HEALTH INSURANCE FOR SINGLES AND COUPLES 1 APRIL 2015

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1 HEALTH INSURANCE FOR SINGLES AND COUPLES 1 APRIL 2015

2 Welcome TO QUEENSLAND COUNTRY In short, Queensland Country Health Fund (Queensland Country) has been at it for over 35 years, and takes pride in offering you a flexible, affordable and comprehensive health cover. Your health is our number one priority. This brochure provides an overview of the features and benefits of Singles and Couples Combined Cover to enable a good understanding of the level of cover available. For more information regarding health insurance please refer to our Membership Guide or visit us at [ 2 ]

3 CONTENTS Why do I need health insurance cover? 4 Singles and Couples Combined Cover 5 Hospital cover 6 What s covered in Hospital 8 How it works in relation to doctor s charges 10 Extras Cover 11 Extras Cover benefits 12 How much are the premiums 14 Managing your health insurance cover online 16 How to pay contributions 17 In more detail 18 Privacy policy & Private Health Insurance complaints 25 Contact details 26 we offer you flexible, comprehensive and affordable health cover. HOW TO JOIN call [ 3 ]

4 WHY DO I NEED HEALTH INSURANCE COVER? As a young person it s sometimes hard to understand why it is necessary to have health insurance. What does health insurance offer for someone who is young and healthy? Making health care services affordable Health insurance covers more than visits to the hospital. There are many health care services that young people need that are not covered by Medicare. Services like dental, optical, physiotherapy and massage are not normally covered by Medicare. Private health insurance with Queensland Country can help cover the costs of these services ensuring you can afford to receive treatment when you need it. Avoid higher health insurance costs Lifetime Health Cover is a Federal Government initiative that came into effect on the 1st July It is designed to reward people who join a private health fund earlier in life by securing lower premiums. Under Lifetime Health Cover, if you don t have hospital cover on the 1st July following your 31st birthday, then for each year you delay joining, your premium will increase. Avoid extra tax The Medicare Levy Surcharge is a Federal Government initiative to encourage higher income earners to take out private health insurance. Under the Medicare Levy Surcharge you may have to pay an extra 1% to 1.5% in tax if your income* exceeds certain thresholds and you don t have hospital cover. You may well find that the cost of our Singles and Couple Combined Cover is less than the additional surcharge which means you may be better off financially and have the peace of mind of having a hospital cover as well. Australian Government Rebate on private health insurance The Australian Government Rebate on private health insurance was introduced as a financial incentive to assist Australians afford private health cover, and to recognise the contribution that people with private health insurance are making to their own health care costs. Rebate entitlement depends on your age, and income*. From 1 April 2014, the rebate is now indexed each year by the difference between CPI and the industry average increase in premiums using a Government-calculated formula. It s up to you to nominate a rebate tier (based on your age and income*). Some people choose to take their rebate up front as a lower premium, but if you d prefer to claim the rebate as a lump sum through your tax at the end of the financial year, you can simply choose to pay the full premium with no rebate deducted. * This information is intended as a guide only and does not take into account your personal circumstances. For more information regarding the Rebate and MLS, including the calculation method for this income known as income for Medicare Levy Surcharge purposes, please seek the advice of your tax agent, financial advisor or contact the Australian Taxation Office (ATO) Help Line on or visit their website at Income-for-Medicare-levy-surcharge/ [ 4 ]

5 SINGLES AND COUPLES COMBINED COVER Getting started with health insurance has never been easier. Queensland Country offers our Singles and Couples Combined Cover designed to provide younger people with the cover they need, without paying for benefits that won t be used. Singles and Couples Combined Cover provides: Cover for Private Hospital treatment for a range of commonly needed treatments for conditions like tonsillitis, knee reconstructions, appendicitis etc. This hospital cover has some restricted and excluded benefits. Queensland Country offers: Value for money health insurance products with comprehensive benefits Access to your health insurance policy information via our Online Member Services Very high levels of Member satisfaction which is confirmed with Member surveys Cover for a number of commonly used extras like dental, physiotherapy, massage, optical etc. Competitive pricing to make health insurance affordable [ 5 ]

