CONTENTS. Welcome to Queensland Country Health Fund 4. Dependant children 10. Dependants to age Your membership card 6

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1 MEMBERSHIP GUIDE This guide should be read in conjunction with one or more of the following: Health Benefits Guide Smart Start Singles and Couples brochure Young Extras brochure

2 CONTENTS Welcome to Queensland Country Health Fund 4 Your membership card 6 Safeguard your membership card 6 Additional cards 6 Replacement cards 6 Online services 7 Registering is easy 7 Managing your membership 8 Membership year 8 Cooling off period 8 Policy types 8 Level of cover 9 Role of the policyholder 9 Dependant children 10 Dependants to age Student dependants up to age Apprentice dependants up to age Adult dependants up to Changing your cover 11 Change of membership details 11 Upgrading your cover 11 Downgrading your cover 12 Adding or removing a person from your membership 12 Adding a newborn baby 12 Transferring from another fund (Portability) 13 Delegated authority 9 [ 2 ]

3 Temporary suspension of membership 14 General conditions for suspension 14 Overseas travel 14 Medicare Levy Surcharge warning 15 Waiting periods 16 Benefit Limitation Periods 17 What waiting periods apply at Queensland Country Health Fund? 19 Pre-existing conditions 21 Restrictions and exclusions 22 Claiming your benefits 23 Excesses 29 Premium information 30 Government initiatives 32 Australian Government Rebate on private health insurance 32 Medicare Levy Surcharge 33 Lifetime Health Cover 34 Direct debit request service agreement 35 Privacy Policy 38 Queensland Country Health Fund rules 38 Compliments and complaints 39 Private Health Insurance Code of Conduct 40 Intermediary Remuneration 40 Contact us 42 [ 3 ]

4 Welcome TO QUEENSLAND COUNTRY HEALTH FUND This membership guide has been designed to help simplify private health insurance, and allow you to better understand your membership entitlements and responsibilities. This guide summarises Queensland Country Health Fund rules and policies and provides useful information about your membership card, online services, claiming, managing your membership, paying premiums, and much more. Please take some time to read this guide carefully, particularly the sections on waiting periods, including the pre-existing condition/ailment rule and hospital cover with restricted services and benefit exclusions applicable for Smart Start product. Please ensure that all documentation is read carefully before any decision is made to purchase a health insurance product and all the information is retained for future reference. Keep this guide in a safe place together with other Queensland Country Health Fund documents. If you anticipate undergoing any treatment for which you are expecting a benefit from Queensland Country Health Fund, we recommend you contact us before commencing treatment, to confirm your benefit entitlement. And remember, as with all forms of insurance, you should review your health cover from time to time to ensure you continue to have the cover that is best for you. The information in this membership guide is current as at 1 April 2014 and is subject to change. Thank you for choosing Queensland Country Health Fund! Thank you for choosing Queensland Country Health Fund! [ 4 ]

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6 YOUR MEMBERSHIP CARD Your membership card is important. It identifies you as a Member of Queensland Country Health Fund when you go to hospital or make an electronic claim at an allied health service provider (e.g. dentist, optometrist, etc) displaying the HICAPS or IBA Health logo. Your membership card shows your membership number, who is covered and the date you joined the health fund which is identified as your anniversary date. The importance of this date will be covered later in this guide. If you add or remove people covered by the membership, a new card will be issued. Safeguard your membership card Your membership card gives your health provider direct access to your benefits. Here are a few tips to help you safeguard your membership card: Treat your membership card like a credit card and keep it in your wallet or purse Advise us immediately if your card is lost or stolen Never leave your card with a health provider Always check the health provider s receipt carefully before signing Additional cards As the policyholder; you can request additional membership cards for those listed on your membership who are over 16 years of age and/or living at another address. Replacement cards If your membership card is damaged or has been misplaced you can order a replacement card. To do this, you can log on to Online Member Service (OMS) via our website and order a replacement card yourself, it s that easy! (if you are not already registered for OMS please refer to page 7 for details on how to register) or alternatively you can contact us on or and a replacement card will be arranged for you. [ 6 ]

7 ONLINE SERVICES The Queensland Country Health Fund website provides you with the convenience of managing your membership online, at a time that suits you. From the website you can access online services which allows you to: View your membership details View your cover details Update your address and contact details Change your level of cover Add dependants Lodge a claim for ancillary services (Extras) See Online claiming information in this Guide for further details. View your claims history View your remaining limits View your payment details Set up direct debit for the automatic payment of your premiums Set up direct credit for receiving your benefit payments Change your password Download your annual Private Health Insurance Tax Statement Make a contribution payment by credit card Order replacement membership cards Registering is easy To register for Online Member Service (OMS) go to To access OMS, all you need to do is register on the home page of our website The register icon is located at the top right hand corner of the screen. Once you have registered using your membership number and choice of password, click on the Login tab and enter your membership number and password. Now you re ready to go! [ 7 ]

