MEMBERSHIP GUIDE. Working Visa Health Insurance. Effective 1 December Membership Guide 1

Transcription

1 MEMBERSHIP GUIDE Working Visa Health Insurance Effective 1 December 2014 Membership Guide 1

2 This guide applies to the following covers: Top 85 Working Visa Health Insurance, Working Visa Hospital and Medical Insurance, Working Visa Hospital Insurance and Working Visa Basic Insurance. * You should read this guide in conjunction with the Cover Summary that you would have received when you joined or changed your cover. If you did not receive, or no longer have, your Cover Summary please contact Medibank on or visit for more information. * Please note Working Visa Basic Insurance is only available to purchase through migration agents. 2 Membership Guide

3 Important information about your cover Medibank s Working Visa Health Insurance covers are designed for people who: do not hold permanent resident status in Australia; are visiting Australia for business purposes; are not eligible for full Medicare benefits (including Australians residing permanently overseas and most residents of Norfolk Island); and are not eligible for membership of Overseas Student Health Cover (OSHC). In addition, Medibank Working Visa Health Insurance may be suitable for people who want to supplement any entitlements they may have under Reciprocal Health Care Agreements (RHCA) which exist between Australia and a number of other countries. Working Visa and Health Insurance requirements Medibank Working Visa Health Insurance may only be purchased by people who are in Australia on certain working-type visas approved by The Department of Immigration and Border Protection and Medibank. This includes but is not limited to the following: It is your responsibility to inform Medibank immediately if you cease to comply with the above eligibility requirements. Please note that Medibank can request proof of your eligibility for Working Visa Health Insurance at any time. If you are found to be ineligible for Working Visa Health Insurance, Medibank may take steps including terminating your membership or transferring you to an alternative cover. Medibank may backdate this change and require you to pay any additional premiums and/or repay any higher benefits you received on your Working Visa Health Insurance cover. If you become a permanent Australian resident, or otherwise become entitled to full Medicare benefits, these covers may no longer be appropriate and you should contact us to discuss alternative health cover. If you are in Australia on a working-type visa but your visa sub class is not mentioned on page 3, you can call us on , ( if calling from outside Australia) or visit a Medibank store to find out if you are eligible for Working Visa Health Insurance. Visa sub class* Visa Type 401 Exchange 402 Training and Research 420 Entertainment 400 Temporary Business Short Stay 457 Temporary Business Long Stay 485 Temporary Graduate * Visa sub classes are subject to change by the Australian government from time to time. Membership Guide 3

4 What s Inside Your guide to Membership 6 Categories of membership 6 Policy holder and members 6 Responsibilities of the Policy holder 7 Managing the membership Policy holder and their partner 7 Your Membership 8 Adding a child to a single/couple membership 8 Adding a child to a family membership 8 Changes to existing memberships 8 Changes to the terms and conditions of your membership 8 Membership review (or cooling off ) period 9 Suspension of membership 9 Goods and Services Tax (GST) 9 Your membership card 9 Your Premiums 10 Premium payment options 10 Premium protection 11 Premium arrears 11 Premium refunds 11 General Information about your cover 12 Benefits for hospital treatment 12 Members Choice hospitals 12 Non Members Choice private hospitals 12 Surgically implanted prostheses and other items 12 Hospital benefit exclusions 13 General benefit restrictions 13 General benefit exclusions 14 Hospital excess 14 Benefits for in-hospital and out-of hospital medical services 15 Doctors admitting rights 15 Extras Services 15 Members Choice extras providers 15 Non Members Choice extras providers 15 Annual limits 15 Lifetime limit 15 Repatriation benefit 16 Top 85 Working Visa Health Insurance 16 Working Visa Hospital and Medical Insurance 16 Working Visa Hospital Insurance 17 Working Visa Basic Insurance 17 4 Membership Guide

5 What s Inside Ambulance Services 18 What is covered? 18 What is not covered? 18 Waiting Periods 19 Pre-existing conditions (PEC) 20 Obstetrics-related services waiting period 21 Accidents and associated waiting periods 21 Reduced and restricted benefit payments 22 Benefit replacement periods 22 Appliances requiring referrals 22 Benefits for prescription-only pharmaceuticals 23 Benefits for PBS Pharmaceuticals 23 Benefits for non PBS pharmaceuticals 24 How benefits are assessed 25 Hospital benefits: overnight stay patients 25 Same-day hospital benefits 25 Long stay hospital patients 25 Extras benefits 25 Making a claim 26 Paid accounts 26 Unpaid accounts 26 Hospital claims 26 Claims documentation 26 Time limit for submitting a claim 26 Other important information 27 Disclaimer 27 Transferring from another Australian registered health fund (portability) 27 Compensation and damages 28 Medibank Privacy Statement 28 Medibank Online medibank.com.au 29 Your feedback 30 Resolution of complaints 30 Private Health Insurance Code of Conduct 30 Private Patients Hospital Charter 30 Membership Guide 5

