Cover for the whole family

Transcription

1 Cover for the whole family

2 Why take out private health insurance? Enjoy the peace of mind of knowing your family is protected with family health cover Private health insurance allows you to be safe in the knowledge that you are protected when those unexpected accidents occur. Our hospital and extras products provide the right coverage, such as hospital cover especially priced for single parent families. At GMHBA, we understand the decision to get private health Insurance can be challenging. So many questions: When do I need it?, What does it cover? and How much can we save on tax? In this brochure, we hope to answer all of your questions and more. We are here to help you every step. Let us look at your family s specific needs to help you determine the best cover. So, here are the basics first. Minimise tax If your family s taxable income is over the amount set by the government, you can avoid paying the extra 1%-1.5% Medicare Levy Surcharge (MLS) by taking out any one of our family hospital covers. The cost of some GMHBA hospital covers could be cheaper than paying the Medicare Levy Surcharge. You can find more information at privatehealth.gov.au or ato.gov.au Australian Government Rebate The Australian Government Rebate reduces the cost of private health insurance and makes your cover more affordable. This rebate is available to any Australian who is eligible for Medicare and, depending on your income and the age of the oldest person on your policy, the government may pay a percentage of your premium. The rebate applies to all GMHBA covers and there are a number of ways to claim the Australian Government Rebate: As a premium reduction through GMHBA or as; A lump sum payment when lodging your annual tax return. Avoid paying higher premiums after you turn 31 By taking out hospital cover before the 1st of July after your 31st birthday, you will avoid paying a higher premium. After this date, you pay an extra 2% on premiums for each year you don t have hospital cover. The Australian Government introduced the Lifetime Health Cover Loading (LHC) to encourage people to take out hospital cover early in life and maintain it. So, every year you wait adds extra to your premium and when you finally do take out hospital cover your premium could increase 2% a year up to 70%. If you re a couple, any applicable loadings are shared across your membership. It s easy to avoid the additional loading. Take out hospital cover by the 1st July, following your 31st birthday and ensure you have continuous cover. ii

3 Why choose GMHBA Health Insurance? Not for profit Money back guarantee Multi award winner Established insurer Australia wide Friendly expert staff Easy online claims As an Australian not for profit health fund with over 80 years experience, we put people before profit and are the health insurer of choice for more than 260,000 Australians. Our range of affordable health covers deliver real value, great benefits and the freedom to choose your own provider, not one that s chosen for you. Through our personalised approach and exceptional customer service, we provide more choice and flexibility when it comes to the health of you and your family. A Members Own Health Fund We ve joined 14 other like-minded health funds that are run to benefit you and your family, rather than investors or overseas owners. With Members Own Health Funds, you are treated as a member, not a number or a profit centre. The Members Own Health Funds brand carries the promise that participating funds: Are run to benefit members not shareholders or overseas owners On average give more (of members premiums) back to members* Offer a better, more personalised service to their members^ At GMHBA we believe this is how a health fund should be run, because we re for people, not profit. That s why we re proud to be a Members Own Health Fund. For more information visit membersown.com.au or gmhba.com.au *Based on paid benefits as a percentage of premiums. ^Based on member retention rates of 2+ years and complaints to the Private Health Insurance Ombudsman. Claims based on five year average, aggregated outcomes of Members Own Health Funds versus the group comprising Medibank, AHM, nib and Bupa. 1

4 GMHBA rewards you Choosing to have combined hospital and extras cover allows you to enjoy the benefits of GMHBA s member loyalty program, Connect Rewards Plus. This program allows members to accumulate Connect Rewards dollars year on year. The amount of dollars you receive depends on how long you have been a GMHBA member and your level of hospital cover. So, the longer you have been with us the more rewards dollars you will receive. Here s how it works The table below details the Connect Rewards Plus dollars earned based on members tenure and level of hospital cover. Connect Rewards Plus benefit entitlements remain available while combined hospital and extras cover is maintained continuously. Years of membership (tenure) Hospital cover Bronze $0 $40 $60 $80 $100 Silver $20 $60 $80 $100 $120 Gold^ without Gap Saver $40 $80 $100 $120 $140 with Gap Saver $80 $120 $140 $160 $180 ^ Gold Hospital cover rewards includes cover with and without pregnancy. Please note: benefits listed in this table apply to family, couples and single parent memberships. Rewards for singles are half those listed in the table. Here are some benefit examples. 1. A family on Gold Hospital with Gap Saver and Gold Extras who have held continuous combined cover for eight years will receive $160 Connect Rewards Plus dollars in that year. 2. A single on Gold Hospital (without Gap Saver) and Bronze Extras after their first year of cover will receive $20 Connect Rewards Plus dollars. Use your rewards to reduce or eliminate out of pocket expenses: Automatically claim inpatient medical gap Reduce your hospital excess Double your optical limit * Increase annual limits for: * physiotherapy chiropractic/osteopathic remedial massage Increase major dental benefits including: * crowns bridgework dentures surgical extractions implants indirect restorations orthodontic endodontic services Please note: services listed within the program must be provided by practitioners who are registered with recognised bodies approved by GMHBA. A doctors letter of recommendation may be required to claim some items. For further details, please review the Important Information Guide at gmhba.com.au or call * Only available on services already included in your extras cover and only when annual limits have been reached. 2

