Ultimate Health Cover

Transcription

1 Ultimate Health Cover 1 April 2013 Your level of cover is a packaged hospital and extras cover. HOSPITAL COVER Your hospital cover provides comprehensive cover that helps pay for hospital and in-patient medical expenses in private and public hospitals. Plus you receive additional benefits unique to this cover. WHAT S COVERED Hospital Costs With us you are covered as a private patient in most hospitals that Bupa has an agreement with (known as Members First and Network hospitals) across Australia for any treatment which is recognised by Medicare and is not restricted or excluded under your cover. When admitted to these hospitals, in most cases you will be covered for all in-hospital charges including; accommodation for overnight or same day stays operating theatre, intensive care and labour ward fees supplied pharmaceuticals approved by the Pharmaceutical Benefits Scheme allied services including physiotherapy, occupational therapy and dietetics dressings and other consumables pathology and radiology diagnostic tests (recognised by Medicare) performed in hospital by Bupa contracted providers surgically implanted prostheses up to the approved benefits in the Government s Prostheses List private room where available. A small number of these hospitals may charge a fixed daily fee. This fee is capped at a maximum number of days for overnight stays. The hospital should inform you of this fee when you make a booking. This fee is in addition to any excess or co-payment you may have as part of your hospital cover. Medical Costs These are the fees charged by a doctor, surgeon, anesthetist or other specialist for any treatment given to you in hospital. Private health insurance provides you with the choice of your own doctor, and you decide whether you will go to a public or a private hospital that your doctor attends. You may also have more choice as to when you are admitted to hospital. You are covered for: the cost of these medical treatments up to the Medicare Benefit Schedule (MBS) fee. The MBS fee is the amount set by the Federal Government for each medical service covered by Medicare. You must be eligible for Medicare in order to be covered up to the MBS fee. If you choose to be treated as a private patient in a hospital (public or private), Medicare will cover you for 75% of the MBS fee for associated medical costs and we will cover the remaining 25%. If your specialist charges more than the MBS fee there will be a gap for you to pay. However, the Bupa Medical Gap Scheme can help eliminate or reduce the gap for you if your doctor/s choose to use it (please refer to page 2). At Members First day facilities, not only will you be fully covered for the facility accommodation and theatre fees (product excess applies) but there are no out-of-pocket expenses for medical treatments (e.g. your specialist s fees). WHAT S NOT COVERED Hospital Costs Situations when you are likely not to be covered include: During a waiting period A waiting period is the time between when you join us and when you are covered for a service or treatment included in your cover When a service or treatment is excluded from your level of cover When a service or treatment is covered as a minimum benefit and you are admitted to a private hospital, you will not be covered above the minimum benefit If you are admitted to a private hospital that Bupa does not have an agreement with, we will pay shared room minimum. These benefits will only partially cover the full cost and you will have significant out-of-pocket expenses. If you are admitted to a fixed fee hospital, you will not be fully covered and will need to pay a fixed daily fee (in addition to any excess or co-payment). This fee is capped at a maximum number of days for overnight stays. The hospital should inform you of this fee when you make a booking When you have not been admitted into a hospital and are treated as an outpatient (e.g. emergency room treatment, outpatient ante-natal consultations with an obstetrician) For psychiatric and rehabilitation day programs, when you are treated as outpatient at a hospital Bupa does not have an agreement with, you will not be covered above the minimum benefit. Hospital treatment provided by a practitioner not authorised by a hospital to provide that treatment If you are in hospital for 35 days and you have been classified as a nursing home type patient. In this situation you may receive limited benefits or be required to make a personal contribution towards the cost of your care Benefits for pharmaceuticals supplied upon discharge from the hospital If you choose to use your own allied health provider rather than the hospitals practitioner for services that form part of your in-hospital treatment (e.g. chiropractors, dieticians or psychologists) 1 BUPA_UltimateHealthCover_NSW_ACT_0413

