Extras Plus Effective 1 October 2014

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1 Mail: Locked Bag 25, Wollongong NSW Phone: Fax: Web: Extras Plus Effective 1 October 2014 Benefit Summary Note: Annual limits are per person unless specified otherwise. Please keep in mind that each service has a limit and waiting periods may apply. Extras Plus Cover General Dental Service Benefit Annual Limit General Dental Crowns & Bridgework Dentures Implants Set benefits apply to each dental item number. Please contact the fund prior to treatment for details No annual limit $1,000 ($1,500 LB) $650 ($800 LB) $1,000 Orthodontic Treatment 80% of the cost $2,100 ($2,600 LB) lifetime limits apply Optical Pharmaceutical Physiotherapy & Other Therapies Complementary Therapies Glasses / Frames Contact lenses Laser Eye Surgery Prescriptions Physiotherapy Occupational Therapy 100% of cost $ % of balance in excess of PBS amount ($36.90 as at 1/1/2014) Max $65 per script - Initial Consultation - Subsequent consultations Subsequent consultations 11+ Initial Consultation Consultations 2+ $500 per eye every 2 years $40 $30 $20 $60 $35 $500 per person/$1,000 per family $550 per person/$1100 per family Hydrotherapy 80% of the cost up to $15 $200 per person/$400 per family Overall Physiotherapy and Other Therapy limits Chiropractic Acupuncture Osteopathic Podiatry Natural Therapy Remedial Massage Dietetic - Initial Consultation - Subsequent consultations Subsequent consultations 11+ $40 $30 $20 $550 per person/$1,100 per family $435 per person/ $870 per family Chiropractic X Rays 80% of the cost $115 per person/$230 per family Orthotics Overall Complementary Therapies Limit 80% of the cost $250 per person/$500 per family (every 2 years) $750 per person/ $1500 per family Page 1 of 9

2 Additional Benefits Service Benefit Annual Limit Ante/Post Natal Physiotherapy Home Nursing 80% of the cost $150 80% of the cost up to $45 per visit or $90 per day $1,000 Speech Therapy 80% of the cost $800 Hearing Aids 80% of the cost $1,500 (every 5 years) Psychology 80% up to $120 (initial assessment) 80% up to $75 (subsequent consultation) $500 per person/$650 per family Allergy Treatment 80% of the cost $100 Surgical Equipment / Health Aids Health Management Programs Travel Expenses Year 1 Year 2 Year 3 Year 4 Year 5+ 50% of the cost 50% of the cost 60% of the cost 70% of the cost 80% of the cost 100% of the cost $400 $625 $750 $875 $1,000 $150 per single cover $300 per family cover Up to $100 per single cover and $200 per family cover Ambulance (Nationwide, all services) 100% of cost No annual limit Please Note: 1. Financial year is 1 July to 30 June and waiting periods may apply 2. Loyalty Bonus applies after 5 years continuous cover on Extras Plus cover 3. No benefits are payable by the fund when: A contributor is given treatment without charge The services received are not recognised by the fund and are not provided by providers registered with the fund The service is provided outside of the Commonwealth of Australia An entitlement exists or may exist under any compensation, third party or sports club cover A claim for a service is submitted more than 24 months after the date of service A claim is submitted for optical appliances where sight correction is not required The claim benefit is less than $5, although this can be accumulated with other claims Services are provided by family members, relatives, business associates or yourself The claim is for goods or services that are deemed to be primarily for the purposes of sport, recreation or entertainment. General Dental Cover 1. Benefits are payable for General Dental services and procedures such as Diagnostic, Preventative, Extractions, Oral Surgery, Restorations and Endodontics 2. Excludes High Cost Dental: Dentures, Orthodontic, Implants, Crowns and Bridgework (see High Cost Dental Cover) 3. Fixed benefits apply per item/ type of service. Please contact the fund for more details before commencing treatment. There is no annual limit for General Dental Services 4. A 2 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but Contributors transferring from another fund that have lower General Dental limits than onemedifund must wait 2 months before they can claim more than the former funds General Dental limits. Page 2 of 9