6 Your Guide to Membership This guide has been prepared to help you understand what it means to be a member of Medibank, and what your membership entitlements and responsibilities are. This guide must be read in conjunction with the Cover Summary that you would have received with this guide when you joined or changed cover. Medibank s main Fund Rules are available for you to read online at medibank.com.au and additional rules relating to your cover can be viewed at any Medibank store. The information contained in this guide is a summary of the Fund Rules and policies of Medibank as at the date of this guide. If you anticipate treatment for which you are expecting a benefit from Medibank, please contact us before commencing treatment to confirm your benefit entitlement. If you hold a cover that is not listed in this guide, please contact us for details of the services covered and benefit eligibility and conditions. Please read this guide carefully and keep it in a safe place together with your other Medibank documents. If you require further information about your entitlements or anything in this guide, please call us on , or visit one of our stores. All monetary values are expressed in Australian dollars (AUD). Any necessary correspondence will be sent to the most recently advised valid address (where consent has been provided), or to the most recently advised postal address, of the relevant Member. Please ensure that you always notify us: of any change to your and postal address as this will help prevent correspondence from going astray if you become eligible for full Medicare benefits so that we can assist you to arrange more suitable health cover you must inform Medibank immediately if you cease to comply with the eligibility requirements. Categories of membership Medibank offers the following categories of membership: single membership, which covers one person only couple membership, which covers you (the Policy holder) and your partner family membership, which covers you and your partner and: any of your child dependants and/or any of your student dependants. Policy holder and members A Policy holder is a person aged 16 years or over, whose application for membership has been accepted by Medibank, and who is responsible for the membership. A partner is a person who lives with the Policy holder in a marital or de facto relationship and is covered by the Policy holder s membership. A child dependant is a person who is: a child of the Policy holder or their partner, and under the age of 21, and is neither married nor living in a de facto relationship. A student dependant is a person who is: a child of the Policy holder or their partner, and under the age of 25, and neither married nor living in a de facto relationship. In addition, a student dependant must be: registered with Medibank, and undertaking full-time secondary education or tertiary education in Australia in a course approved by Medibank. If a student dependant ceases to be a student, defers their study, or marries or enters a de facto relationship, Medibank must be notified as the student dependant may not be eligible to remain on the membership. 6 Membership Guide

7 Responsibilities of the Policy holder The Policy holder is responsible for the membership and must: ensure that all information supplied to Medibank is true and correct ensure that all members on the membership are aware of and abide by the Fund Rules, the information in this guide and the policies of Medibank including the Privacy Policy have the authority to provide the personal information of other members on the membership make, or authorise the making of, all claims under the policy and must ensure that any claim that includes sensitive information of a member aged 16 years and over, is made having first obtained the consent of that member authorise any health service provider to supply to Medibank any information Medibank considers necessary for the assessment of any claim on the membership, and will ensure that members aged 16 years and over have provided the relevant consent authorise Medibank to supply to any health service provider any information Medibank considers necessary for the assessment of any claim on the membership, and will ensure that members aged 16 years and over have provided the relevant consent make the minimum advance premium payments required. Managing the membership Policy holder and their partner The partner is able to assist the Policy holder in managing most aspects of the membership unless the Policy holder instructs Medibank otherwise. This includes: making claims adding or removing dependants changing cover suspending and reactivating the membership changing contact and bank account details changing payment methods requesting and receiving premium refunds. However, only the Policy holder can remove themselves from the membership or cancel the membership. It is important to be aware that this means Medibank may disclose registered membership details to both the Policy holder and their partner. Membership Guide 7

8 Your Membership Adding a child to a single/couple membership To add a dependent child to your membership you ll need to change from a single or couple membership to a family membership. If you do this within two months from the date of their birth or inclusion in your family unit (for example, through marriage, adoption or fostering) your child won t have to serve any waiting periods that have already been served by the Policy holder. The change will be backdated to the date of birth or the date of inclusion in your family unit. Also, this change of membership means you ll pay higher premiums. Adding a child to a family membership You can add a dependent child to your membership at any time. In the case of a newborn (ie. a child under the age of 12 months), cover can take retrospective effect from the child s date of birth, as long as a request to add the child is made within 12 months from the birth date and where the existing membership commenced no later than the child s date of birth. Where a child is added outside 12 months from the date of birth, cover commences from the date of application or any other future date nominated by the Policy Holder or other authorised person. In any case, if the family membership existed at the child s date of birth, the child will not be required to serve any waiting periods already served by the Policy Holder. Changes to existing memberships You may be asked to provide relevant details if you are: changing your cover changing certain details of your membership, for example, the people it covers. It is important that you provide us with the information requested, in particular, when you are changing an existing membership, please ensure that you provide details of all the people to be covered under that membership from that date. Changes to the terms and conditions of your membership Please note that all members of Medibank are subject to the Fund Rules, which set out the terms and conditions of their cover, as well as the services we pay benefits for. The Fund Rules can be changed from time to time with the approval of the Department of Health. If any changes will have a detrimental effect on your entitlement to benefits we will provide you with reasonable notice in writing before they are due to come into effect. Occasionally, Medibank may need to close a health insurance cover. If we need to close a cover that you are on, we may move you to another cover as similar as possible in price and/or benefits to your old cover. Before doing so, however, we will write to the Policy holder on your membership to explain what we intend to do. If you continue your membership under the new cover you will be bound by its terms and conditions. If you do not wish to continue under the new cover you have the option of changing to a different cover or cancelling your membership. 8 Membership Guide