8 MANAGING YOUR MEMBERSHIP Membership year Queensland Country Health Fund policies operate on a unique, individualised membership year. The original establishment date of your policy represents the start date of this membership year. This start date is referred to as the anniversary date of your membership. The anniversary date is printed on your membership card for your convenience. Membership claim benefit limits and sub limits are based on an ongoing 12 month cycle from the anniversary date of your membership. In order for you to maximise the benefits available on your chosen cover, it is important to understand when your membership year starts and finishes. An allocated benefit not claimed during any one membership year does not accrue to the next. The membership anniversary date, and proceeding membership year cycle is also the basis for the determination of payment of a Hospital excess (if applicable) when admitted to hospital for an inpatient service. (Refer page 27 of this Guide for further information on membership excess.) Please note: New person/s added to the policy after the original membership start date will have a different anniversary date applied for a period after joining in line with the waiting periods applicable to joining, transferring or upgrading their cover. After all applicable waiting periods have been served, the individuals anniversary date will synchronise with that of the membership they joined. We believe that using the anniversary date of joining our health fund is the most fair and appropriate basis for determining the annual benefits available to you under your chosen level of cover. Cooling off period If for any reason you change your mind within the first 30 days of commencement of your new policy or upgrade of cover, and you have not yet made a claim, simply contact us to cancel your policy and we will refund any premiums you have paid in relation to this cover. Policy types Queensland Country Health Fund offers policies which cover the following combinations of eligible persons: Single Membership: This consists of: cover for one (1) person only. Family Membership: a policy consisting of: 2 Adults (and no-one else) 2 or more people, none of whom is an adult [ 8 ]

9 2 or more people, only 1 of whom is an adult (Single Parent cover) 3 or more people, only 2 of whom is an adult 3 or more people, at least 3 of whom are adults (Family Plus cover is the only eligible option - refer to Adult Dependents up to 25 on page 10 Where special circumstances exist, for example where one person would like to pay for the membership of another person, please contact us for further details on the conditions for this type of arrangement. Level of cover A person may be admitted as a policyholder to the fund in one of the above categories in respect to one of the following covers: Any one level of hospital cover Any combination of one level of hospital cover and one level of Ancillary cover (Extras) Any combined product cover ie. Smart Start Young Singles/Couples combined hospital and extras cover, or Young Extras with no hospital cover Role of the policyholder The policyholder is responsible for the policy and all correspondence will be addressed to them. The policyholder also agrees to make the minimum advance premium payments required to keep the membership financial. Only the policyholder is able to add others to the policy. The policyholder is also responsible for communicating the details of this membership guide, together with the existence of health fund rules, to any current and future Members on the membership. Delegated authority The policyholder may delegate authority to a nominated adult person to: request policy details and other personal information change or update policy details, and submit claims. The authority generally takes the form of a written request to the Health Fund by the Member, or a person appointed as Attorney under a Power of Attorney or as Administrator appointed by an Order of the Queensland Civil and Administrative Tribunal (QCAT) or equivalent body if appointed outside Queensland (order must be registered by QCAT). All delegations of authority are to be provided in writing and signed by the person of authority. Requests received by will not be valid. Please note* Disclosure of personal information relating to claims for a dependant aged 16 years and over will only be made available to a parent or legal guardian if authorised in writing and signed by the dependant under a delegation of authority. [ 9 ]

10 DEPENDANT CHILDREN A dependant child means a legitimate child, an adopted child, a foster child, a stepchild, or an exnuptial child of the policyholder who has not attained the age of 21 years. Dependants up to age 21 Your dependant child can remain covered under your family policy up to age 21 years. The good news is that they can contact us and move straight across to their own single membership without having to serve any waiting periods, providing they have already been served on the family policy. The transfer must be arranged within 63 days of the termination date of the dependant child from the family policy. Student dependants up to age 25 If your dependant child is single and studying full-time at a school, college or university they can remain covered under your family policy up to age 25 years. To remain covered under your family policy their student status must be confirmed at the start of each school or study year. Student dependant status no longer applies when study ceases, defers or reduces to part-time or when the dependant child enters into a married or de facto relationship. Apprentice dependants up to age 25 If your dependant child is single and working or training as an apprentice and earn no more than $30,000 p.a they can remain covered under your family policy up to age 25 years. To remain covered under your family policy their apprentice status must be confirmed at the start of each training year. Apprentice dependant status no longer applies when training ceases, the income threshold is exceeded or when the dependant child enters into a married or de facto relationship. Adult dependants up to 25 If dependant children aged between 21 and 25 years wish to remain on your family policy (as long as they are not married or in a de facto relationship) our Family Plus* cover option will allow these eligible dependants to stay on your Family Plus policy up to the age of 25 years. *Family Plus cover option will be restricted to Private Hospital and Premium Extras or Essential Extras packaged covers only. It will not be available to family or single parent policies with any Hospital Only Product, Private Hospital and Young Extras Product, Smart Start Products or Public Hospital and Extras packaged covers. [ 10 ]