6 HOSPITAL COVER Singles and Couples Combined Cover is a popular choice for young singles and couples. This covers you for the hospital services you are more likely to use. This means if you want the security of hospital cover at any hospital in our Australia-wide network but don t want to pay for benefits you re not likely to use (such as hip replacements) then this is the cover for you. Private hospital cover helps you afford treatment in private or public hospitals. You can receive the required treatment when and where you want it, and it can be performed by the Doctor of your choice. So, as a patient, you have more control, and more importantly you can ensure you receive the best medical care. Private Hospital cover also assists to cover the gap component over the Medicare Benefits Schedule for in-patient services*. AUSTRALIA-WIDE PRIVATE HOSPITAL NETWORK PAY LESS WITH ACCESS GAP COVER PEACE OF MIND WITH THE DOCTOR OF YOUR CHOICE CHOOSE A HIGHER EXCESS TO LOWER YOUR PREMIUM *Singles and Couples Combined Cover has some excluded and restricted benefits [ 6 ]

7 Excess Singles and Couples Combined Cover is available with the choice of a $250 or $500 excess for single membership or couples membership. The excess that applies in any one membership year is $250 or $500, depending on which one you choose. This means for example that regardless of how many times hospitalisation is required throughout the year if you have the $250 excess, you would only pay a maximum of $250 for single membership, and $500 for couples membership. The excess applies to the full cost of hospitalisation at a public, private or day hospital facility and is applicable to both adults and dependants covered under this policy. Out-of-Pocket Expenses It is your right to know if there are any out-of-pocket expenses to help avoid any surprises later. Knowing how much your medical treatment will cost is called Informed Financial Consent and the Federal Government has introduced a checklist providing you with the questions you need to ask before going into hospital. We recommend that you contact us before going into hospital so that we can discuss what your policy will provide cover for. We would also be happy to send you a copy of the checklist. Hospital Network Queensland Country has negotiated Purchaser Provider Agreements with most of the participating private hospitals and day hospital facilities Australia-wide. In most instances, the approved hospital charges for policy holders of a private hospital policy will be covered in full once the agreed excess has been deducted. This means that you will benefit from capped fees we ve negotiated and convenient billing as your invoice will be sent directly to Queensland Country. Private hospitals and day hospital facilities that have not signed an agreement attract reduced benefits which will mean you may incur out-of-pocket expenses for in-hospital treatment. Go to our website to find a hospital most convenient to you. What s Covered in Hospital We will pay benefits for in-patient services in a private hospital where a Medicare benefit is payable and waiting periods have been served, except for restricted services or services not covered (see table on page 8). If you do not have ancillary (extras) cover and exercise physiology, for example, is required in hospital as part of your treatment, then you will not be covered for these services if they are invoiced separately by the Provider. This is also the case for any allied services not covered under this policy. [ 7 ]

8 WHAT S COVERED IN HOSPITAL What s covered Included services Included services Examples of in-hospital treatments we will pay benefits towards: Appendix treatment Accidents Removal of teeth Knee, shoulder and hip investigations Removal of tonsils Hernia surgery Digestive disorders Colonoscopies Kidney stone and gall stone removal Knee & ankle arthroscopy and reconstructions Shoulder arthroscopy and reconstructions Hospital and doctors benefits for included services Choice of doctor/hospital Private hospital accommodation Public hospital accommodation as a private patient (shared room) Theatre fees Surgically implanted prosthesis benefits* Intensive care In-hospital rehabilitation treatments (Rehabilitation for hospital services with restricted or excluded benefit entitlement will have reduced or nil benefit eligibility) Plastic and reconstructive surgery (if medically necessary) Medical Gap Doctors charges in hospital where each doctor chooses to opt in to the Queensland Country Access gap scheme Radiography and pathology services charges ordered by your doctor in hospital. 100% cover where the practitioner participates in the Queensland Country Access gap scheme Most pharmaceuticals directly related to your admission * Some surgically implanted prostheses may be for an excluded benefit therefore no benefit would be payable in this circumstance, for example hip replacement. Waiting periods will apply to all benefits outlined. Please refer to pages for further details. [ 8 ]

