MILDURA DISTRICT HOSPITAL FUND LTD. ABN

Transcription

1 MILDURA DISTRICT HOSPITAL FUND LTD. ABN HEALTH INSURANCE SINCE 1929 A REGISTERED PRIVATE HEALTH INSURER EFFECTIVE APRIL 1 st 2013

2 CONTENTS Page Mildura District Hospital Fund 2 Why have Private Health Insurance? 2 Medicare 3 Choice of Hospital & Extras Cover 3 Five Star Hospital Benefits 4 Hospital Five Star 4 Hospital Five Star Excess 1 4 Hospital Five Star Excess 2 4 Hospital Five Star Excess 3 4 Basic Hospital Benefits 5 Gap Medical Benefits 6 Hospital Benefits Limitations, Prostheses 7 Hospital Waiting Periods 8 Dental Benefits Benefits, Limitations, Waiting Periods 9 Dental Benefit Table 10 Basic Ancillary Benefit Table 11 Ancillary Plus Benefit Table 11 Ancillary Benefits - General Conditions, Waiting Periods 12 Further Details Variations to Benefits, Membership Card 13 Online Member Services, Claiming, Changing Cover 14 Transferring from another Health Fund 14 Arrears, Termination of Membership 15 Dependents 15 Overseas Travel, Reporting Fraud, Calendar Year 15 Lifetime Health Cover 16 Your Rights 17 Cooling Off Period 17 Privacy, Complaints, Disputes and Ombudsman 17 State of the Health Funds Report 17 Australian Government Rebates 18 Membership Application Form Change of Cover Request 19 Bank Direct Debit Authorisation 20 Transfer Certificate Request Form 20 Delegated Authority Form 20 Contact Details 21 IMPORTANT: The information contained in this brochure is current at the time of issue, 1 April 2013, and supersedes all previously published material. Membership of Mildura District Hospital Fund, including entitlement to and payment of benefits, is subject to our Fund Rules and policies. Detailed Fund Rules are available at any time on request. Ensure you read this brochure thoroughly and retain a copy for future reference. This brochure provides all the necessary information you ll require to decide which level of cover best suits you. Should you require more detailed information on any of our services or benefits, please come in to our office or call us on (03) to discuss your health insurance requirements with our friendly staff. 1

3 ABOUT MILDURA DISTRICT HOSPITAL FUND Mildura District Hospital Fund (MDHF) is a regional based not-for-profit health insurance fund and has been in operation since The benefits to you: Not-for-profit, so members get more, not shareholders Over 80 years experience providing health cover Simple great value products Leading independent consumer magazine voted MDHF best value private health insurer for both medium and high level cover in 2011 and 2012 when compared to all 37 health funds Extensive nationwide hospital agreements Customer service team dedicated to making private health cover simple and easy to understand Your single children remain covered to age 21 and if they are full time students they remain covered to age 25 You can access your membership anytime you need to with our online member services We offer a 2.5% discount for members who pay by direct debit (from a cheque or savings account) WHY HAVE PRIVATE HEALTH INSURANCE? Why hospital cover? Public hospitals are administered by state governments whereas private hospitals operate on a commercial basis. If you are treated by your own doctor or specialist in a public hospital you become a private patient and you will be charged by both the hospital and the doctor. Similarly, you are also charged by both if you are admitted to a private hospital. The major difference is that private hospitals charges are higher and include additional fees such as theatre and labour ward fees. Some of the most common reasons for people taking out hospital cover include: Greater choice of your own doctor More choice of where you are treated Shorter waiting times for elective (non-urgent) surgery Having cover makes out of pocket costs much more manageable, providing financial protection Why extras cover? You don t have to be sick to benefit Extras cover gives you benefits for things that aren t covered by Medicare, such as dental, physiotherapy, naturopathy and remedial massage Prescription glasses, contact lenses You can claim on the spot using your MDHF membership card at more than 52,000 participating providers nationally 2