5 GMHBA health programs and Best Doctors Health programs We give you access to a number of health and wellbeing programs including home care and support for specific health conditions. The following health programs are available to all members with hospital cover. Hospital in the Home Hospital in the Home (HITH) is a hospital substitution service that allows members to access acute care services including medication management, intravenous therapy, nursing and continence management in the comfort of their own home. Rehabilitation in the Home Rehabilitation in the Home (RITH) is hospital substitution and provides services that would otherwise be completed in a rehabilitation facility or hospital. Services may include: physiotherapy, occupational therapy, care coordination and personal care. Best Doctors Best Doctors was established to connect people with a health condition to a network of specialists within the Best Doctors network in order to get a second opinion on their health care. Through this service you will have access to leading specialists from around the world that will: Review your medical records. Provide answers to any questions you may have. Provide a written report on your current diagnosis and either confirm the current treatment plan or suggest an alternative, which you can share with your treating doctor. To find out more information on our health and wellbeing programs and Best Doctors visit the GMHBA website or call us. New Family Program The New Family Program is a specialised program to assist parents in the first few months when a baby is welcomed into a family. It is available to members with hospital cover that includes pregnancy. 3

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7 Our hospital cover For the growing or settled family, our range of hospital covers makes it easy for you to manage your family s health. You can select the level of cover suited to your family s needs and for the things that are important to you, without paying for the things you don t need, like pregnancy. With GMHBA hospital cover you will: Have a greater choice of who treats you; Have more choice on where you are treated; Have a greater choice about when you are treated; Receive treatment as a private patient; Lock in your Lifetime Health Cover age; and Avoid the Medicare Levy Surcharge, if it applies to you. Whether you re getting health cover for total peace of mind and protection, to avoid the Medicare Levy Surcharge or to lock in your Lifetime Health Cover loading, we ve got a cover to suit your family s needs and budget. Excess option GMHBA s range of hospital covers often feature an excess to let GMHBA members share some of the cost of hospital admissions in return for lower premiums. For excess options, please refer to page 25. Bronze Hospital Bronze Hospital is a great choice for those families on a budget. This affordable cover provides a safety net with your own choice of doctor as a private patient in a public hospital. This basic cover will give you access to common treatments with some exclusions to help reduce the premium. Silver Hospital Great value cover in a private hospital paying for most in-patient treatments, Silver Hospital is an ideal cover for established families who aren t planning on having more children. Silver Hospital excludes selected hospital treatments that may not be relevant to your family s life stage. A co-payment is included to help reduce the premium to give you the option to be treated in a single room. Gold Hospital A comprehensive hospital cover, Gold Hospital gives your family access to a wide range of treatments in a private hospital. You can tailor your cover to suit your family s life stage without paying for services you are unlikely to need. We give you the flexibility to remove pregnancy and/or increase your medical gap cover with our Gap Saver option. Gold Hospital provides comprehensive cover no matter the life stage of your family. 5

8 Bronze Hospital An affordable, basic level of cover, Bronze Hospital gives you and your family treatment as a private patient in a public hospital. What is covered in a public hospital? Bronze Hospital provides cover for accommodation costs when you are admitted to a shared room in a recognised public hospital, 1 less any applicable excess. This is for services such as: Removal of tonsils and adenoids Grommets in ears Removal of appendix Hernia repair Colonoscopy Joint investigation and reconstruction such as knee and shoulder Hospital treatment as a result of an accident sustained after joining 2 Cardiac surgery Psychiatric services Also includes cover across a range of other services What is covered in a private hospital? This product is not recommended if you need to be admitted to a private hospital. For services not listed under exclusions, default benefits are payable for accommodation in private hospitals. The benefit depends on the type of treatment, accommodation or surgery received and length of the hospital stay. Additional private hospital costs such as theatre and delivery suite charges are not covered through Bronze Hospital cover. Health Programs Health and Wellbeing programs Best Doctors New Family Program Exclusions To reduce your premium, Bronze Hospital excludes the following services. Haemodialysis Gastric banding and all obesity surgeries. Please note: Benefits for a single room in a public hospital or treatment in a private hospital when using Bronze Hospital cover will result in significant out of pocket expenses. For further information on private hospital benefits on Bronze Hospital, please call us on or visit a branch. Waiting periods Please refer to page pages regarding waiting periods and pre-existing conditions. Additional benefits In both public and private hospitals, our Bronze Hospital cover includes benefits for: Medical Gap Surgically implanted prostheses 3 Nursing home type patients 4 As a private patient in a public hospital, you may have the choice of doctor if that doctor is available and has the rights of private practice at that hospital. Depending on the situation this may or may not be the same doctor who would have been allocated to you by the hospital as a public patient. 1. Limited benefits may apply to high cost drugs. Drugs purchased outside of the hospital are not included. 2. Accidents bodily injuries resulting from accidents which occur after the date of joining or upgrading to a higher level of cover. For further details, please review the Important Information Guide at gmhba.com.au or call Benefits are no higher than the No Gap Government prescribed benefit. 4. Government prescribed benefits are available towards non-acute hospital care. 6