9 Restricted Benefits If a service is covered as a Restricted Benefit, this means you will be covered with your choice of doctor for shared ward accommodation in a public hospital only. If you go to a private hospital for a specific service which has Restricted Benefits, it is likely to result in large out-of-pocket expenses. Restricted Benefits are amounts set by the Government and are generally not enough to cover accommodation costs in a private hospital. No benefit is paid towards the cost of theatre charges raised for these services. Whilst cover with Restricted Benefits entitles you to your choice of Doctor in a public hospital, your Doctor may not be willing, or able, to treat you in a public facility. What s covered Restricted services restricted restricted restricted restricted restricted restricted restricted in-hospital treatments we will pay a restricted benefit towards: In-hospital psychiatric treatment Cardio-thoracic procedures for example open heart surgery Major eye surgery cataract and eye lenses procedures Obstetric related services birth and pregnancy related services Assisted reproduction services for example IVF Gastric banding and obesity surgery Renal dialysis for chronic renal failure Waiting periods will apply to all benefits outlined. Please refer to pages for further details. Excluded Benefits An excluded service means you will not be covered in a public or private hospital and will not receive a payment from Queensland Country for that service. If you think you may need any of the procedures outlined below you may like to consider taking out a higher level hospital cover. What s not covered Excluded services in-hospital treatments we will not pay a benefit towards: Joint replacements for example an artificial hip replacement Cosmetic surgery (hospital treatment for which Medicare pays no benefit) [ 9 ]

10 HOW IT WORKS IN RELATION TO DOCTORS CHARGES Medicare uses a Medicare Benefits Schedule fee (MBS) for calculating rebates on doctors charges. Queensland Country offers our Access Gap Cover Scheme and we encourage doctors to participate in the scheme. Under the Access Gap Cover Scheme participating doctors who provide a service in hospital can decide to accept up to the Health Fund benefit as full settlement of the account. This means you don t have to make any additional payments for that particular service. The doctor can also accept the fee as part of the payment and will inform you of any gap called the known gap which you will have to pay. If your doctor does not participate in Access Gap, we will only cover the 25% gap between the 75% Medicare Benefit and the Medicare Benefits Schedule fee which may result in larger out-of-pocket expenses for yourself. It s always a good idea to talk to your doctors about their charges prior to your treatment. To find doctors who may participate in the Access Gap Scheme refer to the AHSA website: https://www.ahsa.com.au/web/gapcoversearch [ 10 ]

11 EXTRAS COVER Singles and Couples Combined Cover has been designed to provide good benefits for a broad range of therapies most likely to be used by young people while keeping the cover affordable. Whether you need a massage or a new pair of glasses, Queensland Country can help. Online or on-the-spot claiming! To make it even easier to claim your benefit, participating health professionals have electronic claiming facilities available. HICAPS/IBA is an electronic health claiming and payments system that will process your claim for treatment, on the spot, without leaving the surgery or practice of your provider. GENEROUS ANNUAL LIMITS FOR GENERAL DENTAL AND OPTICAL SERVICES COVER FOR A WIDE RANGE OF ALTERNATIVE THERAPIES INCLUDING REMEDIAL MASSAGE AND PODIATRY EASY CLAIMING WITH HICAPS/ IBA ON THE SPOT CLAIMING COMPETITIVE PREMIUMS Alternatively with Online Claiming we ve now made it easier than ever to claim for a wide range of services when on-thespot claiming isn t available through your provider. Simply go online using your PC, tablet or smart phone! You can claim up to $400 per day in benefits for services up to three (3) months from the actual date of service, treatment or visit. For full terms and conditions visit our website Dental and Optical Preferred Providers Queensland Country has negotiated agreements with a large number of Dental and Optical providers. Services at one of our preferred providers are well priced and are likely to reduce out of pocket expenses for Members. [ 11 ]