3 High Cost Dental Cover 1. Set benefits are payable for each category listed in the table above. Please contact the fund for more details before commencing treatment 2. Annual per person limit applies each financial year (1 July to 30 June) except Orthodontic where a Lifetime Limit applies 3. A 12 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but: Contributors transferring from another fund that have used all or part of their annual High Cost Dental limit with this other fund will only receive the difference between the onemedifund limit and the amount already claimed from the other fund in the first financial year of cover, and Contributors transferring from another fund that have lower High Cost Dental limits than onemedifund must wait 12 months before they can claim more than the former funds High Cost Dental limits. Orthodontic Cover 1. Where you pay for the cost of the orthodontic treatment in full at the treatment commencement, we will pay 80% of the cost to a maximum of your lifetime limit 2. Where you elect to pay the cost of the orthodontic treatment in instalments, we will pay 80% of the cost of each account/ receipt until the maximum lifetime limit has been claimed 3. Please check with the fund prior to committing to the cost of the orthodontic treatment for information about your lifetime limit and other requirements 4. You will need to submit some documentation to make a claim for orthodontic treatment. The fund requires an account/ receipt from the orthodontist, confirmation in writing that the orthodontic appliance has been fitted, a treatment plan from the orthodontist and a signed onemedifund claim form 5. Lifetime limit applies per person, not per family 6. A 12 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but: Contributors transferring from another fund that have used all or part of their Orthodontic lifetime limit with this other fund/s will only receive the difference between the onemedifund lifetime limit and amount already claimed from the other fund, and Contributors transferring from another fund that have a lower Orthodontic lifetime limit than onemedifund must wait 12 months before they can claim more than the former funds Orthodontic lifetime limit. Optical Cover 1. Benefits are payable only on glasses or contact lenses prescribed by a registered optometrist or ophthalmic surgeon, where sight correction is necessary 2. A 6 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but: Contributors transferring from another fund that have used all or part of their annual Optical limit with this other fund will only receive the difference between the onemedifund limit and the amount already claimed from the other fund in the first financial year of cover, and Contributors transferring from another fund that have a lower Optical limit than onemedifund must wait 6 months before they can claim more than the former funds Optical limit. Pharmaceutical Cover 1. Benefits payable only on non Pharmaceutical Benefits Scheme (PBS) prescriptions. No benefits payable on PBS prescriptions or items normally available over the counter. The PBS amount changes on 1 January every year and is $36.90 as at 1/1/ A 2 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but Contributors transferring from another fund that have a lower Pharmaceutical limit than onemedifund must wait 2 months before they can claim more than the former funds Pharmaceutical limit. Page 3 of 9

4 Ambulance Cover What we will cover % reimbursement of the cost of service, irrespective of distance travelled within the Commonwealth of Australia 2. There is no annual claim limit on ambulance services and there is no waiting period What We Will Not Pay For 1. Ambulance subscription or state based ambulance levies 2. Ambulance costs that are covered under government legislation or other compensable sources 3. Ambulance services that are not medically necessary Complementary Therapy Cover 1. Benefits payable only on fund recognised services and where the provider is recognised by the fund 2. A 2 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but Contributors transferring from another fund that have a lower Complementary Therapy limit than onemedifund must wait 2 months before they can claim more than the former funds Complementary Therapy limit. Surgical Equipment / Health Aids Cover 1. For items such as glucometer, blood pressure monitor, nebuliser and other approved health aids 2. Please contact the fund for individual benefit item limits and rules before you purchase these items. Travel Expenses 1. Benefits payable only on travel greater than 400kms (round trip) and for a hospital admission 2. A 2 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation). Health Management Programs 1. Benefits are paid for approved programs which aim to prevent or improve a specific health condition. Health screening services such as blood pressure testing, cholesterol checks, mammograms and hearing tests can be claimed with a written recommendation from your health professional. Please contact the fund for details. 2. Under the National Health Act, onemedifund cannot pay benefits for goods and services that are for the purposes of sport, recreation or entertainment, such as gym memberships or sports shoes. Waiting Periods Months 0 Ambulance Claim Category 0 Accidents requiring hospitalisation Transfers from other funds or parent s cover for equivalent level of cover and if currently financial with the 0 other fund 2 On commencement of the fund or upgrading your level of cover (apart from these noted below) 2 General Dental, Pharmaceutical, Physiotherapy and Complementary Therapies 6 Optical and Health Management Benefits 12 High-cost dentistry including crowns, bridgework, implants, orthodontics and dentures Pre-existing conditions Any ailment, illness, or condition that you had signs or symptoms of (in the opinion of a medical practitioner appointed by the health insurer) that existed during the 6 months prior to you commencing hospital cover or upgrading to a higher Hospital cover. It is not necessary that you or 12 your doctor knew what your condition was or that the condition had been diagnosed. A condition can still be classed as pre-existing even if you had not seen your doctor about it before commencing Hospital cover or upgrading to a higher Hospital cover. Note: This waiting period applies to Hospital cover only, and does not apply to Extras cover. 24 Laser eye surgery and hearing aids Page 4 of 9