9 Membership review (or cooling off ) period We understand that you may want time to review your membership once you have completed your application. To cater for this, Medibank gives you a review period of 30 days from the date your new or changed cover commences. If, during this period, you decide that you do not want the cover or you want to change it in any way, we will either refund your premium payment or transfer you to a more appropriate cover effective from the date your new or changed cover commenced provided you have not made a claim during the review period. If you choose to increase your level of cover from that date you will be required to pay any difference in premiums and you will be subject to waiting periods and other restrictions associated with the higher level of cover. Please note: during the membership review period, you may not return to a cover that Medibank has closed unless specifically permitted by us. Suspension of membership If you leave Australia, for example to return to your home country for a period of time, you may apply to Medibank to have your membership suspended. Before a membership can be suspended, premiums must be paid to a date at least two weeks in advance of the date the suspension is due to commence. Please note that: benefits are not payable for services provided or items purchased during a period of suspended membership the minimum period for which you can suspend your membership is two months ie. if you leave Australia for less than two months, you cannot suspend your membership you cannot suspend your membership for a combined total of more than four months in any 12-month period. Under Top 85 Working Visa Health Insurance annual limits for some extras services increase each 1 January where the membership has been continuous throughout the previous calendar year. Please note that you may not be entitled to any such increase where, in the previous calendar year, your membership was suspended for any period of time. Medibank can provide further information about the conditions under which you may suspend your membership. Goods and Services Tax (GST ) Working Visa Health Insurance is subject to a Goods and Services Tax (GST), which is included in the premium you pay. Under Medibank s Fund Rules, if you are covered by Working Visa Health Insurance it is assumed you have no entitlement to claim any part of the GST as an input tax credit. If you are eligible and intend to claim back part or all of the GST you must notify us in writing. Your membership card When you take out Working Visa Health Insurance we will send you a membership card that identifies you as a member. Use this card when you need to make a premium payment or a claim, arrange admission to hospital, visit an extras provider, or make any other type of enquiry. Please do not send us your card when making a claim by mail. A new card will be issued to you if you make any changes to your cover or to the people covered by the membership. You are responsible for any claims made using your card. Keep your card safe and advise us immediately if it is lost or stolen. Medibank will not accept liability for any loss to you resulting from the misuse of a lost or stolen card. You can visit our website at medibank.com.au to request a replacement card. Membership Guide 9

10 Your Premiums Premium payment options Medibank premiums must be paid in advance. A number of payment options are available to you: Direct debit Premiums are automatically deducted fortnightly, four-weekly, monthly, quarterly, half-yearly or yearly from your financial institution account or charged monthly to your credit card.* Please note: except for fortnightly and four-weekly payments, Medibank is unable to accept debits on the 29th, 30th or 31st of any month credit card deductions are made only on the 11th day of each month. Direct payment Premiums can be paid monthly, quarterly, half-yearly or yearly in advance. Payment can be made through any of the following options: By phone Call Australia Post on (from within Australia) to register and pay from any financial institution account or by credit card* 24 hours a day, 7 days a week. BPAY Contact your participating financial institution to make this payment direct from your savings, cheque or credit card* account. By mail Complete the payment advice on your Health Cover Account and mail it with your cheque or credit card* details to the address shown on the renewal notice. In person Pay at any branch of Australia Post with a Health Cover Account notice. Internet You may pay your premiums through medibank.com.au If you pay your premiums by direct payment, Medibank will send you a Health Cover Account to let you know when your next premium is due and the amount to be paid. Please provide this account when making payments and keep the top portion as your record of payment. * The only credit cards we accept are Visa and MasterCard. 10 Membership Guide