9 Silver Hospital A moderate level of cover for the settled family, Silver Hospital is ideal if you prefer cover in a private hospital. To keep costs down, Silver Hospital cover includes a co-payment and excludes a range of services and treatments that your family may not need. Silver hospital cover is ideal if you re not planning to extend your family. What is covered in a participating private hospital? Silver Hospital provides cover for services not listed under exclusions at participating private hospitals 1 for a range of services including: Private hospital accommodation in a shared room Partial cover in a single room a co-payment applies 2 Removal of tonsils and adenoids Grommets in ears Removal of appendix Hernia repair Colonoscopies Joint investigation and reconstruction such as knee and shoulder Hospital treatment as a result of an accident sustained after joining 3 Cardiac surgery Psychiatric services Removal of tonsils and adenoids Health Programs Health and Wellbeing programs Best Doctors New Family Program What is covered in a public hospital? For services not listed under exclusions, Silver Hospital provides cover 1 as a private patient in a public hospital for accommodation in a shared room or partial cover in a single room. Co-payments of $100 per day apply for single rooms, capped at seven days per admission. Exclusions To reduce your premium, Silver Hospital excludes the following services. Pregnancy and birth related services IVF and related services Joint replacement Cosmetic surgery Dental implants Cataract surgery and corneal transplants Haemodialysis Gastric banding and all obesity surgeries Waiting periods Please refer to page pages regarding waiting periods and pre-existing conditions. Benefit limitation periods A 24 month benefit limitation period applies to psychiatric services. Other private hospitals Fixed benefits are payable in non-participating private hospitals. 1. Limited benefits may apply to high cost drugs. Drugs purchased outside of the hospital are not included. You may be subject to doctors waiting lists in a public hospital. Default benefits are paid for all public hospital episodes. 2. Please note: Some private hospitals on have single rooms and co-payments will apply. 3. Accidents bodily injuries resulting from accidents which occur after the date of joining or upgrading to a higher level of cover. For further details please review the Important Information Guide at gmhba.com.au or call

10 Gold Hospital Tailor your cover to suit your family s life stage with Gold Hospital, our most comprehensive hospital cover. With a family, you will find that it pays to be prepared with our Gold Hospital cover. Gold Hospital gives you the choice and flexibility to increase your medical gap cover with Gap Saver and the ability to remove pregnancy as your needs change. With kids, accidents can and do happen and with Gold Hospital you pay no hospital excess for child dependants under 21. What is covered in a participating private hospital? Gold Hospital provides cover 2 at participating private hospitals for a range of services including: Private hospital accommodation in a shared room or single room (where available) Removal of tonsils and adenoids Grommets in ears Removal of appendix Hernia repair Colonoscopies Joint investigation and reconstruction such as knee and shoulder Hospital treatment as a result of an accident sustained after joining 3 Cardiac surgery Psychiatric services Other agreed services or treatments What is covered in a public hospital? You will be covered 1 for hospital accommodation costs when you are admitted to a single or shared room (subject to bed availability) as a private patient in a public hospital. Health Programs Health and Wellbeing programs Best Doctors New Family Program Gold Hospital optional add-on Top cover Gap Saver Increase your medical gap benefits with Gap Saver^ and receive a single room guarantee. Please refer to page 22 for further details. Healthy Start Benefit Gold Hospital provides an additional benefit of up to $500 per childbirth admission to help cover the obstetrician s medical gap (inpatient services only). For further information on the Healthy Start Benefit, visit gmhba.com.au or call No excess for child dependants No excess applies for child dependants under 21 on Gold Hospital cover. Benefit limitation periods A 24-month benefit limitation period applies to the following services: psychiatric, haemodialysis, gastric banding and all obesity surgeries. Waiting periods Please refer to page pages regarding waiting periods and pre-existing conditions month waiting periods apply for pregnancy after the date of joining or upgrading your cover. 2. Limited benefits may apply to high cost drugs. Drugs purchased outside of the hospital are not included. You may be subject to doctors waiting lists in a public hospital. 3. Accidents bodily injuries resulting from accidents which occur after the date of joining or upgrading to a higher level of cover. 8

