1 HEALTH INSURANCE FOR singles and couples EFFECTIVE 1 FEBRUARY 2012 better health cover shouldn t hurt
2 welcome to Queensland Country Health Fund In short, Queensland Country Health Fund has been at it for over 30 years, and takes pride in offering you a flexible, affordable and comprehensive health cover. Queensland Country Health Fund is a not-for-profit fund, so there s only your health to consider. And that s our number one priority. This brochure provides an overview of the features and benefits of Smart Start Health Insurance to enable a good understanding of the level of cover available. For more information regarding health insurance please refer to our Membership Guide or visit us at
4 Smart Start Cover Getting started with health insurance has never been easier. Queensland Country Health Fund offers Smart Start designed to provide younger people with the cover they need, without paying for benefits that won t be used. Smart Start provides: Cover for Private Hospital treatment for a range of commonly needed treatments for conditions like tonsillitis, knee reconstructions, appendicitis etc. This hospital cover has some restricted and excluded benefits. Cover for a number of commonly used Extras like dental, physiotherapy, massage, optical etc. Competitive pricing to make health insurance affordable Queensland Country Health Fund offers: Value for money health - insurance products with comprehensive benefits As a not-for-profit health fund we are focused on providing great service to Members Access to your health insurance policy information via our online web services Very high levels of Member satisfaction which is confirmed with Member surveys
5 Why do I need Health Insurance Cover? As a young person it s sometimes hard to understand why it is necessary to have health insurance. What does health insurance offer for someone who is young and healthy? Making health care services affordable Health insurance covers more than visits to the hospital. There are many health care services that young people need that are not covered by Medicare. Services like dental, optical, physiotherapy and massage are not normally covered by Medicare. Private health insurance with Queensland Country can help cover the costs of these services ensuring you can afford to receive treatment when you need it. Avoid higher health insurance costs Lifetime Health Cover is a Federal Government initiative that came into effect on the 1st July It is designed to reward people who join a private health fund earlier in life by securing lower premiums. Under Lifetime Health Cover, if you don t have hospital cover on the 1st July following your 31st birthday, then for each year you delay joining, you premium will increase. Avoid extra tax If your taxable income is $80,000 a year for singles (combined taxable income of $160,000 for couples or families) you could be paying the additional 1% Medicare Levy Surcharge*. You can avoid this by taking out cover with Queensland Country. You may well find that the cost of our Smart Start health insurance is less than the additional 1% surcharge which means that you will be better off financially and have hospital cover. * These thresholds apply to the 2011/12 financial year, and will be indexed annually for each subsequent year. Please refer to our Membership Guide for more information regarding the Medicare Levy Surcharge. Federal Government Rebate The Federal Government will pay a 30% rebate on private health insurance premiums depending on your entitlement. This rebate recognises the contribution that people with private health insurance are making to their own health costs. This makes health insurance even more affordable....each year you delay joining, your premium will increase.
6 Hospital Cover Smart Start is a popular choice for young singles and couples. Smart Start covers you for the hospital services you are more likely to use. This means if you want the security of hospital cover at any hospital in our Australia-wide network but don t want to pay for benefits you re not likely to use (such as hip replacements or renal dialysis) then this is the cover for you. Private Hospital cover helps you afford treatment in private or public hospitals. You can receive the required treatment when and where you want it, and it can be performed by the Doctor of your choice. So, as a patient, you have more control, and more importantly you can ensure you receive the best medical care. Private Hospital cover also assists to cover the gap component over the Medicare Benefits Schedule for in-patient services*. Key Features Australia-wide private hospital network Pay less with Access Gap Cover Peace of mind with the doctor of your choice Choose a higher excess to lower your premium *Smart Start has some excluded and restricted benefits 4