4 WHAT MEDICARE DOES & DOES NOT COVER Medicare refunds a proportion of the Medicare Benefits Schedule fee for out-of-hospital services provided by your doctor or specialist, plus shared room accommodation in a public hospital with treatment being provided by a doctor or specialist allocated by the hospital. It s simple but it s not enough. Medicare does not cover such things as: Your choice of doctor or specialist in a public hospital Any private hospital accommodation or treatment Gap between the Medicare refund and Medicare Benefits Schedule fee for private medical services rendered to hospital patients Dental, physiotherapy, speech therapy, chiropractic services, podiatry or psychology (except in very special circumstances) Glasses, contact lenses, hearing aids and other appliances CHOICE OF HOSPITAL COVER We offer two kinds of hospital cover Top Hospital Cover (with or without an excess) or Basic Hospital Cover. FIVE STAR HOSPITAL BENEFITS BASIC HOSPITAL BENEFITS Your choice of doctor Your choice of hospital Options to reduce your premiums by paying an excess Private or shared room in an agreement private hospital or day hospital facility Out-ofpockets apply Private room in a public hospital Out-ofpockets apply Shared room in a public hospital CHOICE OF EXTRAS COVER You can take hospital cover on its own, but most people add extras cover to give them fuller coverage. A - BASIC ANCILLARY - Our most basic extras cover which includes some cover for frequently used services like optical, chiropractic, and physiotherapy. A1 ANCILLARY PLUS - Our best ancillary cover. Get more back with higher benefits and annual limits for a wide range of services including remedial massage and clinical psychology. D DENTAL - Recommended for people wanting dental cover either alone or in combination with ancillary or hospital cover. 3

5 H4 - Five Star Hospital Benefits HOSPITAL BENEFITS FIVE STAR HOSPITAL BENEFITS H4 Five Star Hospital Benefits is designed for people who want the best hospital cover available throughout Australia with no excess. What is special about Five Star Hospital cover is that the 100% contract that we have with the Mildura Private Hospital has been extended to cover a comprehensive range of private hospitals throughout Australia, particularly those that are most commonly utilised by our members. Excess Options to Reduce your Hospital Premium An excess is a set amount you agree to pay upfront when you are admitted into hospital before your benefit is paid. The excess only applies if hospitalised as an overnight or day patient. For singles the excess is only payable once per calendar year, irrespective of the length of stay or number of admissions in that year. For families, the excess is only payable once per person per calendar year, with a maximum of two excesses per calendar year for the entire family, irrespective of the length of stay or number of admissions in that year. Maximum Excess for the Year Excess Singles Couple/Family F1 Five Star Hospital Benefits $150 $150 $300 F2 Five Star Hospital Benefits $250 $250 $500 F3 Five Star Hospital Benefits $500 $500 $1,000 NOTE: The excess is payable for all overnight admissions in all hospitals. The excess is also payable for same day procedures at all hospitals with the exception of the Mildura Private Hospital. Summary Of Benefits Note: The excess per person is only payable once per calendar year to the maximums shown. For example, if Kate is on F1 and is hospitalised more than once in that year, she only pays the excess of $150 on her 1st admission. If her partner is also admitted during the year, they will pay another $150 excess on admission. 100% of shared or private room and additional costs (e.g. theatre, intensive care unit, high dependency unit) in Mildura Private Hospital and all public hospitals and contracted private hospitals throughout Australia. Default benefits are the minimum level of hospital benefits payable to non-contracted hospitals (refer page 5). For all medical services provided while an inpatient in hospital, Medicare pays 75% of the Medicare benefits schedule (MBS) fee and MDHF pays the remaining 25%. Because some doctors charge fees above the MBS fee, there may be a gap, and you may incur out-of-pocket expenses. See Gap Medical Benefits page 6 for more details. We recommend that, if you require treatment in a private hospital other than the Mildura Private Hospital, you check with the Fund prior to admission, and if the hospital is not a contracted hospital, we will negotiate directly with the hospital prior to your hospitalisation. In the event of an emergency admission to a non-contracted private hospital, benefits will automatically be paid at the average contract rate. Base Rates (No Rebate) Rates after deducting Australian Government 30% Rebate (refer page 18)* F/nightly Monthly Quarterly Yearly F/nightly Monthly Quarterly Yearly H4 Five Star Hospital Benefits Couples/Family $ $ $ $3, $96.60 $ $ $2, F1 Five Star Hospital Excess 1 Couples/Family $ $ $ $3, $89.30 $ $ $2, F2 Five Star Hospital Excess 2 Couples/Family $ $ $ $3, $84.55 $ $ $2, F3 Five Star Hospital Excess 3 Couples/Family $ $ $ $2, $72.50 $ $ $1, H4 Five Star Hospital Benefits Single $69.00 $ $ $1, $48.30 $ $ $1, F1 Five Star Hospital Excess 1 Single $63.80 $ $ $1, $44.65 $96.70 $ $1, F2 Five Star Hospital Excess 2 Single $60.40 $ $ $1, $42.25 $91.55 $ $1, F3 Five Star Hospital Excess 3 Single $51.80 $ $ $1, $36.25 $78.50 $ $ *Australian Government Rebates range from 0% to 40% and depend on age and income levels. The most common rebate of 30% is shown above. Members who are currently on direct debit or choose to go on direct debit (from a savings or cheque account only) will attract a further 2.5% discount. 4