11 Premium protection Medibank premiums can change from time to time. If we change the premium for your cover, we will write to tell you what your new premium is at least 14 days before the change is due to take place. Where premiums for an existing membership have been accepted for a period in advance of the effective date of any increase, the date you have paid up to will not change and the new premium will apply from your next payment. However, if you make any changes to your level of cover or membership category or suspend or reactivate your membership during the protected period, the new premium will apply from the date of the change or the date you resume your membership. The date you have paid up to will then be adjusted accordingly. Premium protection does not protect you against any other changes made to the terms and conditions of your membership (see page 8). Premium arrears Benefits are not payable for services provided or items purchased whilst the membership is in arrears. Upon payment of the outstanding arrears, benefits may be considered in respect of those claims. If your premiums are in arrears you will be sent a reminder notice. If your premiums remain in arrears for more than two consecutive months, your cover will lapse and your membership will be closed. If this occurs, we will notify you in writing. You can bring your membership up to date provided that it is not more than two months in arrears. You are responsible for ensuring that your premium payments are up to date. Premium refunds If you close your membership before you arrive in Australia, you may apply for a refund of premiums paid in advance. To obtain a refund, you must apply in writing to Medibank and provide documentary proof of your circumstances eg. a letter from an Australian Embassy advising that your visa to Australia has not been approved, or a receipt for the cancellation of your airfare to Australia. Medibank will apply an administration fee for each application, and refund all remaining monies. If you have already arrived in Australia and wish to close your membership, your refund will be calculated from the date you apply to have your membership closed. An administration fee will also apply in these instances unless application is made within the membership review period (see page 9). Membership Guide 11

12 General Information about your Cover Working Visa Health Insurance helps pay for your medical bills, and your expenses in all public and private hospitals throughout Australia. Benefits for hospital treatment Benefits are payable towards hospital charges for podiatric surgery (performed by an accredited podiatrist) and dental procedures. Limited benefits apply when these procedures are performed in a non Members Choice private hospital (For more information on the benefits payable at Members Choice and Non-Members Choice Hospitals please see below) Note: Not all services are available at all hospitals. Please check with your hospital prior to admission. After Medibank has paid you any benefits, you are responsible for paying any amounts remaining on the hospital or medical accounts. You should confirm all likely out-of-pocket expenses with your doctor and/or hospital before your admission. Your membership card will show the level of cover you hold at the date of issue of the card. Members Choice hospitals Members Choice hospitals are private hospitals with which Medibank has negotiated special agreements for the cost of accommodation, theatre and treatment provided and charged by the hospital. Under these agreements, the hospital is granted Members Choice status. By visiting a Members Choice private hospital, you ll get better value for money compared to a non Members Choice hospital as long as the service you receive is covered by our agreements. A full list of Members Choice hospitals may be obtained by visiting one of our stores, calling us on or visiting our website at medibank.com.au Non Members Choice private hospitals Members receiving hospital treatment in a non Members Choice private hospital are entitled to a range of benefits as determined by Medibank from time to time. These benefits are generally lower than those payable for treatment in a Members Choice hospital and, depending on the charges raised by the hospital, could result in significant out-of-pocket expenses for members. Surgically implanted prostheses and other items The Federal Government publishes a prostheses schedule that sets out the minimum benefits health funds must pay to members with hospital cover for these items. If you are going to be admitted to hospital for a procedure in which a prosthesis is to be surgically implanted or applied, we recommend that, before admission, you ask your doctor to provide you with an estimate for the cost of the prosthesis they will be using for your procedure. Once you know how much the prosthesis will cost, you should then provide your doctor with Informed Financial Consent and it is preferable that this is in writing. You can obtain an Informed Financial Consent form from your doctor. You will need to speak with us, your doctor and your hospital to confirm what your likely out-of-pocket expenses are going to be. Benefits are not payable for any prosthesis or other item associated with an excluded service under your cover. If your cover includes an excess (see page 13), the excess will not apply to the benefit payable for a prosthesis. 12 Membership Guide

13 Hospital benefit exclusions The following benefits are not payable on any Working Visa Health Insurance covers : treatment arranged before coming to Australia cosmetic treatment pharmaceuticals prescribed for cosmetic purposes prostheses not on the Federal Government s Prostheses Schedule (see page 11) hospital charges for podiatric surgery performed by a non-accredited podiatrist the gap for surgically implanted prostheses and other items on the Federal Government s Prostheses Schedule. items such as newspapers, TV hire etc not covered by the Medibank agreement (if any) with the hospital charges for all other services not covered, or not fully covered, by the Medibank agreement (if any) with the hospital, or under the extras component of Top 85 Working Visa Health Insurance pharmaceuticals or other items which are not related to the reason for admission, or not covered by the Medibank agreement (if any) with the hospital or provided on discharge from the hospital charges by your doctor in excess of the Medibank benefit. Benefits may not be payable for: outpatient or accident and emergency department charges raised by a private hospital same day procedures determined by the Federal Government as not requiring hospitalisation where your doctor has not provided suitable certification that treatment is required as an admitted in-patient in hospital procedures not listed in the Medicare Benefits Schedule (see page 14). Please contact Medibank on or visit one of our stores for more details. General benefit restrictions In some situations, Medibank may refuse or reduce benefits such as where: we consider that one service forms part of another service the number of services performed or items provided exceeds a pre-determined number that are payable in a certain period or course of treatment a provider has charged for two or more consultations on the same day, except where it can be shown that two separate attendances took place, and that these attendances are clearly identifiable as separate consultations on the member s account the service is performed in stages and a separate benefit cannot be claimed for each stage a waiting period (including the PEC waiting period), or benefit replacement period applies the service has been incompletely or incorrectly itemised on the account or claim documentation the claim has been submitted more than two years after the date of service you have reached your annual limit or lifetime limit for the particular service or group of services benefits are payable, or cover is provided, by another party the treatment is rendered by a provider to their partner, dependant, business partner or business partner s partner or dependant. Please also see the section on hospital benefit exclusions. Membership Guide 13