11 CHANGING YOUR COVER Change of membership details You are required to advise Queensland Country Health Fund of any change to your membership details. In general, changes can be managed by you online or you can notify us by phone, , fax or post. Typical changes and accepted methods of notification include but are not limited to: change of contact details change of name change of partner adding a new dependant changes to student/apprentice dependant status All of the above changes, can be notified by going online, by a phone call to us or in writing via post or fax. The following changes require a form to be completed: registering to receive the change to Australian Government rebate via reduced premiums registering to pay your premiums automatically through a nominated bank account or credit card via the direct debit system Upgrading your cover If you are upgrading your cover or transferring from another health fund you may need to serve waiting periods on the upgraded portion of your cover. Upgrading your cover includes: increasing the level of cover adding a new cover, and reducing or removing an excess* You will, however, be entitled to the benefits of your previous cover for the duration of any waiting period. *Note: When an existing membership has an excess of $250 or $500 and the decision is made by the policyholder to select a lower level of excess i.e. Nil or $250, then any in-patient hospitalisation will be subject to the following excess conditions: [ 11 ]

12 CHANGING YOUR COVER CONT. Within the first two (2) month period from the date of upgrade, the previous level of cover or excess will apply for in-patient hospitalisation. Within the first twelve (12) month period after upgrade, any hospitalisation resulting from a Pre-Existing Condition, previous level of cover or excess will apply. For accidental injury, cover or excess upgrades are immediate (excluding sporting and school accidents which are subject to a two (2) month waiting period) *Note: Payment of hospital excesses are based on a membership year as different funds have a different basis of calculation for this period, if you transfer or upgrade cover it is possible for an individual to pay two hospital excesses within the first 12 months of cover. This may be due to these hospital services falling under two separate identifiable Membership years due to the transfer or upgrade of cover. Downgrading your cover You may choose to downgrade your cover by: reducing the level of cover removing a current cover, or increasing or adding an excess. In these circumstances you will not serve additional waiting periods and the new excess will apply to in-patient hospital services immediately. However, waiting periods will apply should you subsequently upgrade at a later date. Adding or removing a person from your membership Let us know if you would like to add or remove a person from your membership. Any person being added to the membership may have to serve waiting periods for benefits, depending on their previous cover or health insurance history. We will ensure that you continue to have the best level of cover for your needs if changes are made to your policy. Adding a newborn baby To add a newborn baby to your policy you will need to do this within two months from the date of their birth. The child will not have to serve any waiting periods* that have already been served by the Policy holder providing that the change is made to the policy within this time frame. The policy alteration will be backdated to the child s date of birth. This change of membership means that you [ 12 ]

13 CHANGING YOUR COVER CONT. will have higher policy premiums if you currently have a single cover. No change in premium will occur for existing single parent or family covers. If a newborn is added to the policy later than two months after their date of birth, the child will have to serve all waiting periods applicable to their cover commencing from the date they are added to the policy. *For policy holders with no previous cover, pre-existing condition waiting periods may apply to the baby within the first 12 months of cover. Transferring from another fund (Portability) When transferring from another health fund you will not have to re-serve applicable waiting periods provided that: you join Queensland Country Health Fund within sixty-three (63) days of the date on which you ceased to be covered by another Australian registered health fund; and you have served the applicable waiting periods with that former health fund; and we have received your Transfer Certificate from that health fund showing previous level of cover. Benefits will not be paid by Queensland Country Health Fund for any services during the lapse period between the date you ceased cover with your former health fund and the date you join Queensland Country Health Fund. We are unable to backdate membership join date. If these conditions are satisfied then from the date of joining, you will be not have to serve the normal waiting periods when transferring to an equal or lower level of cover. However when additional benefits or better conditions are gained by an Inter-fund transfer, normal waiting periods will apply to the additional or upgraded benefits and conditions. In instances where you are transferring from another Australian registered health fund policy that did not provide any benefit entitlement for hospital treatments or services, you will be required to serve the applicable waiting periods for the hospital component of your cover with our Fund. Any loyalty bonus or other similar entitlements (for example increased limits for orthodontics or package bonuses) built up with your former health insurer will not transfer to Queensland Country Health Fund. Where limits apply, including lifetime limits, any benefits paid under your previous cover are treated as if Queensland Country Health Fund has paid them and this may affect the payment of benefits on items/services already claimed under your previous policy cover. If you transfer to Queensland Country Health Fund more than sixty-three (63) days after your previous cover has ceased, you will have to serve all waiting periods applicable to your new cover. [ 13 ]