7 Excess Smart Start package cover can come with a choice of a $250 or $500 excess for single membership or couples membership. The excess that applies in any one membership year is $250 or $500, depending on which one you choose. This means for example that regardless of how many times hospitalisation is required throughout the year if you have the $250 excess, you would only pay a maximum of $250 for single membership, and $500 for couples membership. The excess applies to the full cost of hospitalisation at a public, private or day hospital facility. Out-of-Pocket Expenses It is your right to know if there are any out-ofpocket expenses to help avoid any surprises later. Knowing how much your medical treatment will cost is called Informed Financial Consent and the Government has introduced a checklist providing you with the questions you need to ask before going into hospital. We recommend that you contact us before going into hospital so that we can discuss what your policy will provide cover for. We would also be happy to send you a copy of the checklist. Hospital Network Queensland Country Health Fund has negotiated Purchaser Provider Agreements with most of the participating private hospitals and day hospital facilities Australia-wide. In most instances, the approved hospital charges for policyholders of a Private Hospital policy will be covered in full once the agreed excess has been deducted. This means that you will benefit from capped fees we ve negotiated and convenient billing as your invoice will be sent directly to Queensland Country. Private hospitals and day hospital facilities that have not signed an agreement attract reduced benefits which will mean you may incur out-of-pocket expenses for in-hospital treatment. Go to our website to find a hospital most convenient to you. What s Covered in Hospital For services in a private hospital, except restricted services or services not covered (see table on page 6), where a Medicare benefit is payable and waiting periods have been served, we will pay benefits towards (less any applicable excess). 5
8 What s covered in Hospital What s covered Included services Examples of in-hospital treatments we will pay benefits towards: Appendix treatment Accidents Removal of teeth Knee, shoulder and hip investigations Removal of tonsils Hernia surgery Digestive disorders Colonoscopies Kidney stone and gall stone removal Knee & ankle arthroscopy and reconstructions Shoulder arthroscopy and reconstructions Hospital and doctors benefits for included services Choice of doctor/hospital Private hospital accommodation Public hospital accommodation as a private patient (shared room) Theatre fees Surgically implanted prosthesis benefits* Intensive care In-hospital rehabilitation treatments Plastic and reconstructive surgery (if medically necessary) Medical Gap Doctors charges in hospital where each doctor chooses to opt in to the Queensland Country Access gap scheme Radiography and pathology services charges ordered by your doctor in hospital. 100% cover where the practitioner participates in the Queensland Country Access gap scheme Most pharmaceuticals directly related to your admission * Some surgically implanted prostheses may be for an excluded benefit therefore no benefit would be payable in this circumstance, for example hip replacement. 6 * Waiting periods
9 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 amounts 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 these services. What s covered Restricted services restricted restricted restricted restricted restricted restricted restricted in-hospital treatments we will pay a restricted benefit towards: In-hospital psychiatric treatment Cardio-thoracic procedures for example open heart surgery Major eye surgery cataract and eye lenses procedures Obstetric related services birth and pregnancy related services Assisted reproduction services for example IVF Gastric banding and obesity surgery Renal dialysis for chronic renal failure 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 for that service. If you think you may need any of the procedures outlined below you may like to consider taking out a higher level hospital cover. What s not covered Excluded services in-hospital treatments we will not pay a benefit towards: Joint replacements for example an artificial hip replacement Cosmetic surgery (hospital treatment for which Medicare pays no benefit) Some high costs drugs 7
10 How it works in relation to doctor s charges Medicare uses a Medicare Benefits Schedule fee (MBS) for calculating rebates on doctors charges. Queensland Country offers our Access Gap Cover Scheme and we encourage doctors to participate in the scheme. Under the Access Gap Cover Scheme participating doctors who provide a service in hospital can decide to accept up to the Health Fund benefit as full settlement of the account. This means you don t have to make any additional payments for that particular service. The doctor can also accept the fee as part of the payment and will inform you of any gap called the known gap which you will have to pay. If you doctor does not participate in Access Gap, we will only cover the 25% gap between the 75% Medicare Benefit and the Medicare Benefits Schedule fee which may result in larger out-of-pocket expenses for yourself. It s always a good idea to talk to your doctors about their charges prior to your treatment.