14 General benefit exclusions Medibank does not pay benefits: for claims for services rendered while premiums are in arrears or the membership is suspended for claims for medical appliances, prescription-only pharmaceuticals and other items purchased outside Australia including those purchased by mail order or over the Internet direct from a supplier outside Australia for claims for services where an entitlement exists, or may exist, to compensation or damages (see page 28) for treatment from providers who are not recognised by Medibank for the purpose of paying benefits. Should you wish to check if a provider is recognised by Medibank, please call or visit one of our stores for oral contraceptives for any subsidised pharmaceuticals that you receive under the Pharmaceutical Benefits Scheme (if you are eligible) for some other pharmaceuticals (see pages 22 24) for treatment not considered medically necessary (eg. health screening services as required for employment or visa renewal purposes) where the claim form or application form contains false or inaccurate information for extras services provided at a public hospital or publicly funded facility where the service is provided in an aged care service. Hospital excess An excess is an amount you must contribute towards your hospital treatment and is deducted from the benefits we pay when you make a hospital claim. Top 85 Working Visa Health Insurance has an optional excess of $300 per person per calendar year. Working Visa Hospital and Medical Insurance and Working Visa Hospital Insurance has an excess of $300 per person per calendar year. Working Visa Basic Insurance has $nil excess per person per calendar year. The excess does not apply to benefits for surgically implanted prostheses and other items included on the Federal Government s Prostheses Schedule, medical treatment or ambulance services. The excess will apply only where the Policy holder or partner is hospitalised. It will not apply to hospital treatment involving child dependants or student dependants. The excess applies per member per calendar year. After Medibank has paid the benefit to which you are entitled, you are responsible for paying any amounts remaining on hospital accounts. You should confirm all likely out-of-pocket expenses with your doctor and/or hospital before your admission. 14 Membership Guide

15 Benefits for in-hospital and out-of-hospital medical services Where a benefit is payable, cover is provided, subject to any exclusions applicable to your cover, for all medical services listed in the Medicare Benefits Schedule (MBS) but only when the services have been provided by a medical practitioner. The MBS is a Federal Government schedule that lists all the services for which Medicare benefits are payable and the rules that apply to the payment of those benefits. Your doctor or surgeon will be able to advise you of the MBS item number(s) for any proposed treatment. Benefits are generally not payable for a professional service for which a Medicare benefit is, or may be, payable; or for a service not listed in the MBS. You will have to pay any additional cost if the doctor charges more than the benefits we pay you. Under Top 85 Working Visa Health Insurance, Working Visa Hospital Insurance, Working Visa Hospital and Medical Insurance, and Working Visa Basic Insurance benefits are payable for CPAP-type devices or similar devices approved by Medibank when: you have undergone an overnight investigation for sleep apnoea for which a Medicare benefit would normally be payable for Australian residents; and the device is requested by a medical practitioner; and the device is purchased or hired within 12 months of undergoing the investigation. Doctors admitting rights Not all doctors have rights to treat admitted patients in all hospitals. Your doctor will be able to tell you to which hospitals they have admitting rights. Extras Services Members Choice extras providers Medibank has negotiated agreements with a number of extras providers i.e. dentists, dental prosthetists, optical retail outlets, physiotherapists, chiropractors, podiatrists, naturopaths, acupuncturists and remedial massage therapists to help minimise out-of-pocket expenses for our members. For details of Members Choice providers call us on or visit our website at medibank.com.au Non Members Choice extras providers Subject to any applicable rules and conditions (such as annual limits), benefits are payable at rates determined by Medibank from time to time for approved services and items. Please contact us on if you require further information on these benefits. Annual limits An annual limit is the maximum amount of benefits that can be claimed for a particular extras service or group of extras services within a specified period (usually a calendar year, 1 January to 31 December). Once the annual limit applicable to the extras service has been reached, no further benefits are payable for that service for that person (or membership where applicable) within that calendar year or other applicable period. Please refer to your Cover Summary (sent to you at your time of joining) for details about the annual limits that apply to your cover. The benefit we pay for a particular claim may be less than the annual limit and less than your provider s charge. This means you may have out-of-pocket expenses. Lifetime limit A lifetime limit is the maximum cumulative benefit we pay over your lifetime towards a service or group of services. *Working Visa Basic Insurance has a maximum repatriation benefit of $10,000 for mortal remains and $100,000 if you are sick or injured and suffering a substantial life-altering disability, or a serious medical condition, as determined by Medibank Membership Guide 15