6 H1 Basic Hospital HOSPITAL BENEFITS BASIC HOSPITAL BENEFITS A basic level of hospital cover, designed for those who just want the basics. It is designed for those who want full cover against the cost of shared room accommodation in public hospitals as a private patient with choice of doctor or specialist. No excess Choice of doctor or specialist from one of the ones associated with the public hospital Covers the cost of a shared ward in a public hospital Gap Medical Benefits NOTE: Public hospital waiting lists may still apply Summary Of Benefits Benefits equal to 100% of day procedure and shared room fees in all public hospitals throughout Australia. Private hospital treatment, including Mildura Private Hospital, will attract default benefits as detailed below. For all medical services provided while an inpatient in hospital, Medicare pays 75% of the Medicare benefits schedule ( MBS ) fee and MDHF pays the remaining 25%. Because some doctors charge fees above the MBS fee, there may be a gap, and you may incur out-of-pocket expenses. See Gap Medical Benefits page 6 for more details. H1 Basic Hospital cover has been designed for people wanting the option of choice of doctor or specialist when admitted to a public hospital. Even though default benefits are paid against the cost of private hospital treatment, this table is not recommended for people wanting comprehensive private hospital cover. Default Benefits Default benefits are the government prescribed benefits applicable for each different patient category (advanced surgery, surgical/ obstetrics, medical, psychiatric or rehabilitation) for shared room accommodation in public hospitals, as per the current Private Health Insurance (Benefit Requirements) Rules. Any difference between the default government prescribed benefit and the hospital charge will result in out-of-pocket costs. Note: Your costs are covered by MDHF for shared room accommodation in a public hospital. But your costs are not covered by MDHF for: a private room in a public hospital, or Mildura Private Hospital, or any other private hospital in Australia. With Basic Hospital cover, staying in a private room in a public hospital or a private hospital will result in significant out-of-pocket expenses. If you want your hospital cover to cover you for costs in either of those scenarios you should consider MDHF s Five Star Hospital Benefits cover. Base Rates (No Rebate) Rates after deducting Australian Government 30% Rebate (refer page 18)* F/nightly Monthly Quarterly Yearly F/nightly Monthly Quarterly Yearly H1 Basic Hospital Couples/Family $84.40 $ $ $2, $59.05 $ $ $1, H1 Basic Hospital Single $42.20 $91.40 $ $1, $29.50 $63.95 $ $ *Australian Government Rebates range from 0% to 40% and depend on age and income levels. The most common rebate of 30% is shown above. Members who are currently on direct debit or choose to go on direct debit (from a savings or cheque account only) will attract a further 2.5% discount. 5