11 Compare our hospital cover This table provides a quick comparison of the main features of GMHBA s hospital covers. For more information visit our website. Excess options Bronze Hospital Silver Hospital Gold Hospital Level 0 NIL NIL NIL Level 1 $250 $250 $250 Level 2 $500 $500 $500 Some of the common services covered include: Accommodation for overnight and same day surgery Accommodation single room (where available) ^ # Accommodation shared room Accidents Appendicitis a Health Programs and Best Doctors Dental implant surgery a Gastric banding and all obesity surgeries a b Intensive and coronary care a IVF and assisted reproductive services a Joint investigations eg. knee arthroscopy a Joint reconstructions eg. knee a Joint replacements eg. hip a Medical gap cover Minor gynaecological procedures a Operating theatre a Pregnancy related services (including childbirth) d Psychiatric services a b b Rehabilitation services Removal of tonsils and adenoids a Removal of appendix a Surgically implanted prostheses (Government Prosthesis List group benefits) c Options: Remove IVF related services and pregnancy d - - Gap Saver increased medical gap cover and single room guarantee e - - Cover provided in a participating private hospital Public hospital cover as a private patient only No benefits payable # Partial coverage, a co-payment of $100 per day applies to a maximum of $700 per admission ^ Benefits for a single room in a public hospital will result in significant out of pocket expenses a. A pre-existing condition (PEC) is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by GMHBA (not your own doctor), existed at any time during the six months preceding the day on which you purchased your hospital cover or upgraded to a higher level of hospital cover and/or benefit entitlement. b. During the first 24 months of cover (after the standard hospital waiting periods have been served), benefits paid for these services will be limited to public hospital benefits only. c. Benefits are no higher than the no gap government prescribed benefit. d. 12 month waiting periods apply for pregnancy after the date of joining or upgrading your cover. e. We will pay you $100 per day (up to a maximum of $300 for 3 days) if you stay in a shared room when you requested a single room. This is only available for overnight accommodation in a private hospital. Day stays are ineligible for this payment. 9

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13 Our extras cover GMHBA offers a range of extras covers for you and your family to enjoy. We allow you the freedom to choose your own local health care provider, like your own dentist or physiotherapist. Because our benefits are not specific to preferred providers, you will receive the same benefits whoever you select. You can also enjoy the advantages of selecting from set benefits where you receive a set amount each time you claim or the percentage back option. Our extras cover provides benefits for services including dental, optical, physiotherapy, naturopathy, podiatry and chiropractic. The cost of these services is often not covered by Medicare but our Extras cover allows you to claim back a percentage of the fee. The services that are covered and to what extent depend on the level of extras cover you choose. Bronze Extras Bronze Extras is a great entry level option for those families on a budget who want a basic level of coverage across essential treatments such as preventative dental, general dental, physiotherapy and optical. To reduce the premium, Bronze Extras excludes certain services including major dental and orthodontics. Choose from set benefits or 55% back to give you more confidence when you visit your local health care provider. Silver Extras Offering a moderate level of cover on a range of popular services, Silver Extras provides a medium level of benefits and annual limits. You and your family will enjoy coverage across a range of services such as general and major dental, optical, physiotherapy, speech therapy and remedial massage. Choose from set benefits or 65% back on your service so that you can experience great value from your cover. Gold Extras Gold Extras cover provides your family with comprehensive coverage across a wide range of extras services as well as the highest level of benefits and annual limits. Gold Extras gives you total peace of mind, knowing you and your family are covered on our highest level of extras cover. You have the flexibility to choose from set benefits or 75% back, giving you more confidence when you visit your local health care provider. 11

14 Bronze Extras A basic level of cover for the budget conscious family, Bronze Extras covers your family for the essentials. You will feel confident in the knowledge that your family is covered across a range of essentials. Some services are excluded to keep premiums affordable including major dental and orthodontics. What is covered? Preventative dental General dental Optical Physiotherapy Hydrotherapy Myotherapy Occupational therapy Pharmacy and travel vaccinations Waiting periods Please refer to page 24 regarding waiting periods. Bronze Extras lets you choose from: Set benefits When you receive treatment for a covered extras service you will receive a set amount back, known as a set benefit. 55% Back The percentage back option gives you the certainty of receiving 55% when you claim up to annual limits. For further product details, you can review the Important Information Guide at gmhba.com.au or call

15 Silver Extras Offering a moderate level of cover across a range of services, Silver Extras gives your family peace of mind. A great level of cover for everyday use without having to pay more for high limits you are unlikely to reach. Silver Extras includes coverage across a range of popular services such as general and major dental, orthodontics, optical, physiotherapy and speech therapy. What is covered? Preventative dental General dental Major dental Orthodontics Optical Physiotherapy Remedial massage Speech therapy Chiropractic Pharmacy and travel vaccinations Psychology Podiatry Alternative therapies Ambulance subscription* Eye therapy Homeopathy Hydrotherapy Myotherapy Occupational therapy A range of other services Silver Extras lets you choose from: Set benefits When you receive treatment for a covered extras service you will receive a set amount back, known as a set benefit. 65% Back The percentage back option gives you the certainty of receiving 65% when you claim up to annual limits. For further product details, you can review the Important Information Guide at gmhba.com.au or call Waiting periods Please refer to page 24 regarding waiting periods. * Publicly funded Ambulance services and State Government ambulance transport schemes are excluded. Benefits for an ambulance subscription are determined by state of residence. 13