11 Extras Cover Smart Start has been designed to provide good benefits for a broad range of therapies most likely to be used by young people while keeping the cover affordable. Whether you need a massage or a new pair of glasses, Queensland Country can help. On-the-spot Claiming To make it even easier to claim your benefit, participating health professionals have electronic claiming facilities available. HICAPS/IBA is an electronic health claiming and payments system that will process your claim for treatment, on the spot, without leaving the surgery or practice. You simply swipe your Queensland Country Member card and just pay the gap, it s that easy. You don t need to fill in claim forms, wait for benefits to be paid or wait in line. Optical Discounts Queensland Country Health Fund has negotiated agreements with a large number of optical providers across Australia. When you visit one of our preferred optical providers you will receive great discounts on frames, lenses and contact lenses. Queensland Country Health Fund Members receive a discount of 21% on all glasses frames and lenses and a discount of 10% on all contact lenses purchased at retail stores. Further details of these providers can be seen at under Cover Options. Key Features Generous annual limits for general dental and optical services Cover for a wide range of alternative therapies including remedial massage and podiatry Easy claiming with HICAPS/IBA on the spot claiming Competitive premiums 9
12 Extras Cover benefits Services Waiting Period Benefit Limits Examples of maximum benefits Dental Benefits General Dental 2 months $500 per person up to Periodic oral examination $32.00 $1000 per policy Scale & Clean $53.00 Fluoride treatment $15.00 Major Dental 12 months $500 per person up to Surgical tooth extraction $ $1000 per policy Full crown veneered $ Endodontic 12 months Filing of one root canal $90.00 Orthodontic Optical Benefits 12 months Single & Multi-focal 2 months $200 per person up to Single vision lenses & frames $200 lenses & frames $400 per policy Repair to frames $200 Contact lenses $200 Physiotherapy Physiotherapy 2 months $300 per person up to Initial visit $40.00 $600 per policy Subsequent visit $30.00 Alternative Therapies Chiropractic Osteopathy Remedial massage/ Bowen therapy 2 months $200 per therapy/ $400 per person up to $800 per policy Braces for upper & lower teeth, including removal plus fitting of retainer $ Lifetime limit $ per person Benefits are paid at 70% of cost Initial visit $30.00 Subsequent visit $30.00 Podiatry Initial visit $30.00 Subsequent visit $30.00 Orthotics 75% of cost up to sub-limit Acupuncture Dietician Initial visit $30.00 Subsequent visit $30.00 Initial visit $50.00 Subsequent visit $30.00 Other Services Pharmaceutical 2 months $150 per person up to $30 per script $300 per policy 10 Healthy Living benefit 2 months $125 per policy Benefits up to the policy limit are available for: Your choice of quit smoking programs Your choice of weight loss programs Skin checks through mole mapping Consultation fees for metabolic dieticians and nutritionists when providing assistance with weight loss
13 How much are the premiums? Hospital & Extras What you ll pay Smart Start 250 Single Single Couple Couple no rebate with rebate no rebate with rebate $31.60 weekly $22.10 weekly $63.20 weekly $44.20 weekly $ monthly $95.85 monthly $ monthly $ monthly ($250 Excess) ($250 Excess) $ quarterly $ quarterly $ quarterly $ quarterly $ monthly $ monthly $1, monthly $1, monthly $1, yearly $1, yearly $3, yearly $2, yearly Smart Start 500 $27.95 weekly $19.55 weekly $55.85 weekly $39.05 weekly $ monthly $84.65 monthly $ monthly $ monthly ($500 Excess) $ quarterly $ quarterly $ quarterly $ quarterly $ monthly $ monthly $1, monthly $1, monthly $1, yearly $1, yearly $2, yearly $2, yearly Join Queensland Country today Joining our fund is simple. Choose one of the following options that suit you: Call us on freecall Apply online through our online application process at Complete the application at the back of this brochure and mail it to us Visit a retail Service Centre and let one of our friendly staff assist you Drop into one of Queensland Country Credit Union s 23 branches in Queensland Switch to Queensland Country Health Fund If you are a member of another health fund, it s quick and simple to transfer to us. Simply complete our membership application and cancel any direct debits you may have with your old fund. We will contact your old fund and arrange for the transfer of cover. Money back guarantee If you are not completely satisfied with your new health insurance policy we will provide a refund of any premium paid (if a claim hasn t been made) if you write to us advising that you are not satisfied with your policy within 30 days of the commencement date of your policy. 11
14 12 In more detail We have included information you may need. Additional information is available in the Membership Guide. Pre-Existing Conditions A pre-existing ailment, illness or condition is one where, after examining evidence, a medical adviser, or other relevant health care practitioner appointed by Queensland Country Health Fund would consider that signs or symptoms would have been in existence at any time during the six months preceding the application for membership or upgrade of cover. You may have a pre-existing condition, ailment or illness without being aware of it. In these cases, there is a 12 month waiting period before you are entitled to claim benefits for treatment. It is not necessary for the signs or symptoms to have been diagnosed by a doctor when a Member joined or upgraded their level of cover. Surgery for assisted fertility programs such as IVF or GIFT (restricted benefit), Sterilisation or Vasectomy are elective and attract a 12 month waiting period as does obstetrics-related services. The 12 month Pre-existing condition waiting period can be applied to all hospital or hospital substitute treatment for which we pay benefits. However, a two month waiting period applies to the following services: approved psychiatric treatment (restricted benefit only) approved rehabilitation treatment, or palliative care. The 12 month waiting period for the treatment of a Pre-existing Condition can also apply to ancillary (Extras) services.