14 TEMPORARY SUSPENSION OF MEMBERSHIP General conditions for suspension To suspend your cover you must make application to Queensland Country Health Fund, prior to the nominated suspension date. Applications for suspension will not be processed retrospectively. The period of suspension does not qualify for the purpose of completing Benefit Limitation Periods, or accumulative benefit entitlement. At the time of suspension, all waiting periods must have been served on your membership. Premiums must have been paid up to the date of suspension before a suspension can be considered. The total membership must be suspended. Benefits are not payable for treatment received during the period of suspension. For any condition, ailment and/or illness developed in the suspension period, Pre-Existing Condition waiting periods (e.g. 12 months hospital cover) will apply. To avoid additional waiting periods the membership must be reactivated within one month, of the relevant reason for suspension ceasing to apply, or the maximum period of suspension being reached. To avoid adding to the number of days in which you are without hospital cover which could, eventually impact on your premium, it is important that the membership be resumed and active from the date the reason for suspension ceased to apply, or the maximum suspension period was reached. (For further information on the effect which a period of absence from hospital cover may have on your premium refer to the section on Lifetime Health Cover.) Overseas travel If you re lucky enough to travel overseas, and you re going to be absent from Australia for a period of more than 4 weeks and less than 24 months, and provided you ve fulfilled all the above criteria, you may apply for a suspension on your membership. [ 14 ]

15 The health fund may agree to your request on the following basis: The suspension date will be the day after departure from Australia. The total membership must be suspended; all those covered by the membership (including dependants) must be travelling overseas. You will be required to apply in writing for re-instatement within one month of re-entry to Australia. Proof of your re-entry date must accompany this request for re-instatement. Proof of re-entry must be in the form of an International Movement Record covering the period of suspension from the original date of departure from Australia. This information can be obtained from the Department of Immigration on A Request for International Movement Records (Form 1359) can be accessed on the Department s website The re-instatement date will be the date of re-entry into Australia. If you are travelling for leisure you should consider taking out travel insurance. Medicare Levy Surcharge Warning With the suspension of your private health insurance policy, you may be liable for the Medicare levy surcharge if your taxable income exceeds the relevant threshold and you are still a resident for tax purposes during the time you are away. More information is available on the website of the Australian Taxation Office under the heading Medicare levy. A breach of any of the above conditions could result in the Membership Suspension Agreement being declared null and void. [ 15 ]

16 WAITING PERIODS What is a waiting period? A waiting period is an initial period of health fund membership which no benefit is payable for certain procedures or services. Waiting periods can also apply to any additional benefits when you change (upgrade) your health insurance cover. Why do waiting periods apply? If there were no waiting periods, people could take out cover or upgrade to a higher cover only when they knew they required treatment, or suspected they might require treatment. Their costs would then have to be paid by the long-term Members of the fund leading to much higher premiums for all fund Members. This would not be fair. Therefore, when you join a health fund or upgrade your existing cover you may have to wait a period of time before you can claim benefits. When do waiting periods apply? Waiting periods apply where a person: is insured for the first time or has not been insured within the previous two or more months. upgrades to a higher level of cover (includes reducing or removing an excess or co-payment). transfers from another fund and has not completed our waiting periods for equivalent benefits, or chooses to upgrade their cover when they transfer. Note: When upgrading to a higher level of cover you will be entitled to the benefits applicable to your previous cover for the duration of applicable waiting periods for treatments or services mutually eligible for benefits under both policies. [ 16 ]

17 BENEFIT LIMITATION PERIODS (BLP S) A Benefit Limitation Period is similar to a waiting period with a key difference. A BLP is an initial period of time during which only a minimum (restricted*) benefit is paid by us for certain hospital treatments or procedures, where as a waiting period is an initial period of health fund membership where no benefit is payable for certain services, when joining the fund with no previous health cover, or a lapse in cover in excess of 63 days. If a Benefit Limitation Period applies to a treatment or procedure benefit for these services is restricted to the minimum default benefit as determined by the Minister for Health. These default benefits are generally not adequate to cover private hospital costs, and will only fully cover shared ward costs in a public hospital. Undertaking treatment for the following hospital procedures during a Benefit Limitation Period, would result in large out of pocket expenses if undertaking treatment in a private facility: A benefit limitation period of two years (24 months) applies to bariatric surgery (weight loss surgery) including but not limited to gastric banding, gastric sleeving /diversion; and gastric bypass surgery; including replacement, repair or adjustments A benefit limitation period of two years (24 months) applies to Hip or Knee Joint Replacements Will Benefit Limitation Periods affect me? I M TRANSFERRING FROM ANOTHER HEALTH FUND BLP s do not apply to new Members transferring from another private health insurer or to existing members changing their level of hospital cover; providing they are transferring within 63 days of ceasing their previous cover. The balance of any waiting periods not fully served on transferring from your previous health cover are required to be served prior to entitlement to any benefits in a private or public hospital. [ 17 ]