16 Gold Extras For comprehensive coverage across a range of services with generous benefits and annual limits, Gold Extras is an ideal cover. Enjoy the highest benefits on our top family extras cover across a range of popular services. What s covered? Preventative dental General dental Major dental Orthodontics Optical Physiotherapy Hydrotherapy Exercise physiology Myotherapy Speech therapy Chiropractic Antenatal and postnatal Pharmacy Psychology Podiatry Alternative therapies Remedial massage Ambulance subscription * Eye therapy Homeopathy Occupational therapy A range of other services Gold Extras lets you choose from: Set benefits When you receive treatment for a covered extras service you will receive a set amount back, known as a set benefit. 75% Back The percentage back option gives you the certainty of receiving 75% when you claim up to annual limits. For further product details, you can review the Important Information Guide at gmhba.com.au or call Waiting periods Please refer to page 24 regarding waiting periods. * Publicly funded ambulance services and State Government ambulance transport schemes are excluded. Benefits for an ambulance subscription are determined by the state of residence 14

17 Compare our extras cover This table details your extras options at a glance using an easy to follow star system. The more stars shown the better coverage and benefits. Bronze Silver Gold General dental Major dental and orthodontics Optical Physiotherapy, myotherapy and hydrotherapy Orthodontis Exercise physiology Speech therapy Chiropractic and osteopathy Pharmacy including travel vaccinations Psychology Antenatal and postnatal Podiatry and foot orthotics Acupuncture, naturopathy and homeopathy Remedial massage Dietetics and Diabetes education consultation Psychology Eye therapy Audiology Occupational therapy Nursing Blood glucose monitor Extremity pump Dietary fluoride supplement Hearing aids Home nursing Nebuliser pump Pressure garments (GMHBA approved) Prostheses (GMHBA approved, non-surgical) Sleep apnoea monitor Tens monitor Orthopaedic appliances Ambulance subscription subsidy^ Weight loss program ^ To be fully covered for Ambulance services, we recommend that you take out an ambulance subscription in your state or territory. You can claim a refund on one ambulance subscription per membership each calendar year on gold and silver extras. Publicly funded ambulance services and State Government ambulance transport schemes are excluded. 15

18 How much can be claimed on extras? Please refer to the Important Information Guide on gmhba.com.au or call for further information on our extras benefits. Extras Services Dental The benefits shown are the annual limits for each type of dental service. The annual limit is a combined general and major dental limit. There are further sub limits within some of these dental services. Overall dental annual limit Per person, per calendar year General dental eg. Diagnostic services, simple extractions (not including surgical extractions of wisdom teeth) and restorative services (limited benefits apply to precious restorations) Preventative services eg. Periodic examination and removal of plaque Major dental Maximum benefit per calendar year. Set benefits apply up to annual limits Orthodontics Waiting Periods Orthodontic maximum benefit per course of treatment Orthodontic lifetime benefit limit Combined crown and bridgework Indirect restorations Annual limit per family Implants Dentures Full upper and lower dentures per 2 years Optical Prescription spectacles, contact lenses and frames (non-prescription sunglasses are excluded). Laser surgery claimable on Gold Extras only Physiotherapy, myotherapy and hydrotherapy Annual limit combined with exercise physiology Initial visit Subsequent visits Class attendance $240 annual limit per person applies. This is included within your overall annual limit Annual limit per family Exercise Physiology Annual limit combined with physiotherapy, myotherapy and hydrotherapy Initial visit Subsequent visits Annual limit per family 6 months 16

19 Bronze Extras Silver Extras Gold Extras Set Benefits 55% Set Benefits 65% Set Benefits 75% Set benefits apply $1,000 $1,500 $2,000 55% up to annual limits Set benefits apply 65% up to annual limits Set benefits apply 75% up to annual limits Up to $300 55% up to $300 Up to $400 65% up to $400 Up to $500 75% up to $ Year 1-3 Year 4 Year 5 Year 6+ $320 $400 $470 $570 65% up to $320 65% up to $400 65% up to $470 65% up to $570 Year 1-3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10+ $450 $550 $600 $650 $700 $750 $800 $ $1,710 $2, $1,900 $2, $450 $ $350 $ $700 $ $500 $ $420 $500 75% up to $450 75% up to $550 75% up to $600 75% up to $650 75% up to $700 75% up to $750 75% up to $800 75% up to $850 80% 55% 80% 65% 100% 75% $150 $200 $250 $30 55% $35 65% $40 75% $22 55% $26 65% $30 75% $10 55% $20 65% $30 75% $300 $400 $500 $600 $800 $1, $40 75% $30 75% $ $1,000 17

20 How much can be claimed on extras? Extras Services Chiropractic and osteopathy Initial visit Subsequent visits Chiropractic x-ray Annual limit per family Naturopathy, homeopathy, acupuncture (annual limit combined with remedial massage) Initial visit Subsequent visits Annual limit per family Remedial Massage (annual limit combined with naturopathy, homepathy and acupuncture) Initial visit Subsequent visits Annual limit per family Ambulance subscription/transport To be fully covered for Ambulance services, we recommend that you take out an ambulance subscription in your state or territory. You can claim a refund on one ambulance subscription per membership each calendar year under Gold Extras and Silver Extras (excluding Tas/Qld/NSW). A transport benefit per trip is payable, however this will result in significant out of pocket costs. Publicly funded ambulance services and State Government Ambulance transport schemes are excluded (Tas/Qld/NSW) Annual subscription refund Transport benefit (per trip) Psychology Initial visit Subsequent visits Annual limit per family Pharmacy including travel vaccinations private script Private script benefits are only payable towards the cost of prescription pharmaceuticals that are dispensed through a provider in private practice. Pharmaceuticals must be classed as either Schedule 4 or Schedule 8 for benefits to be paid. Members pay the first maximum PBS contribution then the following benefit is paid towards the balance Annual limit per family Dietetics and Diabetes Education Consultations Initial visit Subsequent visits Waiting Periods N/A 18