16 Repatriation benefit Under Working Visa Health Insurance covers,* Medibank may arrange, and pay the reasonable cost of repatriating: a sick or injured member who is suffering a substantial life-altering disability, or a serious medical condition, as determined by Medibank the mortal remains of a deceased member, where it is legally permissible to do so. The provision of any repatriation benefit is at the discretion of Medibank. A waiting period applies to the provision of the repatriation benefit. This will be the waiting period appropriate to the medical condition that determines the need for repatriation. This benefit is payable only once per person per lifetime. Contact Medibank for further information on the payment of repatriation benefits. Top 85 Working Visa Health Insurance Benefits for in-hospital and out-of-hospital medical services Top 85 Working Visa Health Insurance, provides benefits for treatment from medical practitioners (including specialists), either in or out of hospital. Under Top 85 Working Visa Health Insurance when you receive medical treatment from a medical practitioner, either in or out of hospital, the Medibank benefit will be at least equivalent to the MBS fee. Extras Services Top 85 Working Visa Health Insurance includes benefits for a range of extras services and items such as dental, physiotherapy, chiropractic treatment and prescription lenses. These are known as ancillary services or extras. Please refer to the Cover Summary sent to you at the time of joining. Benefits for treatment provided by recognised extras providers are generally payable per item or service, and are subject to annual limits, waiting periods (pages 18 20), reduced and restricted benefit payments (pages 13 and 21) and other fund and assessing rules. A single consultation or charge may involve a number of items, to which the above conditions may apply. For further details about how benefits are assessed, please see page 24. Benefits for prescription-only pharmaceuticals, PBS Pharmaceuticals and non PBS pharmaceuticals For more information on the benefits payable for prescription only pharmaceuticals, PBS Pharmaceuticals and non-pbs pharmaceuticals please refer to pages Working Visa Hospital and Medical Insurance Benefits for in-hospital and out-of-hospital medical services Working Visa Hospital and Medical Insurance provide benefits for treatment from medical practitioners (including specialists), either in or out of hospital Under Working Visa Hospital and Medical Insurance, when you receive medical treatment from a medical practitioner, either in or out of hospital, the Medibank benefit will be at least equivalent to the MBS fee. Extras Services We do not pay benefits for extras services provided under Working Visa Hospital and Medical Insurance If you wish to be covered for these expenses, you should consider taking out Top 85 Working Visa Health Insurance from us. Benefits for prescription-only pharmaceuticals, PBS Pharmaceuticals and non PBS pharmaceuticals For more information on the benefits payable for prescription only pharmaceuticals, PBS Pharmaceuticals and non-pbs pharmaceuticals please refer to pages Membership Guide

17 Working Visa Hospital Insurance Benefits for in-hospital and out-of-hospital medical services Working Visa Hospital Insurance only provides benefits for treatment from medical practitioners (including specialists) provided whilst you are an admitted patient in a hospital. It does not provide benefits towards out-of-hospital medical claims (eg. visits to a doctor or outpatient treatment in a public hospital accident and emergency department). Under Working Visa Hospital Insurance, when you receive medical treatment whilst you are an admitted patient in a hospital, the Medibank benefit will be at least equivalent to the MBS fee. Extras Services Please note: we do not pay benefits for extras services provided under Working Visa Hospital Insurance. If you wish to be covered for these expenses, you should consider taking out Top 85 Working Visa Health Insurance from us. Benefits for prescription-only pharmaceuticals, PBS Pharmaceuticals and non PBS pharmaceuticals For more information on the benefits payable for prescription only pharmaceuticals, PBS Pharmaceuticals and non-pbs pharmaceuticals please refer to pages Working Visa Basic Insurance Benefits for in-hospital and out-of-hospital medical services Working Visa Basic Insurance provides benefits towards in and out of hospital medical claims (where treatment is provided by medical practitioners, including specialists), with the exception of outpatient obstetrics related services and psychiatric services. Working Visa Basic insurance doesn t cover you for fertility treatment including IVF and GIFT (In Vitro Fertilisation and Gamete Intra-Fallopian Transfer), bone marrow transplants or organ transplants. Extras Services Please note: we do not pay benefits for extras services provided under Working Visa Basic Insurance. If you wish to be covered for these expenses, you should consider taking out Top 85 Working Visa Health Insurance from us. Benefits for prescription-only pharmaceuticals, PBS Pharmaceuticals and non PBS pharmaceuticals For more information on the benefits payable for prescription only pharmaceuticals, PBS Pharmaceuticals and non-pbs pharmaceuticals please refer to pages Membership Guide 17