18 BENEFIT LIMITATION PERIODS (BLP S) CONT. I M NEW TO PRIVATE HEALTH INSURANCE OR BEEN OUT OF IT FOR A WHILE! Benefit limitation periods however will apply to New Members new to private health cover and to Members rejoining after a lapse in private hospital cover in excess of 63 days. In these instances applicable hospital waiting periods will need to be firstly served, after which, the Benefit Limitation Period conditions will apply to the above hospital treatments for the remaining period, up to the first 24 months of membership with our Fund After the Benefit Limitation Period has elapsed, you would be entitled to full benefits for the condition or treatment applicable to your chosen level of hospital cover. Other hospital treatments or services covered by our Fund under your chosen level of cover will not be affected by the Benefit Limitation Period restrictions. * See restricted benefits information in Restrictions and Exclusions section in this Guide. [ 18 ]

19 WHAT WAITING PERIODS APPLY AT QUEENSLAND COUNTRY HEALTH FUND? Waiting periods that apply to Queensland Country Health cover are: 12 months for a pre-existing condition (excluding rehabilitation, psychiatric care and palliative care) # 12 months for obstetric (pregnancy) related services # 12 months for surgery for assisted fertility programs such as IVF or GIFT, sterilization or vasectomy, elective surgery # 12 months Cardiothoracic procedures - for example Open Heart Surgery # 12 months for Major Eye surgery - Cataract and eye lenses procedures # 12 months for Gastric Banding and Obesity Surgery # ^ 12 months for Renal dialysis - for chronic renal failure # 12 months for Hip and Knee Joint Replacement Surgery^ 12 months for Mechanical Appliances and Artificial Aids # 12 months for treatment under major dental categories including: Periodontics - specialised gum treatments # Surgical Extraction - includes wisdom tooth extraction Endodontic services - includes root canal therapy - # Crowns and Bridges Orthodontics - braces etc # Prosthodontics - Dentures # 12 months for the supply of hearing aids # 12 months for Childbirth Education # 12 months Health Evaluations # 2 months for all other dental treatments including: Diagnostic - includes examinations and consultations Preventative - includes cleaning and scaling, fluoride treatment etc Simple Extraction Restorative - composite and amalgam fillings General services - includes occlusal splints. [ 19 ]

20 WHAT WAITING PERIODS APPLY AT QUEENSLAND COUNTRY HEALTH FUND? CONT. 2 months for Optical services 2 months for Ancillary Therapies including: Acupuncture Audiology # Chiropractor Foot Orthoses and Orthopaedic Shoes # Massage Therapy/Bowen Therapy/Myotherapy Osteopathy Naturopathy # Dietician Occupational Therapy # Orthoptic Therapy # Physiotherapy Exercise Physiology # Podiatry Psychology # Speech Therapy # 2 months for Healthy Living Benefits 2 months for Pharmaceutical Benefits Cover for an accident is immediate provided it is not recoverable from another source such as Workers Compensation, third party or other liability provision. School accidents* are subject to a 2 month waiting period. # * An ailment, illness, condition or injury associated with a school accident incurred prior to joining the health fund will be subject to 12 months waiting period. # Not every health cover product provides benefits for these services/treatments, please check the appropriate Product brochure to determine benefit entitlement conditions for these services. ^ Under our Top Hospital cover range there are Benefit Limitation Periods for these services for up to the first 24 months after joining us after having no previous hospital cover or having a lapse in hospital cover for a period greater than 63 days. See Benefit Limitation Periods information for further details. [ 20 ]

21 PRE-EXISTING CONDITIONS What is a pre-existing condition? A pre-existing condition is an ailment, illness or condition where in the opinion of a medical practitioner appointed by Queensland Country Health Fund the signs or symptoms of that ailment, illness or condition existed at any time in the period of six months, ending on the day on which the person became insured under the policy. It is not necessary that you or your doctor were aware of your condition, or that the condition had been diagnosed. A condition can still be classed as pre-existing, even if you hadn t seen your doctor about it before joining a hospital table or upgrading your hospital cover. Risk factors, including family history of an ailment or condition, are not signs or symptoms of a pre-existing condition. They will not be considered when deciding, whether an ailment or condition is pre-existing. Who decides if I have a pre-existing condition? The only person authorised to decide whether you have a pre-existing condition is a medical or other health practitioner appointed by Queensland Country Health Fund. The practitioner will consider the opinion of, and evidence presented by your treating practitioner/s before making an informed judgement. If you have had your current cover for less than 12 months and need treatment, you should confirm with Queensland Country Health Fund whether the pre-existing condition waiting period will apply. Queensland Country Health Fund may require you and your long-term treating practitioner/s to complete a Medical Report Form in order to obtain facts about your illness. The practitioner appointed by Queensland Country Health Fund to review your case will need a number of business days to investigate and make an assessment. Any fee charged by your treating practitioner/s for completion of reports will not be paid by Queensland Country Health Fund and will be have to be settled privately by the Member. [ 21 ]

