Public Hospital. Bronze Extras * Ambulance cover

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1 Effective 1 July 2015 Hospital & Bronze Extras * *This cover is closed to new members Our Hospital & Bronze Extras cover gives you cover as a private patient in a public hospital for most services, as well as cover for the essential extras - like general dental, physio and chiro. Hospital + Bronze Extras * + Ambulance cover peoplecare.com.au Please read this document carefully and keep it for future reference. For the most up-to-date info, visit peoplecare.com.au. 0615v1.0

2 Hospital cover Here s what you re covered for: Hospital service Covered Ambulance (see page 4) 4 Hospital accommodation (a private or public hospital bed in a shared or private room) Same-day patient fees Intensive care In-hospital pharmacy (pharmacy items that you are given while you re admitted to hospital) Theatre fees for services included in your cover^ Palliative care Psychiatric services Rehabilitation Pregnancy & birth related services Assisted reproductive services (like IVF) Major eye surgery (like cataracts & lens) Cardio-thoracic & related services (e.g. heart & chest) Dialysis for chronic renal failure Sterilisation Plastic & reconstructive surgery Hip & knee replacements & related services Other joint replacements & related services (shoulder, wrist, ankle, elbow) Spinal procedures & related services Gastric banding & obesity related services Other Medicare eligible services n/a n/a Cosmetic surgery 6 Private hospital stays If you need treatment in a private hospital, you won t receive any benefits from us and you will have significant out-of-pocket costs. Always check with us to see if you re covered before receiving treatment. What s not covered (Hospital) There are a few things that aren t covered by your hospital cover. They are: Treatment & services received within your waiting periods (see page 4) Treatments & services that Medicare doesn t cover (like cosmetic surgery) Treatment & services received outside Australia Treatment & services covered by compensation or another type of insurance (like third party or sports club insurance) Treatment & services received more than 2 years ago Outpatient treatment & services (unless there s a special agreement between us and the hospital) Some high cost drugs Prostheses that aren t approved by the Commonwealth Government. (A prosthesis is an artificial substitute for a body part) Ambulance subscriptions or state-based ambulance levies Ambulance services paid for by the Government, compensation or another type of insurance Ambulance services that aren t medically necessary Pharmacy - most pharmacy items that you re given while you re in hospital are covered by your hospital bill. The hospital may charge you extra for pharmacy items that you take home with you and this isn t covered by your hospital cover. Please get in touch with us if you re planning a hospital admission so we can talk you through your cover and any out-of-pocket costs you might have. Services not covered by Medicare 6 ^ You are not covered for theatre fees on excluded or restricted services. Please keep in mind that this isn t the full list of services covered. If you re planning a trip to hospital, it s always a good idea to call us and check what you re covered for before being admitted. 2

3 Bronze Extras cover Here s what you re covered for: Service Benefit Annual limit Ambulance Ambulance 100% No limit Chiropractic & osteopathic Complementary therapies Chiropractic Osteopathic Chiropractic x-ray Remedial massage Myotherapy Homeopathy Naturopathy Herbal medicine consultation (Chinese or Western) initial consult: $35 standard consult 1-10: $25 standard consult 11+: $15 60% of cost 60% of cost $350 per person $700 per family $170 per person $340 per family Dental General dental (basic restoration (fillings), diagnostic services, extractions, oral surgery) 60% $500 per person Health management programs Quit smoking Stress management Weight management Health education services (e.g. diabetes) Other approved programs 100% There are some rules around what we can and can t pay for. Please contact us for more info. $100 per person $200 per family Optical Glasses & contact lenses 100% of the cost $150 per person Pharmacy Prescriptions 60% up to $50 Physiotherapy Physiotherapy initial consult: $35 standard consult 1-10: $25 standard consult 11+: $15 $350 per person $700 per family $350 per person $700 per family Please keep in mind that this isn t the full list of services covered. It s always best to give us a buzz before having any treatment to check exactly what you re covered for. It s always best to give us a buzz before receiving any treatment or service to check exactly what benefits you ll be able to claim. What s not covered (Extras) There are a few things that aren t covered by your extras cover. They are: Treatment & services received within your waiting periods (see page 4) Treatments & services that Medicare doesn t cover (like cosmetic surgery) Treatment & services received outside Australia Treatment & services covered by compensation or another type of insurance (like third party or sports club insurance) Treatment & services received more than 2 years ago Pharmaceutical Benefits Scheme (PBS) prescriptions, contraceptives or over-the-counter medicines Naturopathic & herbal medicines First aid kits & courses Non-prescription glasses, contacts & sunglasses Treatment & services received from providers that aren t registered or recognised by Peoplecare Treatment & services you weren t charged for Treatment & services received from a family member, relative, business partner or yourself Services for sport, recreation or entertainment Ambulance subscriptions or state-based levies Ambulance services paid for by the Government, compensation or another type of insurance Ambulance services that aren t medically necessary Receipts issued by a third party, like group buying website or group deals If you re using a gift voucher, we can t pay the difference between the cost of the service and the value of the voucher. For example, if you use a $60 voucher to pay for a $40 service, you can only claim back the $40 as the official fee for that service Benefits higher than the amount you paid for the service. For example, if you receive treatment that s discounted from $65 to $30, we only pay a benefit towards the fee you paid (e.g. $30) 3