18 Ambulance services What is covered? Where you need an ambulance and your medical condition means you can t be transported any other way, you ll be covered for services provided by an ambulance provider approved by Medibank, in the following circumstances: ambulance transportation to a hospital or other approved facility to receive immediate professional attention when an ambulance is called to provide immediate professional attention but transport by ambulance is not needed when, as an admitted patient, the hospital requires you to be transferred from one hospital to another (excluding transfers between public hospitals) transport by air ambulance, where pre-approval has been obtained from Medibank by the air ambulance provider. What is not covered? We don t pay benefits for any ambulance service that is not included under What is covered? This includes: ambulance services where immediate professional attention is not required (e.g. general patient transportation) any ambulance transport required after discharge from hospital (e.g. hospital to home) inter-hospital transfers when you re transferred from one public hospital to another public hospital as an admitted patient any ambulance costs that are fully covered by a third party arrangement, such as an ambulance subscription or federal/state/ territory ambulance transportation scheme, WorkCover or the Transport Accident Commission any air ambulance services that are fully subsidised, such as South Care or NRMA Care Flight. For more information call us on Membership Guide

19 Waiting periods A waiting period is a period of time you must serve as a member of a cover before benefits are payable. Benefits are not payable for goods and services obtained while you are serving a waiting period. Waiting periods apply to: new members joining and ex-members re-joining Medibank members who increase their level of cover. During waiting periods, members who change their cover are entitled to benefits under their new cover or benefits under their old cover (as long as the waiting period has been served), whichever are lower members who transfer from another fund. These members will be covered for services on their new cover from the date they join if those services were also included on their cover with their former fund and they ve already served the applicable waiting periods see page 26 Transferring from another Australian registered health fund (portability). The waiting periods for the covers included in this guide are listed below: 2 months psychiatric, rehabilitation and palliative care regardless of whether or not the condition is pre-existing all extras services including ambulance services (as defined under What is covered? section on page 17) except as specified below 6 months optical items (frames, prescription lenses and contact lenses) 12 months pre-existing conditions (PEC: see page 19 for a full explanation of the PEC waiting period) obstetrics-related services (see page 20 for a full explanation of this waiting period) major dental services (major restorative fillings; periodontics; dentures, crowns, bridges and other prosthodontic services) orthodontic (eg. braces and corrective plates) endodontic services (eg. root canal treatment) dental surgical procedures and surgical extractions (eg. extraction of wisdom teeth) breathing appliances nebulisers peak flow meters spacing devices 24 months blood glucose monitors blood pressure monitors 36 months hearing aids Membership Guide 19

20 Pre-existing conditions (PEC ) It is standard practice in the private health insurance industry to apply a waiting period of 12 months before benefits are payable for pre-existing conditions. The 12-month PEC waiting period does not apply to hospital treatment involving psychiatric care, rehabilitation or palliative care. Medibank may refuse benefits or reduce them to the previous level of cover for any claim made in the first 12 months of membership of any cover where, in the opinion of a medical practitioner appointed by Medibank, signs or symptoms of an ailment, illness or condition related to that claim were in existence at any time during the six months before the commencement of that cover. Please note: if you are coming to Australia specifically for medical treatment, this waiting period will apply to treatment you receive in the first 12 months of your cover and Medibank will not pay any benefits during this period. This waiting period still applies even if your ailment, illness or condition was not diagnosed prior to the date of commencing membership or changing cover. Medibank reserves the right to apply, or not to apply, the PEC waiting period to individual claims. This means we can refuse or reduce benefits on later claims even if the PEC waiting period has not been applied to any earlier claims for that ailment, illness or condition. In arriving at a decision, Medibank will consider medical evidence provided by your health care providers. We will request your consent to obtain such evidence in confidence and you will need to authorise its release if you wish us to give further consideration to your claim. Medibank will not pay for the provision of this information. Medibank will apply the PEC waiting period if: you do not authorise the release of medical or paramedical evidence relating to your claim; or following your authorisation, your provider does not release that evidence. If you have less than 12 months continuous membership on your current hospital cover, make sure you contact us on or visit one of our stores before you are admitted to hospital to find out whether the PEC waiting period applies to you. We need up to five working days to make the PEC assessment, subject to the timely receipt of information from your treating providers. Make sure you allow for this timeframe when you agree to a hospital admission date. 20 Membership Guide