22 RESTRICTIONS AND EXCLUSIONS 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 an amount 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 restricted services. Not every health cover product has benefit restrictions, please check the appropriate Product brochure to determine benefit entitlement conditions for individual hospital products. 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 Health Fund for that service. If you think you may require treatment for any excluded services you may like to consider taking one of our Top Hospital cover products. Not every health cover product has excluded benefits, please check the appropriate Product brochure to determine benefit entitlement conditions for individual hospital products. [ 22 ]

23 CLAIMING YOUR BENEFITS Hospital claims In most cases when you are discharged from hospital, your account will be settled directly with the hospital by Queensland Country Health Fund. If your hospital stay was subject to any waiting periods, or involved the payment of an excess, or involved any personal expenses (e.g. telephone calls, newspapers, etc.), then you will be responsible for the expense, and the hospital may require settlement on discharge. As a member of the Australian Health Services Alliance (AHSA), Queensland Country Health Fund has negotiated Purchaser Provider Agreements with most of the participating private hospitals and day hospital facilities Australia-wide. Go to our website to find a hospital most convenient to you The Medicare Benefit Schedule and Access Gap The Medicare Benefits Schedule (MBS) is a list of fees for medical services issued by the Federal Government. If you have Private Health Insurance and are admitted to hospital as a private patient, Medicare pays a benefit of 75% of the MBS fee and the remaining 25% of the MBS fee is paid by Queensland Country Health Fund. If a doctor raises a charge that is above the MBS fee, this amount is known as a Medical Gap. Queensland Country Health Fund has an initiative which can help policyholders to minimise or, in some cases, eliminate out-of-pocket expenses (for inpatient services) by reducing or eliminating these Medical Gaps. This scheme is known as Access Gap. Before admission to hospital you should ask your doctor to inform you of all medical fees that may be charged and whether he/she participates in our Access Gap scheme. If the doctor/s elects not to participate in the Access Gap scheme and charges above the MBS fee, this additional amount will need to be paid for by you. Before any hospital treatment you should confirm by asking for a written estimate of costs of treatment from your doctor/s. This is known as Informed Financial Consent. The Access Gap scheme also applies to the costs of other specialists involved in your surgery such as, anaesthetists and assisting surgeons etc. These professionals should also be consulted in regards to any out-of-pocket expenses for their services. There is a search engine facility on the web to help you identify participating Access Gap doctors at: to ensure that the doctor is going to participate for your individual treatment. It is recommended that you personally consult the specialist in regards to the out of pocket expenses for the service. [ 23 ]

24 CLAIMING YOUR BENEFITS CONT. Prostheses Many hospital procedures include the use of prosthetic items (surgically implanted medical devices, such as hip and knee joints and heart pacemakers). The Federal Government regularly issues a Prostheses Schedule to health funds. An industry group of clinical experts review all prosthetic items. There will be at least one prosthetic item for every relevant procedure that is listed in the Medicare Benefits Schedule that is fully covered by your hospital cover (a no gap item). In some circumstances you and your surgeon may feel it is more appropriate to your individual medical needs to use a prosthetic item from the Prostheses Schedule other than the no gap item. Where the cost of the recommended prosthetic item is above the minimum prosthesis benefit from the Prostheses Schedule, you will be responsible for the additional amount. It is recommended that prior to your surgery you discuss with your surgeon the cost of the surgery including any out-of-pocket expenses associated with either the surgery and/or the recommended prosthesis item. Benefits are not payable for any prosthesis associated with an excluded service under your hospital cover. Mechanical Appliances and Artificial Aids Eligibility for benefits for a wide range of Mechanical Appliances and Artificial Aids is only available under our private hospital cover suite. Benefits for some items are restricted to hire only for a maximum period of 3 months. Benefit replacement periods restrictions also apply to some items. When claiming for these items a letter from your doctor or relevant practitioner is required, and in some circumstances only after an inpatient hospitalisation. Prior to purchase or hire of any mechanical appliance or artificial aid, please contact the fund for the conditions of claiming the benefit. Length of Stay All Queensland Country Health Fund hospital covers provide Members with cover as long as they require hospital treatment provided, they obtain certification of ongoing acute care after 35 days of continuous hospitalisation. If such certification is not provided, a lower benefit will be paid. Ancillary (Extras) claims Using your membership card Your Queensland Country Health Fund membership card enables your benefit to be paid directly to participating allied health service providers who display the HICAPS or IBA Health logo. After the services have been provided your membership card will be swiped and your claim processed in seconds. The appropriate benefit for your level of cover is automatically credited to the health care provider, so you only need to pay the difference (if any) between the service cost and benefit. It is fast, convenient and there are no claim forms to fill in. [ 24 ]