21 Bronze Extras Silver Extras Gold Extras Set Benefits 55% Set Benefits 65% Set Benefits 75% - - $24 65% $27 75% - - $18 65% $20 75% $40 65% $44 75% - - $300 $ $600 $ $20 65% $27 75% - - $15 65% $20 75% - - $300 $ $600 $ $20 65% $23 75% - - $15 65% $17 75% - - $300 $ $600 $ % 65% 100% 75% - - $300 $ $500 $ $39 65% $45 75% - - $29 65% $34 75% - - $350 $ $600 $800 $20 55% $23 65% $27 75% $150 $250 $350 $350 $450 $ $56 65% $60 75% - - $41 65% $45 75% - - $400 $500 19

22 How much can be claimed on extras? Extras Services Fluoride dietary supplement Benefits payable towards the cost of dietary supplements dispensed by a chemist or dentist. Benefit up to Maximum benefit per person Audiology Initial visit Subsequent visits Antenatal and postnatal classes Sessions and courses must be provided by a registered midwives or physiotherapists in a private practice. Benefits are not payable for courses or sessions that are paid for by Medicare. Initial visit Subsequent visits Eye therapy and speech therapy Initial visit Subsequent visit Occupational therapy Initial visit Subsequent visits Annual limit per family Podiatry Initial visit Subsequent visits Comprehensive treatment initial visit Comprehensive treatment subsequent visits Surgical procedures 80% of the cost up to Nursing Home (bush) nursing benefit for each visit Registered nurse visit (private practice), benefit per hour Maximum benefit for each day Prostheses (non-surgical) Prostheses include a range of approved non-surgically implanted prostheses (eg. wigs) A doctor s letter of recommendation is required prior to claiming. Benefit up to Maximum benefit per person every 3 years Waiting Periods 20

23 Bronze Extras Silver Extras Gold Extras Set Benefits 55% Set Benefits 65% Set Benefits 75% $16 55% $19 65% $22 75% $45 $45 $ $35 65% $41 75% - - $27 65% $31 75% - - $400 $ $48 75% $42 75% $ $30 65% $35 75% - - $23 65% $26 75% - - $400 $500 $30 55% $36 65% $42 75% $23 55% $27 65% $31 75% $300 $400 $350 $600 $800 $1, $26 65% $30 75% - - $20 65% $23 75% $33 65% $39 75% $25 65% $29 75% $115 65% $115 75% - - $250 $ $8 65% $8 75% - - $8 65% $8 75% - - $48 65% $48 75% - - $1,000 $1, $130 65% $160 75% - - $200 $250 21

24 How much can be claimed on extras? Extras Services Health aids and appliances A doctor s letter of recommendation is required prior to claiming and are limited to one item per membership every 3 years. Blood glucose monitor Extremity pump Nebuliser pump Sleep apnoea monitor Tens monitor Hearing aids Maximum benefit per person every 3 years Orthopaedic repairs Health aids and appliances (continued) Orthotic appliances (foot) Must be custom made by a podiatrist or orthotist, and not by a chiropractor or physiotherapist. Annual limit per family Pressure garments Garments must be supplied through a private company or therapist in private practice. A doctor s letter recommending the appliance must accompany each claim for benefits. Orthopaedic appliances Must be custom made and GMHBA specified and approved. Maximum benefit per person Weight loss program Benefit payable at a participating weight loss program and is recommended in writing by a doctor. Benefit on achieving 10% of start weight Benefit on achieving goal weight (within 24 months) Lifetime benefit limit per policy Waiting Periods All extras services must be provided by practitioners in private practice who are appropriately registered bodies approved by GMHBA Health Insurance. All benefits listed are per calendar year, unless otherwise specified. Preventative Health Benefits We give you access to a range of preventive health benefits listed below. Preventative Health Bowel cancer identification kits (purchased through GMHBA) Melanoma Surveillance Photography Quit smoking programs Nicotine replacements patches Service limit 1 every 2 years 1 per year 1 per year 1 x 12 course of patches per year 22