4 Ambulance cover Did you know that an ambulance ride could cost your thousands? We ve got your back with our Australiawide, 100% ambulance cover. What s covered: 100% of the cost of medically necessary ambulance treatment and transport within Australia no matter how far you need to travel Air, land and sea ambulance No annual limits No waiting periods What s not covered: Love a free ride Ambulance subscriptions or state-based ambulance levies Ambulance services paid for by the government, compensation or another type of insurance Ambulance services that aren t medically necessary Waiting periods Nobody likes waiting, but all health funds have waiting periods on some services to keep things fair for all members. The following waiting periods apply before these services are covered on your membership: Hospital services Waiting period Extras services Waiting period Ambulance Hospitalisation related to an accident Services covered by another fund (when transferring directly to a similar level of cover) Joining the fund Upgrading your cover Health programs (see page xx) No waiting period 2 months Ambulance Services covered by another fund (when transferring directly to a similar level of cover) Joining the fund Upgrading your cover Rehabilitation, psychiatric services and palliative care General dental, pharmacy, physio, chiro, podiatry and natural therapies No waiting period 2 months Rehabilitation, psychiatric services and palliative care Optical and health management programs 6 months Pregnancy & birth related services Pre-existing conditions (see below) 12 months High cost dentistry including crowns, bridgework, implants, orthodontics, endodontics, periodontics and dentures 12 months Extras services Laser eye surgery & hearing aids 24 months Don t worry, if you re transferring from another fund we ll make sure we recognise any waiting periods you ve already served! What s a pre-existing condition? Pre-existing conditions have a special, government-regulated waiting period of 12 months. They only apply to hospital cover. A pre-existing condition is any ailment, illness or condition that you had signs or symptoms of (in the opinion of a medical practitioner appointed by the health insurer) that existed during the 6 months before you joined or upgraded hospital cover. It s not actually necessary that you or your doctor knew what your condition was, or that the condition had been diagnosed. A condition can still be classed as pre-existing even if you hadn t seen your doctor about it before joining or upgrading hospital cover. 4