25 CLAIMING YOUR BENEFITS CONT. Online Claiming We ve now made it even easier to claim for a wide range of services when on-the-spot claiming isn t available through your provider. Simply go online using your PC, tablet or smart phone! Log in to Online Member Services through our website where you will find instructions on how to submit your claim, it s really easy!! Eligibility: A Member must have held membership with Queensland Country Health Fund for more than 3 months Hold an ancillary(extras) product Policy is financial ( paid up to date) Conditions: Claim limit of $400 per day per person The service being claimed must have been provided within the last (3) calendar months Queensland Country does not require receipts to be sent in for online claims however subject to random reviews you may be required to present these receipts. Please retain your original receipt for 12 months after submission of your claim/s. Services must be provided by approved practitioners in private practice Only claims for the following services# will be accepted using Online Claiming: Acupuncture Audiology Chiropractor Dental General services only (NO major dental or Orthodontic treatment*) Dietetics Homeopathy Massage Naturopathy Occupational Therapy Optical Osteopathy Physiotherapy Podiatry consultations only ( Benefits for Orthotics and other appliance*) Psychology Speech Therapy #Some of these services are not available on Young Extras cover * Eligible benefits for these services have to be claimed either in person, by mail or via claim lodgement) For more information on Online Claiming please consult our website [ 25 ]

26 CLAIMING YOUR BENEFITS CONT. Direct claims payment service Access your benefits quickly and easily with our direct claims payment service. Once we receive and process your claim, your benefits will be deposited into your nominated bank, credit union or building society account. You will not have to waste time in bank queues, or wait for the cheque to clear. To register an account for direct claims payment: By fax call or the details of your preferred direct claims payment account complete the account crediting information section on our claim form, or log in to Online Member Service (OMS) and add or change direct credit details To claim your benefit via fax, simply fax your completed claim form, and original receipts directly to us on We will then process and send benefit remittance via direct credit to your nominated bank, credit union or building society account. Alternatively we can send you a cheque in the mail. Please keep the original invoices/receipts for a period of seven (7) years for audit purposes. By mail To claim your benefit by mail, complete a claim form, attach your original invoices/receipts, and mail them to us. By To save time, you can also us the completed claim form and attached invoices/receipts. If you use this method, please keep your original documents for a period of seven (7) years for audit purposes. In person If you wish to claim in person you can visit one of our Health Fund Service Centres or any Queensland Country Credit Union branch. Contact details for all of the above methods can be found in the Contact Us section in the back of this guide. Obtaining a claim form Claim forms are available for download from our website, by phoning or from your local Queensland Country Credit Union branch. Queensland Country Health Fund, from time to time, may include a claim form with certain communications to you. [ 26 ]

27 CLAIMING YOUR BENEFITS CONT. Paid accounts If you have already paid the health care provider, we can credit your benefit payment directly into your nominated bank, credit union or building society. Alternatively we will send you a cheque. Unpaid accounts In most cases, where you submit a claim directly to Queensland Country Health Fund, you will receive a cheque in the name of the provider, to enable you to settle the account. Where your provider submits a claim directly to Queensland Country Health Fund, or you send in an Access Gap Cover endorsed account, we will pay your provider directly. Claiming conditions A claim for benefits must be lodged within two (2) years of the date of the service. Benefits will be refused if a claim is lodged after this period. For Queensland Country Health Fund to assess your claim all invoices/receipts must be originals (or provider endorsed duplicates) and include the: appropriate item number or full description of the service or product patient s name date of service fee charged provider s name, qualifications and practice address, and provider number (if applicable) tooth numbers are required on dental accounts where treatment has taken place on individual teeth. Benefits and limits are assessed having regard to the date on which the services were rendered or product supplied, except for courses of orthodontic treatment. Limits renew each anniversary date of your membership. Services must be provided by approved practitioners in private practice, or salaried doctors in public hospitals. All documents submitted in connection with a claim become the property of Queensland Country Health Fund, unless otherwise agreed, by the health fund. Benefits are not payable for claims for services rendered while premiums are in arrears or the membership is suspended. Benefits are not payable, or may be payable at a reduced rate, during any applicable waiting periods. Benefits payable on hospital services within a designated Benefit Limitation Period (BLP) will be the minimum benefit declared by the Minister for Health, except when a waiting period is being served, in which case no benefit applies. Benefits are not payable for claims for services rendered outside Australia or, for items purchased or hired from overseas suppliers. Benefits are not payable on claims subject to compensation, third party or other liability provision. Benefits are not payable for treatment rendered by a provider to the provider s partner (spouse or de facto) or dependant children or partner s dependant children if a legally enforceable debt is not raised. [ 27 ]

