Health Insurance MEMBERSHIP GUIDE

Transcription

1 Health Insurance MEMBERSHIP GUIDE Effective February 2015

2 This guide is a summary of the Fund Rules and policies of Medibank Private affecting members who are Australian residents. 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. 2 Membership guide

3 INFORMATION FOR NON-RESIDENTS OF AUSTRALIA Please note covers referred to in this guide are generally not suitable for visitors from overseas, including visitors from countries with which the Australian Government has Reciprocal Health Care arrangements. Our Membership guides for Visitors Health Insurance, Working Visa Health Insurance and Overseas Student Health Cover provide information about health cover that may be more appropriate for visitors from overseas. Further details are available from Medibank stores or on our website at medibank.com.au Membership guide 3

4 WHAT S INSIDE 06 YOUR GUIDE TO MEMBERSHIP 07 YOUR MEMBERSHIP 07 Categories of membership 07 Policy holder and members 08 Responsibilities of the Policy holder 08 Managing the membership Policy holder and their partner 09 Adding a child to a single membership 09 Adding a child to a couple or family membership 09 Changes to existing memberships 09 Changes to the terms and conditions of your membership 10 Membership review ( cooling off ) period 10 Suspension of membership 11 Your membership card 11 YOUR PREMIUMS 11 Premium payment options 12 Premium protection 12 Premium arrears 12 Premium refunds 12 Moving interstate 13 Lifetime Health Cover (LHC) 14 Permitted days without hospital cover 14 Exceptions 14 Special rules apply 14 Australian Government Rebate on private health insurance 15 HOSPITAL COVER 15 Benefits for hospital treatment 16 Members Choice hospitals 16 Non Members Choice hospitals 16 Surgically implanted prostheses and other items 17 Hospital benefit exclusions 18 Hospital covers with restricted services 18 Federal government minimum benefit 19 Hospital covers with an excess 20 Benefits for in-hospital medical services and GapCover 20 Doctors admitting rights 21 AMBULANCE SERVICES 21 What is covered? 21 What is not covered? 22 Already covered? 22 Ambulance services with hospital cover 22 Ambulance services with extras cover 22 Standalone Ambulance Cover 23 EXTRAS COVER 23 Members Choice extras providers 23 Non Members Choice extras providers 23 Annual limits 23 Lifetime limit 23 Prescription pharmaceuticals non-pbs 4 Membership guide

5 24 WAITING PERIODS 24 Pre-existing conditions (PEC) 25 Obstetrics-related services waiting period 26 Accidents and associated waiting periods 27 REDUCED AND RESTRICTED BENEFIT PAYMENTS 27 Benefit replacement periods 27 General benefit restrictions 28 General benefit exclusions 28 Appliances requiring referrals 29 HOW BENEFITS ARE ASSESSED 29 Hospital benefits overnight stay patients 29 Same-day hospital benefits 29 Long stay hospital patients 29 Extras benefits 30 Interstate benefits 31 OTHER IMPORTANT INFORMATION 31 Members Choice network 31 Disclaimer 32 Transferring from another Australian registered health fund (portability) 32 Portability and Lifetime Health Cover (LHC) 33 Compensation and damages 33 Medibank privacy statement 34 Your feedback 34 Resolution of complaints 35 Private Health Insurance Code of Conduct 35 Private Patients Hospital Charter 30 MAKING A CLAIM 30 Hospital claims 30 Claims documentation 30 Time limit for submitting a claim 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. The guide must be read in conjunction with the Cover summary sent to you at the time of joining or changing 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. Medibank also offers corporate equivalents (covers arranged with an organisation) for some of our covers. Please contact us for more information. 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. 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. This will help prevent correspondence from going astray. 6 Membership guide

7 YOUR MEMBERSHIP 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 Single parent family* membership, which covers you and: any of your child dependants and/or any of your student dependants. Family membership*, which covers you and your partner and: any of your child dependants and/or any of your student dependants. Medibank also provides an option for families with adult dependants*, where, for an additional cost, you can extend a single parent family, couple or family membership to also include any of your children who: have reached the age of 21 but are under 25 are not studying full time, and are not married or in a de facto relationship. * This option is not available on all Medibank covers. Please contact for more information. 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 not married or living in a de facto relationship. A student dependant is a person who is: is a child of the Policy holder or their partner, and has reached the age of 21 but is under 25, and is not married or living in a de facto relationship, and is studying full-time. 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. Membership guide 7