7 GAP MEDICAL BENEFITS Your doctor, specialist, surgeon, anaesthetist, pathologist or radiologist all charge for the medical treatments they provide in hospital. If the service or treatment is recognised and claimable from Medicare, then MDHF can help reduce or even eliminate the cost to you. Level 1 As a private patient receiving medical treatment in hospital, you are covered for these medical treatments up to the Medicare Benefit Schedule (MBS) fee. The MBS fee is the amount set by the Federal Government for each medical service covered by Medicare. Medicare pays 75% of the fee; MDHF will pay the remaining 25% of the MBS fee. 100% of MBS fee (total Medicare and Fund Gap Medical Benefit for all recognised and claimable services) Some doctors charge above the MBS fee. If your specialist charges more than the MBS fee there will be a gap for you to pay. MDHF can help reduce or avoid these extra expenses with our Informed Financial Consent or Simplified Billing agreements. Level 2 (Informed Financial Consent) Before going to hospital, your doctor should inform you of the actual fee for your treatment and any out-of-pocket expenses you will incur. MDHF provides a higher medical rebate in return for your doctor informing you in advance of any costs you will have to meet (Informed Financial Consent). Where you have received Informed Financial Consent the Fund will pay: 35% of MBS fee (all services other than pathology and radiology) 25% of MBS fee for pathology and radiology 110% of MBS fee (total Medicare and Fund Gap Medical Benefit for all services other than pathology and radiology) Level 3 (Informed Financial Consent/Simplified Billing) Where you have received Informed Financial Consent and your doctor participates in a Simplified Billing Arrangement for those services (the doctor sends your bills directly to the Fund for processing), Level 3 Gap Medical Benefits will be paid by the Fund. 45% of MBS fee (all services other than pathology and radiology) 25% of the MBS fee for pathology and radiology 120% of MBS fee (total Medicare and Fund Gap Medical Benefit for all services other than pathology and radiology) We recommend that you get a detailed quote from all possible attending medical practitioners prior to being hospitalised in order to be fully informed of the actual fees being charged and all out-ofpocket costs you are likely to incur. 6

8 HOSPITAL BENEFITS Limitations of Hospital Benefits Entitlements to benefits shall extend for the full calendar year for each Fund member or their dependents. Benefits are payable for treatment received from any approved hospital in Australia. Members are advised that MDHF is not permitted to pay benefits in excess of actual hospital costs. Hospital benefits are payable for 365 days of the year, except in the case of some long stay nursing home type patients (whose daily benefit will be reduced after 35 days and for whom a daily patient co-payment will apply) and specific cases in which the hospital/ medical practitioner does not supply relevant documentation for continuation of benefits. MDHF does not pay any benefits for cosmetic surgery. We generally do not pay benefits where the government pays no Medicare Benefits Schedule fee, such as medical services for surgical procedures performed by a surgical podiatrist. Note: If, on checking, you find that your planned procedure has no Medicare item number, contact us and we can advise whether or not we pay a benefit for that procedure. Prostheses A prosthesis is a surgically implanted medical device or artificial body part, like hip and knee joints and heart pacemakers. If you are having a procedure involving implantation of a prosthesis, there is always at least one that will be fully covered by your hospital cover, which MDHF will fully pay for, leaving you with no gap amount to pay. This is called a no gap item. But in a few situations, you and your doctor may want to use a different prosthesis, which costs more than the standard no gap prosthesis fee. If so, you will need to pay this additional amount yourself. How do I find out if I am fully covered for my prosthesis? It is important to talk to your medical practitioner to find out whether a prosthesis will be used during your procedure. Once you have confirmed this, you will need to know: The item number and charge for the prosthesis you need; and The item number of the procedure you will be having. When you have this information, simply contact us and we will be glad to advise you of the Fund benefit payable for the prosthesis and any out-of-pocket costs. 7