21 If you proceed with the admission without confirming your benefit entitlements, and Medibank subsequently determines your condition to be pre-existing, you will be required to pay all outstanding hospital and medical charges relating to that admission. In an emergency, we may not have time to determine if you are affected by the PEC waiting period before your admission. Consequently, if: you have served less than 12 months membership on your current hospital cover, and you are admitted to hospital as a private patient, and we later determine that the condition for which you received hospital treatment was pre-existing, you will have to pay for some or all of the hospital and medical charges remaining after any benefits are paid. Medibank reserves the right to also apply the PEC waiting period to extras services. Before doing so we will seek the advice of an appropriate practitioner in determining whether signs or symptoms were in existence six months prior to the cover commencing. Obstetrics-related services waiting period The term obstetrics-related services means those services listed as obstetrics services in the Medicare Benefits Schedule. These services include hospitalisation for antenatal care, management of labour and delivery, and for complications arising from pregnancy, such as a threatened miscarriage. The obstetrics-related services waiting period applies to all obstetrics-related services for a period of 12 months from the date of joining or changing to a relevant cover, and it applies whether or not the member was pregnant at that time. Accidents and associated waiting periods An accident is an unforeseen event, occurring by chance and caused by an external force or object, resulting in involuntary injury to the body requiring immediate treatment. It does not include any unforeseen conditions, the onset of which is due to medical causes. A condition means any actual or perceived state of health for which treatment is sought. It includes but is not limited to states variously described as: abnormality, ailment, disability, disease, disorder, health problem, illness, impairment, impediment, infirmity, injury, malady, sickness or unwellness. The two-month waiting period is waived for claims resulting from an accident occurring during that period. You will have immediate coverage unless: the resulting treatment is an excluded service all other waiting periods apply (eg. the 12 month waiting period for major dental services would still apply for treatment required as a result of an accident). Membership Guide 21

22 Reduced and restricted benefit payments Benefit replacement periods A benefit replacement period applies to certain items. This means that, once you have been paid a benefit for a particular item, you must wait for a certain period of time from the date of the purchase of the item before you are entitled to a benefit for the replacement of that item. Benefit replacement periods apply per person except where otherwise stated. The following benefit replacement periods will apply: 12 months external mammary prostheses repairs of external prostheses and health appliances 2 years wigs hip protectors insulin delivery pens 3 years blood glucose monitors blood pressure monitors breathing appliances nebulisers peak flow meters spacing devices mouthguards (a benefit may be payable for a replacement mouthguard each calendar year for members up to 18 years of age) dentures, crowns and bridges other health appliances and external prostheses (except as specified below) 5 years hearing aids A five-year benefit replacement period applies to Continuous Positive Airways Pressure (CPAP) and other similar approved appliances under all our Working Visa Health Insurance covers. Appliances requiring referrals Where provided under your cover, benefits are payable for the items listed below only where a medical practitioner (or other practitioner as indicated) requests them in writing. blood glucose monitors blood pressure monitors breathing appliances nebulisers peak flow meters spacing devices orthotic appliances for shoes (can also be ordered by podiatrists, physiotherapists and chiropractors) wigs pressure therapy garments (can also be ordered by physiotherapists) pressure stockings braces, splints and orthoses (can also be ordered by orthotists, physiotherapists, occupational therapists or podiatrists) custom-made footwear (can also be ordered by podiatrists or physiotherapists) modifications to footwear (can also be ordered by podiatrists) unspecified external prostheses and health appliances hip protectors insulin delivery pens. 22 Membership Guide

23 Benefits for prescription-only pharmaceuticals Prescription-only pharmaceuticals are those items that are required by law to be prescribed by a medical practitioner, dental practitioner or pharmacist. International visitors to Australia are generally not eligible for subsidised pharmaceuticals under the Pharmaceutical Benefits Scheme (PBS). For prescription-only pharmaceuticals, we will provide the following benefits: PBS listed drugs prescribed according to the PBS approved indications that are administered during and form part of your admitted episode of care (including drugs prescribed upon discharge). Top 85 Working Visa Health Insurance c Benefits payable. See Benefits for PBS pharmaceuticals. Working Visa Hospital and Medical Insurance, Working Visa Hospital Insurance and Working Visa Basic Insurance c Benefits payable. See Benefits for PBS pharmaceuticals. Non PBS pharmaceuticals supplied in or out of hospital by a registered pharmacist, medical practitioner or dentist. c Benefits payable. See Benefits for non PBS pharmaceuticals on page 23. b No benefits payable. See Benefits for non PBS pharmaceuticals on page 23. Oral contraceptives or pharmaceuticals prescribed for cosmetic purposes. b No benefits payable. b No benefits payable. Benefits for PBS Pharmaceuticals Working Visa Health Insurance provides benefits towards all PBS listed drugs that are prescribed according to the PBS approved indications, that are administered during and form part of your admitted episode of care (including drugs prescribed upon discharge). For these pharmaceuticals, you must pay: an amount equivalent to the current non-concessional PBS co-payment; and any costs remaining after the Medibank benefit has been paid. The benefit we pay is equal to the PBS government subsidy (in excess of the non-concessional PBS co-payment amount). Please note: if high cost pharmaceuticals are required for your treatment when in hospital, you may incur significant out-ofpocket expenses. Membership Guide 23