28 CLAIMING YOUR BENEFITS CONT. Registered providers It is a requirement that any practitioner is registered and recognised by the health fund before benefits will be paid. Queensland Country Health Fund will only pay benefits for ancillary, dental and other services if rendered by a provider or practitioner that is recognised by the health fund. We reserve the right to refuse payment for services rendered by a provider who does not satisfy the health funds criteria. Recognition of providers is for the purpose of determining the payment of benefits and should not be taken or considered in any way as approval of, or any recommendation as to the qualifications and skills of, or services provided by, a practitioner or therapist. Members should check with Queensland Country Health Fund, that their practitioner is recognised before commencing treatment. Multiple services in one day Where a Member has two or more consultations for the same type of service on the same day, benefits will only be payable where: the consultations relate to two separate conditions. Where a Member has two consultations with the same provider on the same day, benefits are payable where: two different types of services are provided, and the provider is qualified to perform both types of service. Where two services are required to be performed on the same day, the health fund may ask for clinical evidence of the requirements for this, prior to payment of any benefits. Compensation and damages Benefits are not payable in respect of services provided to a Member as a result of an accident, illness, injury, condition or other incident for which there exists in the opinion of Queensland Country Health Fund, a right to claim compensation or damages from a third party or authority at law or under any insurance or scheme of arrangement. Where Queensland Country Health Fund has paid benefits, whether by way of provisional payments or otherwise and the insured person has received compensation in respect of the injury, the insured person must repay to the Health Fund all benefits received in relation to the injury, upon the determination or settlement of the claim for compensation. The liability of the Member to repay shall apply regardless of whether the Member continues to be a Member of Queensland Country Health Fund. [ 28 ]

29 CLAIMING YOUR BENEFITS CONT. Claims paid in error In the event that a benefit has been paid incorrectly or in error, then Queensland Country Health Fund shall, within 24 months of making the erroneous payment, be entitled to recover any such amount, that should not of been paid under the Fund Rules. Without prejudice to any remedy otherwise available to it, Queensland Country Health Fund shall be entitled to off set against, and deduct from monies otherwise payable then or after by the Fund to the Member, any amount recoverable from a claim paid in error. EXCESSES An excess is the amount you pay up front if you go to hospital or day surgery. You can choose an excess on your cover to save on your premium. The higher the excess, the less you pay in premiums. The excess is applicable to all Members covered, including children/dependants (excluding exempt children as per below) in both public and private hospitals and day surgery facilities, and is applied to the full cost of hospitalisation. Calculation of the excess amount will apply to hospitalisations in the order they are processed by Queensland Country Health Fund The most you ll have to pay each membership year if you choose a cover with a hospital excess is outlined below: EXCESS TYPE SINGLES COVER COUPLES/FAMILY/SINGLE PARENT COVER MAXIMUM PER MEMBERSHIP YEAR MAXIMUM PER PERSON PER MEMBERSHIP YEAR MAXIMUM PER POLICY PER MEMBERSHIP YEAR $250 EXCESS $250 $250 $500 $500 EXCESS $500 $500 $1000 No excess payable for children 10 years and under (Top Hospital product only) If you have a dependant child up to and including the age of 10 years, who needs to be admitted as an inpatient of a hospital or day surgery facility, there would be no requirement for the hospital excess to be paid irrespective of the chosen hospital excess option.* *Note: The excess exemption for children 10 years and under is NOT applicable under Smart Start singles and Couples cover or Intermediate Hospital covers. It is exclusive to our Top Hospital cover product ONLY. [ 29 ]

30 PREMIUM INFORMATION Premiums must be in advance As a policyholder it is your responsibility to ensure that the contribution amounts are correct and made in advance. This is to ensure the efficient processing of claims and hospital eligibility checks. Premium Reviews All health funds undertake a once yearly review of their policy premiums. Every year after a careful review of operating cost and in particular cost of benefits paid, a submission, is made to the Federal Minister for Health and Ageing to request a premium increase for the following year. This review is necessary to ensure the continued sound financial standing of the Fund. A written notification of any change to the premium payable is sent to all members prior to the annual April 1st rate change taking effect, in accordance with the requirements of the Private Health Insurance Act Paying your premiums Queensland Country Health Fund offers a range of payment options, including: Direct debit deductions This is the most popular and convenient method of payment. Facilities are available for policyholders who prefer to have premium payments automatically deducted from bank, credit union or building society accounts on the contribution due date. Payment frequencies are weekly, fortnightly, monthly, quarterly, half yearly and yearly. Credit Card* payment facilities are available for policy holders who prefer to pay via this option. Payments can be deducted under the Direct Debit payment system in accordance with your chosen payment frequency. Your first payment on joining will be deducted on the day policy is loaded or on the future start date of cover. You can also choose to pay your health insurance premiums over the phone by calling or at one of our health fund service centres (locations listed in back of this guide) Alternatively if you are registered for Online Member Service (OMS) you are able to log in and make contributions via credit card with an immediate response. *We do not accept payments via American Express or Diners Club. [ 30 ]

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