8 YOUR MEMBERSHIP 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 Membership 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. 8 Membership guide

9 ADDING A CHILD TO A SINGLE MEMBERSHIP Dependant children can be added to certain covers. To add a dependant child, you ll need to change from a single to a family or single parent 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 COUPLE OR FAMILY MEMBERSHIP You can add a dependent child to your membership at any time. In the case of a newborn (i.e. 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 Minister for 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 one 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. Membership guide 9

10 YOUR MEMBERSHIP 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. Please note: a person may be a member of: a hospital cover, extras cover or both; or a fixed combination of both hospital and extras covers. Some hospital covers must be taken with an extras cover and some extras covers must be taken with a hospital cover. 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 In certain situations, for example during a period of overseas travel or when you are in receipt of certain unemployment benefits, you may apply to Medibank to have your membership suspended. If you have both hospital cover and extras cover, you cannot suspend only one of the covers. This means you cannot suspend hospital cover and retain extras cover, or vice versa. If you have our Ambulance Cover you cannot suspend this cover at any time. 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. you may be subject to the Medicare Levy Surcharge for a period of suspension. if you are travelling overseas: the application to suspend must be made prior to the departure date the minimum period for which you can suspend your membership is two months and the maximum period is four years. You cannot suspend your membership if you are absent from Australia for less than two months. Under some covers, annual benefit entitlements and limits for extras services can 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. 10 Membership guide

11 YOUR PREMIUMS From time to time Medibank may close covers. If your cover is closed while your membership is suspended, upon reactivation you will be transferred to a similar cover or you can choose an alternative cover. The premium applicable to the new cover will apply from the date of the change. Medibank can provide further information about the conditions under which you may suspend your membership. YOUR MEMBERSHIP CARD When you join Medibank, we will send you a membership card that identifies you as a member. Use this card when you need to pay a premium or make 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. 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 membership card. PREMIUM PAYMENT OPTIONS Medibank premiums must be paid in advance. Generally you cannot extend your cover beyond 12 months from the date of your payment. Premiums for our separate Ambulance Cover can only be paid either 6 or 12 months in advance. Payments for Ambulance Cover can be made by: direct debit from a financial institution cheque or savings account, or direct payment (see below for payment options). For all our other covers, the premium payment options available are: 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 account. In person Pay at any branch of Australia Post with a Health Cover Account notice. Membership guide 11

12 YOUR PREMIUMS 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. PREMIUM PROTECTION Medibank premiums can change from time to time subject to approval from the Minister for Health. 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. 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, you may apply for a refund of premiums paid in advance. Your refund will generally be calculated from the date of application. An administration fee may apply. MOVING INTERSTATE Premiums (and some benefits) vary from state to state. You are required to pay the premium applicable to the state or territory in which you reside. If you move interstate you must notify us of your new address within two months of moving. 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 pages 8-10). 12 Membership guide

13 LIFETIME HEALTH COVER (LHC) Under the current LHC provisions, people who take out hospital cover after the 1 July following their 31st birthday must pay more for their premiums. They must pay a 2% loading on top of a base-rate (normal) single member premium (or their share of a couple or family premium) for each year or part-year they were without hospital cover from the relevant 1 July date. Example: Jane turns 31 on 1 December If she takes out hospital cover by 1 July 2013, she will pay the base rate premium. If she takes out hospital cover on 2 July 2013, she will pay a 2% loading. If Jane further delays taking out hospital cover, then an additional 2% loading will be charged for each year or part-year that she remains without cover after 30 June The loading is removed after a member has held hospital cover, for which premiums have been increased by the application of the loading, for a continuous period of 10 years or for a cumulative period of 10 years interrupted only by permitted days without hospital cover. If the loading has been applied and has then been lifted under the application of this 10-year rule, that loading must be re-applied if the person subsequently ceases to hold hospital cover and then takes it up again, unless that interim period without hospital cover comprises only permitted days without hospital cover. Membership guide 13