9 HOSPITAL BENEFITS Hospital Waiting Periods The following waiting periods apply before fund benefits are payable: Sickness - 2 months after commencement of membership. Accidents - There is no waiting period for treatment you require as a result of an accident sustained after joining us (confirmed by statutory declaration). Assisted Reproductive Services (Including IVF) - 12 months after commencement of membership, H1 Basic Hospital Benefits (only) will be payable on all hospital benefit tables. Benefits will remain restricted to the H1 level of benefits until 24 months after commencement of membership. Thereafter, hospital benefits applicable to the level of cover will apply. Normal waiting periods will also apply in the case of an upgrade of hospital cover. Elective Surgery - 12 months after commencement of membership. Obstetric Services - 12 months after commencement of membership. Newborn Babies - Single hospital membership for mothers covers the cost of the birth of the baby but does not cover any costs incurred by the baby. If you have complications and your baby requires any accommodation or medical attention, your baby will not be covered unless they have served the waiting period. So, if you are currently on a single membership, it is recommended that you transfer to a family membership at least 2 months prior to the expected date of delivery. Pre-existing Conditions - Benefit entitlement begins 12 months after commencement of membership. A pre-existing ailment is defined by law as any ailment, illness, or condition that you had signs or symptoms of during the 6 months before you joined the Fund or upgraded to a higher level of cover. It is not necessary that you, your doctor, or dentist 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 practitioner about it before joining the Fund or upgrading to a higher level of cover. The only person authorised to decide that a condition is pre-existing is the medical practitioner appointed by the Fund. In forming an opinion about whether or not an illness was pre-existing, the medical practitioner must take into account information provided by your own practitioner. Transfer to a Higher Table - Contributors increasing their cover will be subject to the above waiting periods. Transfers from other Organisations - Financial members transferring from any other registered private health insurer, who have already served the required waiting periods, will receive immediate cover on an equivalent level of benefit. 8

10 EXTRAS BENEFITS Benefits of our Dental Cover Agreements with local dentists to limit out-of-pocket expenses You can take out dental cover on its own or as a combined cover $30.65 benefit refund on periodic oral examination $37.70 benefit refund on scale & clean $ benefit for full crown veneer (subject to sub limits) Limitation of Dental Benefits The maximum benefit payable in the first year of membership is $300 per person. On the completion of 12 months membership the maximum benefit payable is $1,000 per person per calendar year. Subject to annual maximum benefits per person, the maximum benefit for treatment by an accredited orthodontist is $600 per person per calendar year, with a lifetime maximum orthodontic benefit of $1,500 per person. The maximum benefit allowed for any service listed in the MDHF Dental Benefit Schedule is the benefit prescribed. Benefits are only paid for services rendered by registered practitioners in private practice. The supply of dentures shall be limited to one complete set per person each three membership years. Subject to annual maximum benefits per person, the combined maximum benefit per person for inlay, onlay, crown and bridge treatment is $300 in the first calendar year of membership. This amount increases to $400 for the second calendar year of membership, then by a further $50 each subsequent calendar year, up to a maximum of $600 per person per calendar year in the sixth and subsequent calendar years of continuous dental fund membership. Benefits are not payable in respect of any cosmetic treatment. No Fund benefit will be payable for dental treatment that is subject to reimbursement by Medicare Australia. Dental Waiting Periods The waiting periods before benefit entitlement commences are 24 months for orthodontic treatment, 12 months for supply, repair or alteration of dentures and 2 months for all other treatment. There is no waiting period for dental treatment you require as a result of an accident sustained after joining us, other than dentures (confirmed by statutory declaration). Pre-existing Conditions - 12 months after commencement of membership (see page 8). 9

11 EXTRAS BENEFITS D - DENTAL MDHF has entered into Super or Basic Dental Agreements with most local dentists. Dental agreements provide a value added enhancement to dental insurance. Super Dental Agreements Dental practitioners who have entered into a Super Dental Agreement agree to the following: Limit patient out-of-pocket expenses to a maximum of 30% of the fee on all dental services listed in the MDHF Dental Benefit Schedule (except inlay, onlay, crown and bridge, denture, orthodontic and implant prosthesis procedures) A rebate of up to 60% applies to all denture procedures (subject to benefit limitations) A rebate of up to 50% for most inlay, onlay and crown and bridge procedures (subject to benefit limitations) Orthodontic and implant prosthesis services attract a set benefit without a defined limit on fees Not to raise any other service fees (including infection control fee), other than any applicable GST MDHF will automatically send your benefit entitlement directly to the dentist Basic Dental Agreements Patients of dental practitioners who have entered into a Basic Dental Agreement: Will receive the same dollar value benefits as patients of Super Dental practitioners The practitioner has not agreed to limit your out-of-pocket expenses to the maximums that apply to Super Dental Agreement arrangements You will be advised by the practitioner prior to treatment of the out-of-pocket expenses on the anticipated treatment Practitioners have also agreed not to raise any other service fees (including infection control fee), other than any applicable GST MDHF will automatically send your benefit entitlements direct to the dentist Non-Participating Practitioners If you attend a dental practitioner who does not have a Super Dental or Basic Dental Agreement, you will still receive the same dollar value Super Dental benefits. With no agreement in place we are unable to ensure the dentist will advise on the likely out-of-pocket costs, or provide the direct refund system. However, if you obtain a quote with item numbers from your dentist, we will be happy to advise you of fund benefits payable for the planned procedures and any out-of-pocket costs. Note: Information on your dentist s current agreement arrangement is available from either MDHF or your dentist. Base Rates (No Rebate) Rates after deducting Australian Government 30% Rebate (refer page 18)* F/nightly Monthly Quarterly Yearly F/nightly Monthly Quarterly Yearly D - Dental Couples/Family $25.00 $54.15 $ $ $17.50 $37.90 $ $ D - Dental Single $12.50 $27.05 $81.25 $ $8.75 $18.90 $56.85 $ *Australian Government Rebates range from 0% to 40% and depend on age and income levels. The most common rebate of 30% is shown above. Members who are currently on direct debit or choose to go on direct debit (from a savings or cheque account only) will attract a further 2.5% discount 10