5 Health Programs We all love feeling good, so Peoplecare offer a range of free health programs with our hospital covers to help you stay in the best possible health and out of hospital. My Health Online gives you access to a range of health and wellbeing tools. You can store e-health info about yourself (and share it with your doctor), keep a calendar of healthcare appointments, access a health library and more. Health Risk Assessment asks for your health info across a range of areas and gives you a personalised health report. If your assessment shows any health risks, you ll be given the option to enrol in one of our free programs. Home makes it easy to get out of hospital earlier and receive personal care in your home. If the services you need can be provided at home, you might be able to avoid a hospital stay altogether. Strive for Health has been developed to help members with chronic conditions to manage their health with the help of expert phone or face-toface support at home. Home helps you recover in the comfort of your own home with short term therapy for joint replacements, fractures, spinal conditions, stroke, respiratory conditions, cardiac conditions and mobility problems. We offer physio, occupational therapy and more. Think one of these programs could be for you? Get more info at peoplecare. com.au/myhealthprograms or get in touch on Things to know about Your Extras cover Access Gap Annual limits are based on the financial year (1 July 30 June), and are per person (unless it says otherwise) Health management program benefits are available for approved services that manage or treat a specific health condition. Things like blood pressure testing, cholesterol checks, mammograms and hearing tests can be claimed. To find out if a service you ve received can be claimed for, please get in touch Please keep in mind that we aren t able to pay benefits towards goods and services that are used for sport, recreation or entertainment (like gym memberships or sports shoes) Pharmacy benefits can be claimed for prescription medication that costs more than the current Pharmaceutical Benefit Scheme (PBS) amount. This amount changes on 1 January every year and is $37.70 as at 1 January 2015 Complementary therapy benefits can only be paid for services received by providers registered with either Medicare or the Australian Regional Health Group (ARHG) Complementary therapy benefits can only be paid for services received by providers registered with either Medicare or the Australian Regional Health Group (ARHG) To try and reduce your out-of-pocket costs as much as possible, we have Access Gap arrangements with over 30,000 doctors across Australia. This means you will have either no gap (where we pay the full cost of your treatment) or a known gap (where you ll know your outof-pocket costs before you have treatment). Before you go to hospital, ask your doctor if they ll take part in Access Gap - if they do they ll even send their bills straight to us, making life easier for you. Hospital agreements We have agreements with most private hospitals in Australia. If you re admitted to one of the few private hospitals that we don t have an agreement with, we may not cover the full cost of your hospitalisation. You can search our agreement hospital list at peoplecare.com.au, and we recommend that you give us a buzz if you re planning a hospital admission to discuss exactly what you ll be covered for. 5

6 Making a hospital or medical claim Hospitals will send your claim straight to us and we ll let you know what we ve paid once it s all sorted. You don t have to do anything - too easy! Doctors will usually send their medical claims straight to us as well, but sometimes they don t. If they don t, you ll need to submit a claim to Medicare first (using a Medicare claim form and Medicare 2-Way claim form), and they ll send your claim to us once they ve done their bit. Again, we ll let you know what we ve paid once it s all sorted. Making an extras claim Claiming couldn t be easier! The choice is yours: HICAPS just swipe your membership card at participating providers and we ll pay your benefits straight to the provider. You ll only have to pay the difference between what they charge and our benefit, and you won t have to submit a claim form From your phone with our quick & easy Mobile Claiming app. Download it now from peoplecare. com.au/mobile Online claim for the following services using our Online Member Services at peoplecare.com.au/oms: Dental Chiro Osteo Physio Podiatry Optical Occupational therapy scan and your completed claim form and the receipts for your service to Post send a completed claim form and the receipts for your service to Locked Bag 33, Wollongong NSW 2500 Online Member Services Love having access to your membership 24/7? Then our Online Member Services is for you. If you change your mind Changed your mind about your cover? No worries! Just let us know within 30 days of joining or upgrading your cover and you ll get a full refund of any premiums paid (as long as you haven t made any claims in that time, of course). Your Privacy We re 100% committed to the Privacy Act and Australian Privacy Principles, which means we only collect the information we need to give you access to health services. We won t collect any personal information unless we ve asked first, and we protect the information we do have with everything we ve got. Want more info? You can read our full Privacy Policy at peoplecare.com.au/privacy. Love your thoughts At Peoplecare, it s all about you. We love happy members, and if you re not happy we want to hear about it so we can make things even better. If you have any problems with your cover, give us a buzz on Most of the time we can sort things out on the spot, but you can always ask to speak to a manager or our CEO if you d prefer. If you d rather write to us, you can or write to Locked Bag 33, Wollongong NSW If you re still not happy after contacting us, you can contact the Private Health Insurance Ombudsman (PHIO). PHIO is free, independent and protects the rights of private health fund members. You can call PHIO on , or visit them at Level 22, 580 George Street, Sydney NSW For more information, visit their website phio.org.au. To get a copy of our full complaints policy, go to peoplecare.com.au or contact us and we ll send you a copy. Here is what you can do in Online Member Services wherever and whenever you like: View & update your membership details Check how much of your Extras limits you ve used View your claims history Make a membership payment by credit card Find a registered healthcare provider View & print your annual Tax Statement to get a headstart on your tax And more! Registering is quick and easy, so sign up today at peoplecare.com.au/oms. 6

7 For the most up-to-date info, visit peoplecare.com.au. Please read this document carefully and keep it for future reference.

8 peoplecare.com.au Lysaght Peoplecare Limited. A registered private health insurer. ABN

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