14 YOUR PREMIUMS PERMITTED DAYS WITHOUT HOSPITAL COVER The following are all permitted days without hospital cover : days where a person s hospital cover is suspended under the rules of the person s private health insurer; days when the person is overseas for a continuous period of more than one year (which can include periods of return to Australia of less than 90 days each time); and the first 1,094 days of not having hospital cover. In most cases, any of the days above that occur after a member ceases to have hospital cover for the first time after the 1 July following their 31st birthday are permitted days without hospital cover. EXCEPTIONS People who were born on or before 1 July 1934 can take out hospital cover at any time and will always pay base rate premiums. SPECIAL RULES APPLY Special rules apply to Australians returning from overseas, Norfolk Islanders, Veterans Affairs Gold Card Holders, former members of the Australian Defence Force, staff of the Australian Antarctic Division, refugees and all other categories of migrants to Australia. AUSTRALIAN GOVERNMENT REBATE ON PRIVATE HEALTH INSURANCE If you are eligible for Medicare and have private health cover, you may be entitled to a rebate on the cost of your health cover premium. The rebate applies to both hospital and extras cover. The Australian Government Rebate is applied to the base premium rate only, not to any Lifetime Health Cover loading that may be applicable. The level of rebate percentage you re entitled to is determined by the age of the oldest person covered under the membership and your income. From 1 April 2014, the Federal Government will reduce the rebate percentages annually for all health insurers, based on a calculation that takes in to account the annual industry average rate increase on health insurance premiums and the cost of living. For more information about the income testing and income tiers please contact us on or visit our website. 14 Membership guide

15 HOSPITAL COVER Members may be eligible to continue to receive one of the higher age-based rebate levels even if the person aged 65 or older leaves the membership, for example due to death, divorce or separation. Members should contact Medibank on to confirm their entitlement in these circumstances. Also, if your membership currently receives an increased rebate due to age, then if you are considering removing a member from, or adding a member to, the membership, please contact us to discuss the potential effect on your rebate entitlement. You can receive the rebate in one of two ways: as an automatic reduction in premiums as a tax offset in your annual tax return. If you would like to have an automatic reduction in premiums and have not yet applied for the Australian Government Rebate call us on or go to our website. Medibank allows you to nominate a range of rebate levels to take as an up-front reduction in your premium, and by taking advantage of this, you can reduce the prospect and impact of an overclaiming of rebate entitlement needing to be paid back to the government. Please contact us to find out more about nominating different levels of rebate. Hospital Cover provides benefits towards the cost of hospital accommodation and other hospital charges as well as doctors fees for in-hospital medical services when you are treated as a private patient. Benefits are also payable for ambulance services as defined by us (see page 21). BENEFITS FOR HOSPITAL TREATMENT This section provides details of the benefits payable for hospital treatment. For details of benefits for in-hospital medical treatment (see page 20). Not all services are available at all hospitals. Please check with your hospital prior to admission. Benefits for hospital treatment are generally payable only for treatment for which a Medicare benefit is payable. However, 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 hospital. Benefits are payable under most of our hospital covers for CPAP-type devices. This includes Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) or similar devices approved by Medibank. Benefits are payable when: you have undergone an overnight investigation for sleep apnoea for which a Medicare benefit is payable; and the device is requested by a medical practitioner; and the device is purchased or hired within 12 months of undergoing the investigation. Please refer to your Cover summary to see if you are entitled to benefits. Membership guide 15

16 HOSPITAL COVER After Medibank has paid 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. The benefit Medibank pays towards hospital treatment will be no less than the minimum benefits as set by the Federal Government. 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 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 and is not excluded or restricted under your cover. 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 HOSPITALS Members receiving hospital treatment in a non Members Choice 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. Your doctor should seek your informed financial consent before the procedure. You will need to speak with us, your doctor and your hospital to confirm what your out-of-pocket expenses are going to be. If you have a hospital cover with an excess (see page 19), the excess will not apply to the benefit payable for a prosthesis. Benefits are not payable for any prosthesis associated with an excluded service under your cover. 16 Membership guide

17 HOSPITAL BENEFIT EXCLUSIONS Benefits are not payable for: any services that are excluded under your cover (see the Cover summary) cosmetic treatment pharmaceuticals prescribed for cosmetic purposes prostheses and other items not on the Federal Government s Prostheses Schedule (see page 16) hospital charges for podiatric surgery performed by a non-accredited podiatrist items such as newspapers, TV hire, etc not covered by the Medibank agreement (if any) with the hospital the cost of treatment as an outpatient in an accident and emergency department (medical services provided in such facilities may be claimable from Medicare) 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 the co-payment that you pay for drugs supplied to you under the Pharmaceutical Benefits Scheme (PBS) in a hospital with which Medibank does not have an agreement. Benefits may not be payable for: outpatient treatment or outpatient day programs 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 inpatient in hospital procedures not recognised for Medicare benefits purposes charges by your doctor in excess of the Medicare Benefits Schedule Fee, unless your doctor uses our GapCover scheme (see page 20) or has an agreement with Medibank or with a Members Choice hospital the gap for surgically implanted prostheses and other items on the Federal Government s Prostheses Schedule (see page 16) non-pbs pharmaceuticals charges for extras services not covered by our agreement with the hospital or under your extras cover. Membership guide 17

