Health Insurance - Medibank
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member
guide
Health Insurance
Effective April 2018
Member Guide | 1Information 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 www.medibank.com.au
• Please read this Guide and your Cover Summary
carefully and keep them for your reference.
• If you need further information about your cover
or anything in this Guide, please contact us.
• We’ll send correspondence to your email address,
or your postal address where you have opted out
of email communication. It’s important 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 | 3Before 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 at www.medibank.com.au/health-insurance/glossary
Medibank Joining Statement
By joining Medibank, you (if you are the Policy • authorise any health service provider to
holder) have agreed that you: supply to Medibank any information Medibank
considers necessary for the assessment of any
• will ensure that all information supplied
claim on the membership, and will ensure that
to Medibank is true and correct
members aged 16 years and over have provided
• will keep your membership information the relevant consent
up to date and notify us of any changes
• authorise Medibank to supply to any health
as soon as possible
service provider any information Medibank
• will ensure that all members on the membership considers necessary for the assessment of any
are aware of and abide by Medibank’s Fund Rules, claim on the membership, and will ensure that
the information in this Guide and Medibank’s members aged 16 years and over have provided
policies including its Privacy Policy the relevant consent
• have the authority to provide the personal • will make the minimum advance premium
information of other members on the membership payments required
• will make, or authorise the making of, all claims • are aware that Medibank may terminate your
under the membership and ensure that any claim membership in accordance with Medibank’s
that includes sensitive information of a member Fund Rules.
aged 16 years and over is made having first
obtained the consent of that member
Member Guide | 5What’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 GuideWhat’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
Disclaimer32
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
Complaints34
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 | 7Welcome 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 GuideCooling 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 | 9Managing 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
www.medibank.com.au. 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 www.medibank.com.au; 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 GuideManaging 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 | 11Changing 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 GuideMoving 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
sentencing.
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 | 13Going 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 GuideRegardless 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 www.medibank.com.au 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: www.mbsonline.gov.au
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 | 15Doctors’ 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
OR
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
www.health.gov.au
(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 GuidePharmaceutical 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
Summary)
• 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
www.pbs.gov.au
Member Guide | 17Hospital 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
Accommodation
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.
charges
• 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.
Limited
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.
Included
diagnostics • Your potential out-of-pocket expense – any difference between the MBS
or Limited
(e.g. bloods fee and the amount you’re charged.
service
tests, scans etc.)
18 | Member GuideHospital 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 | 19Mental 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
at www.medibank.com.au
20 | Member GuideHaving 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. www.medibank.com.au.
Contact us to add your baby to your membership. Member Guide | 21Hospital 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).
memberships
• 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 GuideHospital 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 | 23You can also read