12 EXTRAS COVER BENEFITS Services Waiting Period Benefit Limits per membership year Examples of maximum benefits DENTAL BENEFITS GENERAL DENTAL: Diagnostic This includes examinations, consultations, x-rays etc. 2 months $500 per person up to $1000 per policy Periodic oral examination $34 X-rays $23 Preventative This includes cleaning and scaling, fluoride treatment, oral hygiene instruction and mouth guards 2 months Scale & Clean $56 Fluoride treatment $17 Mouth Guard $113 Simple Extraction 2 months Simple extraction $79 Restorative This includes composite and amalgam fillings General Services Occlusal splints 2 months One surface composite filling $68 2 months Occlusal splint $225 Surgical Extraction Wisdom teeth extraction, removal of impacted teeth MAJOR DENTAL: 12 months $500 per person up to $1000 per policy Surgical extraction $135 Periodontics Specialised gum treatment Endodontic Root canal therapy and root fillings 12 months Treatment of acute periodontal infection (per visit) $38 12 months Filling of one root canal $128 Crowns/Bridges 12 months Full Veneered Crown $500 Orthodontics Braces etc 12 months Braces for upper & lower teeth, including removal plus fitting of retainer $500 Lifetime Limit $1000 per person Benefits are paid at 70% of cost OPTICAL BENEFITS Single & Multi-focal lenses & frames 2 months $200 per person up to $400 per policy Single vision lenses & frames $200 Repair to frames $200 Contact lenses $200 PHYSIOTHERAPY Physiotherapy 2 months $400 per person up to $800 per policy Initial visit $42 Subsequent visit $32 Group Therapy - $8 (sub limit of $80 applies) * Benefits are payable for services rendered by Australian Regional Health Group approved providers registered with Queensland Country as well as Bowen Therapists that are registered with the Bowen Association of Australia (BAA) or Bowen Therapists Foundation of Australia (BTFA) # Prescriptions not covered by the PBS, excluding contraceptives and items normally available without prescription and drugs not approved for sale in Australia. A co-payment applies to each prescription item equal to the current PBS General Patient Contribution. Please refer to page 23 for more information. [ 12 ]

13 Services Waiting Period Benefit Limits per membership year Examples of maximum benefits ALTERNATIVE THERAPIES Chiropractic Osteopathy 2 months $300 per therapy $500 per person up to $1000 per policy Remedial Massage Therapy* Bowen Therapy* Myotherapy* Initial visit $30 Subsequent visit $30 Chiro x-rays $50 Podiatry Initial visit $30 Subsequent visit $30 Orthotics 85% of cost up to available policy limits Minor procedures 75% of cost up to available policy limits Acupuncture* Initial visit $30 Subsequent visit $30 Naturopathy* Homeopathy* Initial visit $30 Subsequent visit $30 Dietician Initial visit $55 Subsequent visit $35 OTHER SERVICES Pharmaceutical # 2 months $150 per person up to $300 per policy $30 per script Healthy Living Benefit 2 months $125 per person up to $250 per policy Benefits up to the policy limit are available for: Your choice of quit smoking programs Your choice of weight management programs Participate in other approved health management programs** including: - Gym Membership - Personal Training programs Skin checks through mole mapping Consultation fees for metabolic dieticians and nutritionists when providing assistance with weight management ** To comply with private health insurance legislation you must have been referred by your health care professional to participate in a health management program to address, improve or prevent a specific or medical condition. A Health management Program Benefit Approval Form, available on our website must accompany claim for these benefits. [ 13 ]

14 HOW MUCH ARE THE PREMIUMS? What you ll pay SINGLES COVER WITH BASE TIER REBATE NO REBATE DEDUCTED WEEKLY MONTHLY YEARLY WEEKLY MONTHLY YEARLY Singles and Couples Combined Cover 250 Singles and Couples Combined Cover 500 $24.90 $ $1, $34.50 $ $1, $22.05 $95.45 $1, $30.55 $ $1, COUPLES COVER WITH BASE TIER REBATE NO REBATE DEDUCTED WEEKLY MONTHLY YEARLY WEEKLY MONTHLY YEARLY Singles and Couples Combined Cover 250 Singles and Couples Combined Cover 500 $49.80 $ $2, $69.00 $ $3, $44.05 $ $2, $61.05 $ $3, Normal 2 and 12 month waiting periods apply with our combined products. Premiums are quoted with and without an Australian Government Rebate on private health insurance. Australian Government rebates depend on age and income levels. For more information see page 4. Join Queensland Country today Joining our fund is simple. Choose one of the following options that suit you: Call us on and complete an application over the phone Visit a retail centre and let one of our friendly staff assist you Go to our website and apply online through our online application process. The web address is Drop in to one of Queensland Country Credit Union s 23 branches throughout Queensland Switch to Queensland Country Health Fund If you are a member of another health fund, it s quick and simple to transfer to us. Simply complete our membership application and cancel any direct debits you may have with your old fund. We will contact your old fund and arrange for the transfer of cover of the commencement date of your policy. [ 14 ]