2 WHAT S NOT COVERED (CONTINUED) Hospital treatment for which Medicare pays no benefit, including: medical costs in relation to surgical podiatry (including the fees charged by the podiatric surgeon); cosmetic surgery where not clinically necessary; respite care; experimental treatment and/or any treatment/procedure not approved by the Medical Services Advisory Committee (MSAC)If you elect to be treated as a private patient in a public hospital, we will pay shared room minimum benefits and benefits for prostheses up to the benefit in the Government Prostheses List. This will apply for any treatment recognised by Medicare unless it is excluded or restricted under your cover. If you choose to stay in a private room for an overnight stay, Bupa will pay a fixed benefit in addition to the shared room minimum benefit Where compensation, damages or benefits may be claimed by another source (e.g. Workers Compensation) Personal expenses such as pay TV, internet access, non-local phone calls, newspapers, boarder fees, meals ordered for your visitors, hairdressing and any other personal expenses charged to you, unless included in your cover Any treatment or services rendered outside Australia Medical Costs You will not be covered for; Medical services for surgical procedures performed by a dentist, surgical podiatrist or any other practitioner or service that is not eligible for a rebate by Medicare EXCESS No excess or co-payment applies on this cover MEDICAL GAP SCHEME This is a direct billing arrangement between Bupa and your doctor/s that in most instances eliminates your out-of-pocket expenses for inhospital doctors (relates only to in-hospital cardiologists for GHC) fees (the gap ). If your doctor charges up to the Medicare Benefits Schedule (MBS) fee or is participating in the Bupa Medical Gap Scheme, in most cases you will have no medical gap costs to pay. For doctors who are not participating in our Medical Gap Scheme and are charging above the MBS fee, we will pay the difference between the Medicare benefit and the MBS fee. Any amount above the MBS fee will be the amount you are required to pay and this is referred to as the Medical Gap. GENESIS HEART CARE We ve also partnered with the Genesis Heart Care, a network of cardiologists across Victoria, Queensland, South Australia and Western Australia focusing on providing quality, evidence based cardiology services. When you see a cardiologist from the Genesis Heart Care you will have no out-of-pocket expenses for your in-hospital cardiologist treatment. You ll also be provided with information and advice so you can make informed decisions about your treatment and lifestyle. AMBULANCE You are covered for emergency ambulance services (including on-the-spot treatment and air services) from recognised providers, capped at one service for singles and two services for couples or family memberships per calendar year. EXTRAS COVER Your package includes our highest level of extras cover, providing cover for the services shown below. Benefits listed are examples only and not a complete list. Extras Services Services covered & example items General dental Benefits 100% back up to the first $500 per person, per calendar year then set benefits apply as shown below Annual maximums per person per calendar year Comprehensive oral examination (011) $43.65 Unlimited Scale & clean (114) $88.65 Fluoride application (121) $27.00 Tooth extraction (322) $ Filling/tooth restoration (531) $ Major dental Root canal (417) Full crown (615) Dentures complete (719) 100% back up to your annual maximums $1600 2

3 Orthodontics Optical 100% back up to your annual maximums $1400 Includes a lifetime limit of $3200 per person Our Members First optical providers (BLINK Optical, National Pharmacies Optical and selected independent providers) and our optical partners offer you 'no gap' packages - where you pay nothing provided you have sufficient Annual Maximums. Refer to the list below for the no gap packages available to you and where you can access them. Some examples of benefits paid at all other providers : Frames (110) $ $420 for services by Single vision lens (212) $ Members First providers $300 for services by non Progressive lens (512) $ Members First optical providers No-gap optical packages Members First providers Optical partners Kid's glasses with safety lens - any frame up to $249 Glasses with single vision lens* Glasses with single vision grind lens* Glasses with bifocal lens* Glasses with trifocal lens* Glasses with progressive lens* Disposable contacts - selected 12 months' supply purchased in store Disposable contacts - selected 12 months' supply purchased on-line *Any frame up to $199 Physiotherapy 100% for first $350 per person per calendar year then set benefits apply as shown below Initial attendance $67.50 $1500 Subsequent attendance $57.60 Chiropractic/ Osteopathy 100% for first $350 per person per calendar year then set benefits apply as shown below Initial attendance $72.00 Per person Subsequent attendance $49.50 Ante & post natal services Per family $1600 Covers selected services Set benefits apply $500 Psychology Initial attendance $ Subsequent attendance $ Dietary Initial attendance $55.00 Subsequent attendance $30.00 Podiatry Initial attendance $65.00 Subsequent attendance $