15 Benefit Conditions Queensland Country Health Fund will only pay benefits when: Benefits are not payable, or may be payable at a reduced rate, during any applicable waiting periods. Benefits are not payable for claims for goods purchased or rendered outside of Australia or, for items purchased or hired from overseas suppliers (including internet purchases) Goods or services are provided in Australia (not including items imported by the user via an internet purchase) The Member has been charged for the treatment or service A service or treatment is medically necessary and clinically relevant Services are part of a course of treatment recognised by Queensland Country The service is provided in person The service is provided to a person on the membership The service or treatment has been provided by a practitioner or therapist recognised by Queensland Country Health Fund The treatment or service is covered under the Member s level of cover No benefits are payable from another source (e.g. compensation payment or Government benefit) The conditions of the level of cover have been met A claim for a service rendered is submitted for payment within 24 months of the date of service The waiting period for that service has been served The amount of benefit is calculated on the cost of the treatment or aid to the Member, taking into account any allowances or discounts given by the provider. No benefit paid by Queensland Country Health Fund can exceed the actual charge of the service or appliance.
16 Membership Year All yearly limits and excesses are calculated from the anniversary date of the establishment of the membership. Singles, Couples & Families Single: a single policy covers only one person. Couple: a couple policy covers the person who establishes the policy as well as one other partner/spouse. The policy can be extended to cover dependant children at no additional cost. Family: a family policy covers the person who establishes the policy as well as that person s partner and all dependant children. Always make sure you have waited the sufficient period before claiming, otherwise you may not be covered Waiting Periods So when will I be fully covered you ask? Waiting periods apply when you join any health fund for the very first time or when you upgrade to a higher level of cover. But you won t have to wait if you re transferring to Queensland Country Health Fund from an equivalent or higher level of cover with another health fund, or if you ve been covered by your parents membership and you re just starting out on your own. Waiting periods are necessary to keep health cover fair and aim to protect our existing policyholders who contribute to a fund over a period of time for when they may need cover. If we didn t have these waiting periods people may join, claim for something planned and then leave. Always make sure you have waited the sufficient period before claiming, otherwise you may not be covered! For those of you who are thinking of starting a family, if you have a single policy, to be sure your baby has cover, it is necessary to upgrade your single policy to a family policy no less than two months prior to the actual delivery date.* If you want to change your existing level of Extras cover for one that is more extensive you will be required to serve waits on the increased benefits only. * Waiting periods for pre-existing conditions apply 14
17 Waiting Period Item / Service Dental Diagnostic includes examinations & consultations Preventative includes cleaning and scaling, fluoride treatment etc. Simple extraction Restorative composite and amalgam fillings General services includes mouth guards and Occlusal splints Optical 2 months Acupuncture Chiropractor Massage Therapy Osteopathy Physiotherapy Podiatry Dietitian Healthy Living Benefits Pre-existing Conditions Obstetrics-related Services (restricted benefit) 12 months Major Dental services Periodontics specialised gum treatment Surgical Extraction includes Wisdom tooth extraction Endodontic Services includes root canal therapy Crowns and Bridges Orthodontics Braces etc. Surgery for assisted fertility programs such as IVF or GIFT, sterilization or vasectomy, elective surgery (Restricted benefit) Two month waiting periods apply for most other items or services. The 2 month Waiting Period is waived for treatment arising from an accident (excluding a school and sporting accident) that occurred after joining. 15