12 Service Type EXTRAS BENEFITS A BASIC ANCILLARY & A1 ANCILLARY PLUS Waiting periods Table A Benefit per Visit Initial Consult Subsequent Consult Table A1 Benefit per Visit Initial Consult Subsequent Consult Table A Yearly Limit per Person Table A1 Yearly Limit per Person Physiotherapy/ Osteopathic/ Exercise Physiology/ Occupational Therapy 2 months $27.00 $24.00 $36.00 $32.00 # $ ## $ Chiropody/Podiatry 2 months $25.00 $23.00 $33.00 $30.00 Foot Orthotics 1 year Per schedule Per schedule # $ ## $ Dietician 2 months $25.00 $23.00 $33.00 $30.00 # $ ## $ Speech Therapy 2 months $27.00 $24.00 $36.00 $32.00 # $ ## $ Orthoptic (Eye Therapy) 2 months $25.00 $23.00 $33.00 $30.00 # $ ## $ Naturopathy/ Remedial Massage/ Acupuncture/ Myotherapy No benefit No benefit $29.00 $27.00 No benefit Chiropractic 2 months $22.00 $21.00 $29.00 $27.00 ## $ # $ Chiropractic X-rays (limit 1 per year) $20.00 $40.00 Clinical Psychology - Single Patient Visit $45.00 $ months No benefit No benefit Clinical Psychology - Group Therapy $8.00 $8.00 No benefit ## $ District Visiting Nursing Service (excluding Midwifery Service) 2 months $ $ # $ ## $ Refund on Ambulance subscription payment - Family $ $80.00 $ $ months Refund on Ambulance subscription payment - Single $ $40.00 $ $40.00 Spectacles Full Set $ $ Spectacles Frames $ $ year Spectacles Lenses (per lens) $ $55.00 $ $ Spectacles Contact Lens $ $ Blood Glucose Monitor (per person per 3 year period) 3 years $ $ $ $ Constant Pressure Air Pump (CPAP) (per person per 3 year period) 3 years No benefit $ No benefit $ Artificial Limbs & Prostheses (per person per 2 year period) 1 year 75% of cost 75% of cost $ $ Hearing Aid (per person per 5 year period) 3 years $ $ $ $ Total Benefit Limits per Membership - Membership limit applies for each service group per calendar year (differentiated by colour bands) # $ for Table A ## $1, for Table A1 Base Rates (No Rebate) Rates after deducting Australian Government 30% Rebate (refer page 18)* F/nightly Monthly Quarterly Yearly F/nightly Monthly Quarterly Yearly A - Ancillary Couples/Family $12.80 $27.70 $83.20 $ $8.95 $19.35 $58.20 $ A1 Ancillary Plus Couples/Family $26.00 $56.30 $ $ $18.20 $39.40 $ $ A - Ancillary Single $6.40 $13.85 $41.60 $ $4.45 $9.65 $29.10 $ A1 Ancillary Plus Single $13.00 $28.15 $84.50 $ $9.10 $19.70 $59.15 $ *Australian Government Rebates range from 0% to 40% and depend on age and income levels. The most common rebate of 30% is shown above. Members who are currently on direct debit or choose to go on direct debit (from a savings or cheque account only) will attract a further 2.5% discount. 11