4 Speech therapy Initial attendance $ Subsequent attendance $65.00 Eye therapy Initial attendance $60.00 Subsequent attendance $40.00 Occupational therapy Initial attendance $56.00 Subsequent attendance $37.40 Natural therapies Includes acupuncture, Alexander Technique, Chinese herbalism, exercise physiology, Feldenkrais, homeopathy, iridology, massage, naturopathy and Western herbalism. Massage includes aromatherapy, Bowen Technique, kinesiology, reflexology, shiatsu and remedial massage. Acupuncture initial attendance $35.20 Acupuncture subsequent attendance $26.40 Massage $40.00 Pharmacy Includes sub-limits for massage of up to $250 per person, $500 per family 90% of cost up to annual maximums after deduction of the PBS amount Living Well Provides cover for courses and treatments which help you live a healthier lifestyle. These include: gym memberships, yoga, Kids swimming Programs, Pilates, nicotine replacement therapy and weight management programs. Gym memberships, yoga, Kids swimming programs and Pilates courses require your doctor or Recognised Provider to complete a Living Well form to confirm the program is medically necessary for your health. $1500 Up to 50% of the cost $300 per person Home nursing Covers selected services $40 per day for the first 10 visits $400 Health aids and appliances Blood glucose monitor 100% of cost 1 claim per year up to $600 Asthma pump 100% of cost 1 claim every 2 years up to $500 CPAP devices 100% of cost 1 claim every 2 years up to $1500 (subject to eligibility. Please call for details) TENS machine 100% of cost Up to $1000 per item Blood pressure monitor 100% of cost Up to $1000 per item Hearing aid 100% of cost 1 claim every 3 years up to $850 Hire, repair and maintenance of health aids and appliances 100% of cost Up to $100 Travel and accommodation expenses Helps pay for travel and accommodation benefits for essential medical treatment. $200 for travel expenses $300 for accommodation expenses, capped at $40 per night. 4

5 SPECIAL FEATURES No gap dental for kids and physio for kids. We'll cover all the cost of your kids' dental and physio (in most instances) when treatment is provided by a Members First dentist or Members First Physiotherapist until they turn 25. Excludes orthodontics and hospital treatments. Fund Rules, Annual Maximums and Waiting periods apply. Child dependants only. Gap bonuses Upon joining you receive a $200 gap bonus as well as another $200 each 31 December as long as you're an Ultimate member. You can use the gap bonus to pay for any medical gaps you may incur during a hospital stay. 100% cover for laser eye surgery Receive 100% cover for laser eye correction surgery by a fund-recognised provider. A three year waiting period applies. Special benefits Helps pay towards accommodation and meal costs if your partner, immediate family member, carer or next of kin is required to stay in hospital with you or another person on your membership. 24-hour medical advice line You have access to a toll-free non-emergency medical advice line staffed by medically qualified professionals, 24 hours a day, seven days a week. These professionals can offer you support advice and information. Baby books Receive two free books about parenting. Health subscription refunds Receive a 100% refund on a subscription to the Arthritis Foundation, Asthma Foundation and Diabetes Australia WAITING PERIODS Initial waiting period; palliative care; psychiatric; rehabilitation services and health subscription refunds Living Well benefits; hire, repair and maintenance of health aids and appliances Pre-existing ailments, illnesses or conditions Pregnancy and related services (including childbirth) Major dental, root fillings, orthodontics; selected health aids and appliances Laser eye correction surgery 2 months 6 months 1 year 1 year 1 year 3 years EXTRA VALUE FROM YOUR MEMBERSHIP Self management programs Bupa's self-management programs give you up-to-date and valuable information on how to better manage your chronic health condition together with your doctor or health professional. We have a range of self management health programs covering back pain, arthritis, asthma, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease and angina, diabetes, depression and osteoporosis. Overseas Health Advice Line If the unexpected happens while you re travelling overseas, our 24-hour health advice line can provide you with phone-based support, information and guidance. Plus, if you re planning a trip overseas, you can get pre-departure medical information on the countries you are visiting. Just look for the number on the back of your membership card. Member Discount Partners Keep your mind and body active with some great member discounts on things like gym memberships, movie vouchers and theme park entry. Visit bupa.com.au/memberexclusives Bowel cancer screening kits Bowel cancer can be treated successfully if detected in its early stages. We will pay a benefit towards selected screening kits for bowel cancer. Travel, home and car insurance Bupa travel, home and car insurance provides comprehensive cover you can depend on when you need it most. Plus, if you re a Bupa health member, you can get discounts of 15% on travel insurance premiums and 10% on home and car insurance premiums. Insurance issued by CGU Insurance Limited (CGU) ABN AFSL Any advice is general advice only and does not take into account your individual circumstances. A Product Disclosure Statement is available at bupa.com.au and should be considered before making any decision on this product. Bupa Australia Pty Ltd ABN is authorised representative of CGU. 5

6 CALL US FIRST If you're planning a treatment or a hospital admission, call us first so we can discuss your options, work out what you're covered for, talk through any out of pocket costs and check that you've served any relevant waiting periods. This can help you avoid any unnecessary out of pocket expenses and allow you to make more informed choices and be confident about what to expect when using your cover. Further information can be found in our Important Information flyer and our Fund Rules which are available from our Bupa centres, online or by calling us. 6