15 Money back guarantee If you are not completely satisfied with your new health insurance policy we will provide a refund of any premium paid (if a claim hasn t been made) if you write to us advising that you are not satisfied with your policy within 30 days. [ 15 ]

16 MANAGING YOUR HEALTH INSURANCE COVER ONLINE Online Member Services (OMS) gives you the ability to update your membership details whenever you want, giving you greater control and easy access. You can log on at any time of the day and check your cover; update address details, change your level of cover and even add a new addition to the family. To access OMS, all you need to do is register on the homepage of our website www. qldcountryhealth.com.au. The register icon is located at the top right hand corner of the screen. Once you have registered using your membership number and your choice of password, click on the Login tab and enter your membership number and password. Now you re ready to go! Below is a list of all the different services you can access by registering: Claims history View/print tax statement Update Membership details Change contact details Add new person Change personal details Add student dependant or apprentice Add Medicare card details Add previous cover details Make a contribution payment by credit card Change level of cover Update your method of payment Update the way we pay benefits eg. direct credit Contribution changes View benefit limits Make a claim for ancillary services* *not all ancillary services (Extras) are claimable through Online Claiming see website for further terms and conditions Access to some functions may be limited for your spouse/ partner and dependants. [ 16 ]

17 HOW TO PAY CONTRIBUTIONS Queensland Country offers you a variety of payment options so you can choose the best method for you. You can choose to pay weekly, fortnightly, monthly, quarterly, 6 monthly or yearly, whichever suits you. If you do choose one of the latter options, we ll send you a reminder notice as a courtesy. As a policy holder it is your responsibility to ensure that the payment amounts are correct and made in advance, this avoids claims being rejected due to an un-financial status. Direct Debit Credit Card BPAY BillPaying Direct Debit facilities are available for policy holders who prefer to pay through automatic deductions from their Bank, Building Society, Credit Union accounts and Credit Cards. If this is your preferred method of payment, simply nominate this on the application form, and complete your details or visit our website. A reminder notice is not issued if you pay by direct debit. Credit Card* facilities are available to all policy holders who prefer to pay via this option. If this is your preferred method of payment, simply visit our website and make the payment online through Online Member Services (OMS^). Alternatively, phone us on * We do not accept American Express or Diners Club. ^ Please see page 16 for details on how to register for OMS. BPAY facilities are available to all policy holders who prefer to pay via this option. BPAY allows you to pay your health insurance premium via internet or phone banking, or at your financial institution. The BPAY biller code and your reference number appear on all statements. If you don t receive regular statements please contact us and we ll be happy to supply you with your BPAY biller code and reference number. (This option is not available to eligible BillPaying Service Queensland Country Credit Union offers a BillPaying service through all their branch offices. BillPaying is a comprehensive budgeting and bill paying service that provides a fast and simple way to pay all your bills. If you would like more information on this service, please feel free to contact Queensland Country Credit Union on participants in a Corporate Health Plan) Note: Deadlines may exist for one or more of these payment options. Please consult our Membership Guide for further details. You can choose to pay weekly, fortnightly, monthly, quarterly, 6 monthly or yearly, whichever suits you. [ 17 ]

18 In more detail We have included information you may need. Additional information is available in the Membership Guide. Pre-Existing Conditions A pre-existing ailment, illness or condition is one where, after examining evidence, a medical adviser, or other relevant health care practitioner appointed by Queensland Country would consider that signs or symptoms would have been in existence at any time during the six months preceding the application for membership or upgrade of cover. You may have a pre-existing condition, ailment or illness without being aware of it. In these cases, there is a 12 month waiting period before you are entitled to claim benefits for treatment. It is not necessary for the signs or symptoms to have been diagnosed by a doctor when a Member joined or upgraded their level of cover. Surgery for assisted fertility programs such as IVF or GIFT (restricted benefit), Sterilisation or Vasectomy are elective and attract a 12 month waiting period as does obstetrics-related services. The 12 month Pre-existing condition waiting period can be applied to all hospital or hospital substitute treatment for which we pay benefits. However, a two month waiting period applies to the following services: all other inpatient hospitalisation services/treatments approved psychiatric treatment (restricted benefit only) approved rehabilitation treatment, or palliative care. [ 18 ] The 12 month waiting period for the treatment of a Pre-existing Condition can also apply to ancillary (Extras) services.