25 Bronze Extras Silver Extras Gold Extras Set Benefits 55% Set Benefits 65% Set Benefits 75% % up to $150 65% up to $ % up to $200 75% up to $ % up to $300 65% up to $ % up to $300 75% up to $ % up to $150 65% up to $ % up to $150 75% up to $ % up to $200 65% up to $ % up to $200 75% up to $ % up to $100 65% up to $ % up to $100 75% up to $ % up to $744 65% up to $ % up to $859 75% up to $ $1,200 $1,500 Maximum annual limit per person $30 Maximum annual limit per person $40 Maximum annual limit per person $ $90 65% $103 75% - - $200 $ $400 $550 $42 55% $49 65% $57 75% Maximum $100 per person every 3 years $200 annual limit per person every 3 years $300 annual limit per person $71 55% $84 65% $97 75% $200 every three years $300 every three years $400 annual limit $100 75% $100 75% $400 Bronze Silver Gold $50 per person $100 per family $100 per person $200 per family $150 per person $300 per family 23

26 How long are waiting periods? What are waiting periods? A waiting period is the time between joining GMHBA and when you can start claiming. Waiting periods exist to protect members from claims made by those who join the fund or increase their level of cover because they have a condition or illness that may require treatment. Waiting periods exist across all GMHBA hospital and extras covers and apply to: New memberships (previously uninsured); Existing GMHBA members who upgrade to a higher level of cover or reduce their excess payable; Members who transfer from another health fund who have not fully served the required waiting and/or benefit limitation period for equivalent benefits; as well as Treatment for a pre-existing condition. Waiting periods Hospital services (when included on cover) Accidents bodily injuries resulting from accidents that occur after the date of joining GMHBA or upgrading to a higher cover Pregnancy and birth related services Pre-existing ailment, illness or condition (other than psychiatric, rehabilitation and palliative care) Any other benefit for hospital (or hospital substitution) treatment Extras services (when included on cover) All extras benefits except as specified below Optical Major dental services, including full and partial dentures, orthodontics, crowns and bridgework, endodontic services such as root canal, gold fillings, indirect restorations and surgical extractions of a tooth/teeth including wisdom teeth Health appliances, including nebuliser pump, blood glucose monitor, pressure garments, sleep apnoea monitor, extremity pump, hearing aids, orthopaedic appliances (GMHBA approved), prostheses (GMHBA approved non-surgical), tens monitor, podiatry surgical procedures and orthotic appliances (foot) Period None Period 6 months 24

27 What about pre-existing conditions? A special waiting period applies to obtain benefits for hospital treatment for new members who have pre-existing conditions (PEC). The waiting period also applies to existing members who have recently upgraded their level of cover. If the ailment, illness or condition is considered pre-existing, then: New members must wait for any hospital benefits (other than psychiatric, rehabilitation and palliative care); or Members transferring/upgrading to a higher hospital cover must wait to receive the higher hospital benefits (other than psychiatric, rehabilitation and palliative care). Existing members with at least membership in total across their old and new cover are entitled to the lower benefits on their old cover. Benefit limitation periods During your first 24 months of cover after the standard hospital waiting periods have been served, Gold and Silver Hospital are subject to benefit limitations on selected services. This means that the benefits payable on these services are limited to receiving the public hospital default benefits only, during the 24 month benefit limitation period. Once the waiting and benefit limitation period has been served, you will have access to the benefits applicable on your level of cover. Excess options Save even more on your premium by choosing a calendar-year excess. This is the amount you agree to pay up front before a benefit is paid for overnight or same day hospital admissions. There are three different excess levels available on all GMHBA hospital covers. Excess options tables Level 0 excess Level 1 excess Level 2 excess Admission excess (private hospital-overnight)* NIL $250 $500 Admission excess (public hospital or day stay)* NIL $125 $250 Maximum annual excess per person NIL $250 $500 Maximum annual excess singles NIL $250 $500 Maximum annual excess families NIL $500 $1,000 * The excess admission on Bronze Hospital cover is the maximum annual excess per person. (i.e. on Level 1 excess, a member on Bronze Hospital would pay $250 excess when admitted to a public hospital as a private patient). 25