13 EXTRAS BENEFITS A BASIC ANCILLARY & A1 ANCILLARY PLUS General Conditions With ancillary cover, you can claim benefits for those services listed on your cover and that are not claimable elsewhere. No Fund benefit will therefore be payable for ancillary treatment that is subject to reimbursement by Medicare Australia. All ancillary services must be provided by practitioners registered under State legislation and recognised by Mildura District Hospital Fund Limited, in the course of private practice. Naturopath, remedial massage, myotherapy and acupuncture providers must be recognised in the modality by the Australian Regional Health Group. We can inform you about ancillary providers recognised by our Fund. Benefits will only be paid for one visit per day regardless of the provider within the same service group unless there is at least a minimum four hour gap between visits (confirmed by the provider). Under the Private Health Insurance Act, MDHF cannot pay benefits for goods and services that are primarily for the purposes of sport, recreation, or entertainment. (e.g. we do not cover benefits for sports enhancement). Refund on Ambulance Subscription Payment - If ancillary members choose to cover themselves through an ambulance subscription, we pay a partial reimbursement of their subscription payment. We do not, however, provide ambulance only insurance and do not pay benefits against actual ambulance travel. Foot Orthotics - We pay specified benefits according to item number for foot orthotics listed in our benefits schedule. Foot orthotics must be prepared for the member by a registered podiatrist or by a registered orthotist pursuant to a prescription or referral from a registered podiatrist or medical practitioner, in the course of private practice. We also pay benefits for treatment of ingrown toenails by a registered podiatrist as per schedule. Waiting Periods In cases of treatment resulting from accidents (confirmed by statutory declaration) after commencement of membership, no waiting periods shall apply for all ancillary benefits other than spectacles, hearing aids, artificial limbs and prosthesis benefits, blood glucose monitor and CPAP. NOTE: Yearly limits relate to calendar year. Spectacle Benefits Sunglasses are specifically excluded. 12

14 FURTHER INFORMATION No Fund Benefits will be Payable for the Following: Where the treatment is obtained for purposes of life assurance, or for membership of a friendly society For the treatment of an accident or illness covered by WorkCover third party or damages legislation. For treatment in any hospital or institution which is not an approved hospital under the Commonwealth classification, unless the approval of the Commonwealth is granted to the particular claim Care and accommodation in an aged care service Treatment provided to a person at an emergency department of a hospital Benefits are payable solely in respect of treatment provided in Australia. No benefits will be paid for goods and/or services received overseas or purchased from overseas including items sourced over the internet Certain other expenses precluded under legislation Treatments, services or products not yet delivered to the member Services provided by a family member, relative, business partner, or yourself Ancillary benefits will be payable only when provided on an individual and not on a group session basis, unless specifically stated. Cosmetic treatment Variations to Benefits Benefits and premiums set out in this booklet may increase or decrease from time to time. Members will have the security of knowing that any increase in premiums or perceived reduction in member benefits must be reviewed by the Department of Health and Ageing prior to being implemented. Members will be advised of changes and the date that they are to come into effect at least 30 days prior to the changes taking effect. Member benefits and changes to those benefits are subject to the Fund s by-laws. Membership Card When you join MDHF, a membership card identifying those persons covered under the membership will be issued. The card can be presented at participating health service providers to claim electronically for treatments you receive, eliminating the need to lodge a paper claim form. A new card may be issued when you make changes to your membership. Please note that an existing card will become invalid whenever a new membership card is issued. Keep your card safe and please advise the Fund if your card is lost or stolen. 13