19 Benefit Conditions Queensland Country will only pay benefits when: All applicable waiting periods have been served Goods or services are provided in Australia (not including items imported by the user via an internet purchase) The Member has been charged for the treatment or service A service or treatment is medically necessary and clinically relevant Services are part of a course of treatment recognised by Queensland Country A claim for a service rendered is submitted for payment within 24 months of the date of service The waiting period for that service has been served The amount of benefit is calculated on the cost of the treatment or aid to the Member, taking into account any allowances or discounts given by the provider. No benefit paid by Queensland Country can exceed the actual charge of the service or appliance. Benefits are not payable for claims for goods purchased or rendered outside of Australia or, for items purchased or hired from overseas suppliers (including internet purchases) The service is provided in person The service is provided to a person on the membership The service or treatment has been provided by a practitioner or therapist recognised by Queensland Country The treatment or service is covered under the Member s level of cover No benefits are payable from another source (e.g. compensation payment or Government benefit) The conditions of the level of cover have been met [ 19 ]

20 Membership Year All yearly limits and excesses are calculated from the anniversary date of the establishment of the membership. Singles, Couples & Families Single: a single policy covers only one person. Couple: a couple policy covers the person who establishes the policy as well as one other partner/spouse. The policy can be extended to cover dependant children at no additional cost. Family: a family policy covers the person who establishes the policy as well as that person s partner and all dependant children. Single Parent Family: a single parent family policy covers the person who establishes the policy as well as that person s dependant children. Waiting Periods So when will I be fully covered you ask? Waiting periods apply when you join any health fund for the very first time or when you upgrade to a higher level of cover. But you won t have to wait if you re transferring to Queensland Country from an equivalent or higher level of cover with another health fund, or if you ve been covered by your parents membership and you re just starting out on your own. Waiting periods are necessary to keep health cover fair and aim to protect our existing policy holders who contribute to a fund over a period of time for when they may need cover. If we didn t have these waiting periods people may join, claim for something planned and then leave. Always make sure you have waited the sufficient period before claiming, otherwise you may not be covered! For those of you who are thinking of starting a family, if you have a single policy, to be sure your baby has cover, it is necessary to add a newborn baby to your policy within two months after the date of their birth. Always make sure you have waited the sufficient period before claiming, otherwise you may not be covered The baby will not have to serve any waiting periods* that have already been fully served by the policy holder providing that the change is made to the policy within this time frame. *For policy holders with no previous cover pre-existing condition waiting periods may apply to the baby within the first 12 months. [ 20 ]

21 Waiting Period Item / Service Hospital: For all hospital treatments or services where there are no Pre-existing Conditions (excluding Accidental Injury^). Dental: Diagnostic includes examinations & consultations Preventative includes cleaning and scaling, fluoride treatment etc. Simple extraction Restorative composite and amalgam fillings General services includes mouth guards and Occlusal splints Optical 2 months Acupuncture Chiropractor Remedial Massage Therapy/Bowen Therapy/Myotherapy Osteopathy Physiotherapy Podiatry Dietitian Pharmaceutical Healthy Living Benefits Sporting & School accidents Pre-existing Conditions All Elective Surgery Obstetrics-related Services (restricted benefit) Major Dental services Periodontics specialised gum treatment 12 months Surgical Extraction includes Wisdom tooth extraction Endodontic Services includes root canal therapy Crowns and Bridges Orthodontics Braces etc. Surgery for assisted fertility programs such as IVF or GIFT (Restricted Benefit) Elective Surgery (such as sterilization or vasectomy) ^ Two month waiting periods apply for most other items or services. The 2 month Waiting Period is waived for treatment arising from an accident (excluding a school and sporting accident) that occurred after joining. [ 21 ]

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