28 What is medical gap cover? GMHBA s medical gap cover provides higher benefits than the scheduled fee which will reduce or even eliminate your out of pocket costs for doctor or specialist fees when treated in hospital. What is a scheduled fee (MBS)? The Federal Government created a schedule of fees (Medicare Benefits Schedule) set for eligible services by doctors in a hospital or day surgery. Medicare pays 75% of this scheduled fee for in-patient medical treatments and GMHBA pays the other 25%, up to 100% of the Medical Benefit Schedule (MBS) fee. In the event that your doctor chooses to use GMHBA s medical gap cover and where the actual fee for the anticipated service is greater than the MBS fee, an additional medical gap benefit will be paid equal to 20% of the MBS fee for each service. Our medical gap cover options If your doctor or specialist is one of more than 14,000 who choose to participate in GMHBA s medical gap cover system, two options are available for our hospital products: Option 1 Known gap Your doctor chooses to use GMHBA s medical gap cover system and charges a known patient gap (an amount higher than the scheduled fee). To participate, your doctor must inform you in writing of the cost of the anticipated services, the Medicare and GMHBA benefits and the patient gap before any treatment commences. They must bill us directly for the GMHBA and Medicare benefits. We will arrange to pay these benefits direct to your doctor and all you will need to pay is the known gap. Option 2 No gap Your doctor chooses to use our medical gap cover and not charge a patient gap, your GMHBA benefit and the Medicare benefit will fully cover the doctor s charges. In these instances, your doctor will bill us directly and you will pay nothing. Multiple doctors If other doctors are involved in your treatment (such as anaesthetists) you should ask GMHBA, your doctor or the other medical professionals if they will be using GMHBA s medical gap cover system. If they choose not to, you will still receive a combined Medicare and GMHBA benefit of up to 100% of the MBS fee and (if applicable) any GMHBA member Connect Rewards Plus dollars you may have accrued for medical out of pocket costs that exist. Gap Saver GMHBA s Gap Saver option provides medical gap cover regardless of whether your doctor participates or not. Where the actual fee for the anticipated service is greater than the MBS fee, an additional medical gap benefit will be paid for you, which in most cases will be in excess of 20% of the MBS fee for each service, as paid under our Gold, Silver and Bronze Hospital covers. The additional medical gap benefit under Gold Hospital with Gap Saver will vary by eligible service, please contact GMHBA prior to treatment to determine your additional medical gap cover benefit. Please note: additional medical gap benefits may not be payable towards the cost of imaging or pathology services. Contact GMHBA on for details. The participation in GMHBA s medical gap cover by any medical practitioner is not a recommendation or endorsement by GMHBA of that practitioner. Important: this information is provided as a guide only. Before you have any treatment, we suggest you contact us for the most up to date information. 26

29 Payment method options Direct debit You can save 2% by having your premiums deducted directly from your bank, credit union or building society account. Billing and reminder notices are not sent if you pay by automatic direct debit. Credit card When you choose this option, your premiums are automatically debited from your MasterCard or Visa credit card each month, quarter, half year or year whichever you prefer. Please note that automatic payments from a credit card do not attract the direct debit discount. Billing and reminder notices are not sent if you pay by automatic direct debit. Direct to GMHBA Your premiums can also be paid using any of the following payment method options: a. GMHBA branches payments can be made in cash, cheque or EFTPOS. b. Australia Post payments can be made in cash, cheque or EFTPOS when you present your billing notice at any Australia Post office with the Billpay facility. c. Pay online payments can be made by credit card through NAB s secure on-line payment facility. Simply visit gmhba.com.au and select the pay by web option. Alternately use the BPay facility of your financial institution. d. Pay by phone payments can be made by credit card over the phone using NAB Transact, simply phone Alternately you can use the BPay facility of your financial institution. e. Mail payments must be made by cheque, money order or credit card. Please do not send cash by mail. When making a direct payment either in person or by mail, you must present your billing notice. A billing notice will be sent to you if your premium is paid directly to GMHBA either monthly, quarterly, half-yearly or yearly in advance. 27

30 Joining is easy Online at gmhba.com.au At your local GMHBA Health Insurance branch Call us on Or complete an application form and mail it back to us Switching to GMHBA is easy Moving your health insurance to GMHBA from another health fund may be easier than you think. Not only is it a simple process, but we can help make sure that you aren t left without cover for any period of time, or have to re-serve any waiting periods. Plus you don t need to contact your previous health fund we can do that on your behalf. When you join, all you have to do is consent for GMHBA to cancel your policy. 60 day money back guarantee If you change your mind within 60 days of joining and haven t made a claim, we ll give you your money back. We make it easy to pay your premium You can choose to pay either by direct debit and receive a 2% discount, credit card, at your local GMHBA branch, by telephone or mail. Privacy We value the relationship between GMHBA and our members. An important part of this relationship is our commitment to protecting the personal information entrusted to us by our members. To access our Privacy Statement or our Privacy Policy you can pick up a copy at one of our branches, visit gmhba.com.au or call us on

31 Notes Private Health Insurance Code of Conduct GMHBA are proud to be a compliant member of the Private Health Insurance Code of Conduct. The Private Health Insurance Code of Conduct is designed to help you by providing clear information and transparency in your relationships with health insurers. The code covers four main areas of conduct in private health insurance ensuring: You receive the correct information on private health insurance from appropriately trained staff; You are aware of the internal and external dispute resolution procedures with GMHBA Health Insurance; Policy documentation contains all the information you require to make a fully informed decision about your purchase and all communications between you and GMHBA are conducted in a way that ensures appropriate information flows between the parties; and All information between you and GMHBA is protected in accordance with national and state privacy principles. You can download the code at privatehealth.com.au/codeofconduct 29

32 Branches Geelong: Moorabool Street Belmont: 178 High Street Newcomb: Bellarine Village, Queenscliff Road Norlane: Bellpost Shopping Centre, Anakie Road Ballarat: 62 Bridge Mall Bendigo: Fountain Court, Mitchell Street Colac: 178 Murray Street Hamilton: 182 Gray Street Portland: 112a Percy Street Warrnambool: 114 Lava Street Werribee: Wyndham Private Medical Centre, 242 Hoppers Lane gmhba.com.au Moorabool Street, Geelong, Vic 3220 PO Box 761, Geelong, Vic 3220 Call Fax ABN