5 Please note: If a person is transferring to onemedifund from another fund with an equivalent or higher level of cover, is financial and waiting periods from the previous fund have been served, waiting periods will be waived, but: 1. Contributors transferring from another fund that have used all or part of their annual limits with this other fund will only receive the difference between the onemedifund limit and the amount already claimed from the other fund in the first financial year of cover, and 2. Contributors transferring from another fund that have lower limits than onemedifund must serve the waiting periods listed above before they can claim more than the former funds limit 3. Contributors transferring from another fund will not be entitled to continuity for any Health Management benefits i.e. the normal 6 months waiting period must be served before any benefits are payable. Dependants Children are covered as dependants on a family cover to age: years, even if they are working full time or not, however they must not be married, or years if they are full time students and documentation is provided annually confirming this, however they must not be married. Once dependants cease to be covered under the family cover they are then entitled and strongly encouraged to take their own cover with us and continue to enjoy the exceptional benefits, competitive rates and first class service that we offer. Other Services Electronic "eftpos style" claiming using your onemedifund card is available at more than 21,000 dentists, physiotherapists, optical dispensers, chiropractors, osteopaths and podiatrists Australia wide. Privacy Statement onemedifund respects your privacy and is committed to keeping your personal information safe through compliance with the Privacy Act and the National Privacy Principles. We only collect information that is necessary to assist the fund in providing its services. We do not collect personal information unless we first ask the contributor or individual for it. onemedifund exercises great care to protect the personal information that is held. If you wish to obtain additional information regarding our Privacy Statement please contact the fund Privacy Officer on or us at Cooling off Period We are committed to ensuring that you choose the health cover that is right for you. If for any reason you decide that your choice was not suitable then we will provide a refund of your payment (provided no claims have been made). You will need to contact us within the first 30 days of commencement of the fund or changing your level of cover for this cooling off period to be available. Complaints If you have a complaint about onemedifund please contact the fund on and our staff will help to resolve your issue. Failing this, an escalation process is also available. Full details are included in our complaints resolution statement. If your complaint is not resolved you are entitled to seek the services of the Private Health Insurance Ombudsman (PHIO). PHIO provides free independent services to private health fund contributors. PHIO (www.phio.org.au) can be contacted on and they are located at Level 7, 362 Kent Street, SYDNEY, NSW Code of Conduct This Code was developed by Private Healthcare Australia (PHA) and HIRMAA (representing restricted and regional health funds). As well as promoting improved standards in clarity of information given to contributors, it aims to solve problems between contributors and onemedifund through internal dispute resolution. The Code also ensures that funds inform their members of their entitlement to seek assistance from an external dispute resolution body, such as the Private Health Insurance Ombudsman (PHIO). Page 5 of 9

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9 Please Note: This document should be read carefully and retained for future reference. For further information, please call or National Health Benefits Australia Pty Ltd (trading as onemedifund). A registered private health insurer. ABN Version 1.1 Page 9 of 9

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