18 HOSPITAL COVER HOSPITAL COVERS WITH RESTRICTED SERVICES Benefits for restricted services will not exceed the relevant Federal Government minimum benefit. You will be responsible for any charges in excess of this amount. If you have a cover with restricted services and you are considering going to a private hospital, please call Medibank on or visit one of our stores beforehand to confirm your level of coverage for the proposed treatment. We will need the Medicare Benefits Schedule (MBS) item number(s) for the procedure(s) to ensure that we give you the correct advice. The MBS is a 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. Refer to the Cover summary to see if any restricted services apply under your cover. FEDERAL GOVERNMENT MINIMUM BENEFIT The Federal Government minimum benefit (also known as the Federal Government default benefit) is the amount of benefit determined by the Federal Government as the minimum amount health funds must pay for accommodation costs in private and public hospitals. Medibank pays the minimum benefit for restricted services in private hospitals. Minimum benefits are payable only towards the cost of hospital accommodation and provide no cover for other hospital charges such as labour ward or operating theatre costs associated with the provision of a restricted service. Minimum benefits will not generally cover the full cost of treatment in private hospitals or in day hospital facilities, and you may be left with significant out-of-pocket expenses. Please call us on or visit one of our stores if you would like to know the minimum benefits that may apply to any treatment you anticipate. 18 Membership guide

19 HOSPITAL COVERS WITH AN EXCESS Medibank offers a range of hospital covers, some of which have an excess. An excess is an amount that you must contribute towards your hospital treatment and is deducted from the benefits we pay when you make a hospital claim. Some hospitals may require you to pay this amount at the time of admission. 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. An excess will apply only where the Policy holder or partner is hospitalised. It will not apply to hospital treatment for child dependants; student dependants or adult dependants. For most covers the excess applies per member per calendar year. For some other covers the excess is applied to each episode of hospital treatment up to an annual maximum. 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. If you are discharged from a hospital, and within seven days you are admitted to the same or another hospital for treatment for the same or a related condition, we will treat both periods as one hospital admission for the purpose of your excess. A hospital admission in any other circumstances will be treated as a new period of hospitalisation. Refer to the Cover summary to see if any excess applies to your cover. Membership guide 19

20 HOSPITAL COVER BENEFITS FOR IN-HOSPITAL MEDICAL SERVICES AND GAPCOVER The benefits we pay towards medical services rendered to an admitted patient of a hospital are based on the Medicare Benefits Schedule (MBS) fee. The MBS is a list of all the services Medicare pays benefits for and the rules that apply to the payment of those benefits. Medicare pays 75% of the MBS fee for in-hospital medical services and Medibank pays 25% (if the treatment is included under your cover). No benefits are payable for excluded services or where Medicare benefits are not payable for the procedure. If the doctor charges more than the MBS fee, this will result in out-of-pocket expenses. This is referred to as a gap. Medibank only provides benefits towards the gap where: we have an agreement with your doctor, or the hospital has an agreement with your doctor, or your doctor participates in our GapCover scheme, or your cover includes a feature that provides in-hospital medical benefits in excess of the MBS fee. The gap can be reduced or even eliminated where the doctor participates in our GapCover scheme. Under our GapCover scheme, the maximum amount you can be out-of-pocket or the maximum gap for the treatment you have in hospital is $500 per doctor s claim (ie. per doctor s account). In many cases, there s no gap at all. GapCover does not eliminate amounts that members have agreed to pay under the terms of their cover, eg. hospital excesses. It also doesn t apply to services such as blood tests and x-rays provided by pathologists and radiologists. If you anticipate treatment, we recommend that you ask your doctor before commencing treatment whether there will be any associated out-of-pocket expenses. Further details are available on our website at medibank.com.au or within our GapCover brochure, available upon request. Doctors can decide to use the GapCover scheme on a claim-by-claim basis. Sometimes a paediatrician or other medical practitioner will charge for examining a new born baby in hospital. Unless the baby has been admitted as a private patient in its own right, these accounts are claimable from Medicare only and gap benefits are not payable. DOCTORS ADMITTING RIGHTS Not all doctors have admitting rights to all hospitals. Your doctor will be able to tell you which hospitals they have admitting rights. 20 Membership guide