18 Contribution in arrears A policyholder who fails to pay contributions within 63 days of the day of which contributions were due and payable shall be deemed to be un-financial. No benefits are payable for services rendered whilst a membership remains un-financial. However, provided contributions are paid within 63 days of the due date, the membership will be re-instated. Membership of Queensland Country Health shall automatically cease for any policyholder whose contributions are more than 63 days in arrears. Length of Stay Full hospital benefits are not available after 35 days of continuous hospitalisation unless your doctor certifies the need for continued hospital-level care. Excess Smart Start cover is available with a choice of a $250 or $500 for single membership or couple membership. The excess that applies in any one membership year is $250 or $500, depending on which one you choose. This means for example that regardless of how many times hospitalisation is required throughout the year if you have the $250 excess, you would only pay a maximum of $250 for single membership, and $500 for couple membership. The excess applies to the full cost of hospitalisation at a public, private or day hospital facility. 16 Dependants Dependants include a policyholder s children and stepchildren, legally adopted children or foster children under the age of 21. Dependants turning 21 who are not eligible for cover under a family membership as a student or apprenticeship dependant are required to commence their own membership if they wish to continue private health cover. The good news is that they can move straight across to their own single membership without having to serve any waiting periods. Dependants will be covered as student dependants under their parent s membership from 21 years of age up to 25 years of age, provided the following conditions are satisfied: Is a full time student at a school, college or university who is not aged 25 years or over, or Is an apprentice who is not aged 25 years or over and does not earn more than $20,000 p.a. And does not have a partner If, at any time, your student dependant s situation changes and they no longer meet all the above conditions then please contact us for further information. Cooling Off Period Queensland Country Health Fund will allow any Member who has not yet made a claim to cancel their policy and receive a full refund of any premiums paid within a period of 30 days from the commencement of their policy or upgraded policy.
19 Recognised Providers Queensland Country Health Fund will only pay benefits for ancillary, dental and nursing/ midwifery services where the services are provided by practitioners recognised by Queensland Country. Recognition is subject to change without notice. There are no benefits payable for overseas hospitalisation or ancillary care. 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 that their practitioner is recognised before commencing treatment. Pharmaceutical The Pharmaceutical Benefits Scheme (PBS) is a national pharmaceutical scheme funded by the Federal Government where patients make a contribution to the cost of prescribed drugs. We do not pay for any pharmaceutical prescriptions covered by the Pharmaceutical Benefits Scheme or for contraceptives and items normally available without prescriptions. If the claim is for a PBS Pharmaceutical prescription, or for items dispensed at Public Hospitals or for discharge drugs, Queensland Country Health Fund cannot pay a benefit. Benefits are paid if: Prescribed and dispensed as appears in the MIMS book, and The prescribed medication is noted as S4 or S8 products The item is over the PBS nominated amount You pay the PBS equivalent charge and Queensland Country Health Fund will pay a Benefit above the PBS amount as outlined in the Extras table. Overseas suspension of membership If you re lucky enough to travel overseas, and you re going to be absent from Australia for more than 4 weeks and less than 24 months, and provided you ve fulfilled all other criteria, you may apply for a suspension on your membership. To get the full picture, please call us when you re making your travel plans. Summary of Rules The In more detail pages contain only a summary of the fund rules. The complete rules of the health benefits fund set out in full the terms and conditions of membership and liability under the fund. These rules are available for inspection at Queensland Country Health Fund, Level 1, 296 Ross River Road, Aitkenvale QLD Private Health Insurance Code of Conduct Queensland Country Health Fund is a signatory to the Private Health Insurance Code of Conduct. The code was developed by the health insurance industry and aims to promote the standards of service to be applied throughout the industry. A full copy of the Code is available at 17
22 Contact Details Registered Office 85 Patrick Street, Townsville QLD 4814 Townsville Administration Level Ross River Road Aitkenvale QLD 4814 Telephone: (07) Facsimile: (07) Postal Address: PO Box 42 Aitkenvale QLD 4814 Willows Service Centre Shop 38 Willows Shoppingtown Kirwan QLD 4817 Gladstone Service Centre Shop 39 Gladstone Central Shopping Centre Gladstone QLD 4680 Mount Isa Service Centre 70 Camooweal Street Mount Isa QLD 4825 Telephone: (07) or (07) Facsimile: (07) Postal Address: PO Box 1282 Mount Isa QLD 4825 Burdekin Service Centre 186 Queen St Ayr QLD 4807 Mackay Service Centre Caneland Central Shopping Centre 2 Mangrove Road Mackay QLD 4740 Freecall: Web: 20
23 Please find enclosed: Membership Application and Alteration Advice
24 How to contact us If you have any questions or need more information, please contact us by: Branch Visit our website for a listing of all our branches Website Call Queensland Country Health Fund Ltd ABN is a Registered Private Health Insurer.