitable certification that treatment is required
    date of service                                        as an admitted inpatient in hospital
  – for services in respect of which you have          •	where we consider that one service forms part
    received, or are entitled to receive,                  of another service
    compensation (refer to page 32)
                                                        •	where the number of services performed
  – that are fully covered by a third party               or items provided exceeds a pre-determined
    (refer to page 32)                                     number of services or items over a certain
  – containing false or misleading information            period or course of treatment
    or where the service or treatment has been          •	where a provider has charged for two or more
    incompletely or incorrectly itemised                   consultations on the same day, except where
	– for charges by your doctor in excess of the           it can be shown that two separate attendances
    Medibank benefit payable under your cover              took place, and that these attendances are
                                                           clearly identifiable on the member’s account
•	where the treatment is rendered by providers
                                                           as separate consultations
   who are not recognised by Medibank for the
   purpose of paying benefits (refer to page 32)        •	where the service is performed in stages
                                                           and a separate benefit cannot be claimed
•	for procedures not recognised for Medicare
                                                           for each stage
   benefit purposes
                                                        •	where the member has reached their annual
• for cosmetic treatment
                                                           limit, sub-limit or lifetime limit for the particular
•	for podiatric surgery performed by a non-               item or service, or a group of items or services
   accredited podiatrist
                                                        •	where the treatment is rendered by a provider
• for pharmaceuticals that are:                            to their partner, dependant, business partner
  – prescribed for cosmetic purposes                       or business partner’s partner or dependant

  – provided on discharge from hospital                •	where the treatment is otherwise excluded
                                                           by the operation of a Fund Rule.
  – not covered by Medibank’s agreement
    (if any) with the hospital, including any
    PBS co-payment the member may be
    required to pay
  – non-PBS pharmaceuticals
                                                                                               Member Guide | 23
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