15 FURTHER INFORMATION Online Member Services Using our web services is an easy way of managing your health cover. All you need to do is log in to and you will have access to: View your level of cover, contribution details, benefit limits usage View or change your membership details Download forms and brochures Order a new membership card Print your annual tax statement Print your annual benefits statement Claiming For ancillary and dental services, a lot of service providers are equipped so you can claim on the spot, using your membership card. All you will have to do is simply pay the balance of the bill, avoiding the delay of having to claim from the Fund office. Or, if you prefer, you may submit your claim in person and we will process your claim on the spot and provide you with benefits, either by cash (limits apply), or cheque. Alternatively, send us your claim by , fax, or mail. Simply print a claim form off our website, fill it in and attach any original accounts or receipts from your health care provider/s. Changing Cover You can change your level of cover at any time. If you are upgrading your cover, you will be subject to waiting periods before becoming eligible to claim the higher level of benefit. Where your new level of cover is higher than what you previously held, the lower level of benefit applies during the waiting period (this includes any applicable excess). Transferring from another Health Fund If you are transferring from another Australian health fund to MDHF, you will continue to be covered for all benefit entitlements that you had on your old cover, as long as these services are offered on your new cover with us. When changing health funds, we will count any excesses you have paid as well as any extras benefits paid by your old fund towards your annual maximums in your first year of membership with us. Any benefits paid by your old fund also count towards lifetime limits. You will only have waiting periods for things you are not covered for now. Where your new cover is higher than what you had with your old fund, the lower benefit (including different excess levels) will apply for the waiting period relevant for that service. To transfer, just join our Fund and if you do not already have a clearance certificate, you simply need to fill out the Transfer Certificate Request Form located on our application form and we are happy to request one on your behalf. 14

16 FURTHER INFORMATION Arrears Premiums are payable in advance. MDHF members are responsible for ensuring their premiums are up to date. A person whose membership contributions are in arrears shall not be entitled to benefits. Termination of Membership Membership will cease when premiums fall into arrears by 2 months or more after the premium due date. Dependents Dependent Child aged 21 years - As a dependent child reaches age 21 years, a separate membership for such child must be commenced. Benefits for such child will continue automatically providing the membership is commenced within two months of turning age 21 years. The automatic continuation of cover will require dating and payment of the new membership from the date of the 21st birthday. Student Dependent A full time student at school, college or university, under the age of 25 years, who is not married or in a de facto relationship, will be classed as a dependent providing the contributor registers the child with the Fund each year, from the time the child reaches the age of 21 years. On leaving school, university or college benefits will continue automatically, providing a separate membership is commenced within two months of completing their full time education. The automatic continuation of cover will require dating and payment of the new membership from the date the student ceases qualifying as a student dependent. Overseas Travel To avoid unnecessary expense, you are permitted to temporarily suspend your membership while absent from Australia on overseas travel for work or leisure. The minimum period of suspension is 2 weeks with the maximum being 2 years. Members must provide, prior to departure, satisfactory documentary evidence of departure and return before suspension is permitted. Please be sure to check the rules with our staff before travelling. Depending on income level, suspension of hospital cover may result in the Australian Government s Medicare Levy Surcharge applying while you are overseas. Reporting Fraud If you suspect that a person or group is engaging in health insurance fraud, please contact our investigations team on (03) or investigations@mdhf.com.au. Calendar Year The calendar year is 1 January to 31 December. 15

17 LIFETIME HEALTH COVER Lifetime Health Cover (LHC) is a government initiative that started on 1 July It is aimed at encouraging people to take out hospital cover early in life and maintain it. If you take out hospital cover by 1 July following your 31st birthday and maintain it, you can expect to pay lower contributions throughout your life compared to someone who joins a health fund when they are over 31. If you take out hospital insurance later in life, then you will pay a 2% loading on top of the base premium for every year you are aged over 30. For example, a person who first takes out hospital cover at age 40 will pay 20% more every year than someone who takes out hospital cover at age 30. The longer you leave it, the higher the loading. The maximum loading is 70%. The loading will cease when a person has held hospital cover for ten continuous years. However, the loading may be reapplied if you then cease to hold a hospital cover and subsequently take it up again. Persons born prior to 1 July 1934 are exempt from Lifetime Health Cover. What if I drop my hospital cover? The Government recognises that people may need to drop their hospital cover from time to time throughout their lives for various reasons such as overseas trips or financial difficulties. Therefore, people are able to drop their cover for up to 1,094 days over their lifetime, for whatever reason, without incurring any penalty loading when they rejoin. They will, however, have to serve all the usual waiting periods that apply to new members when they rejoin. Can people vary the level of their health insurance cover under Lifetime Health Cover? Yes. People are able to upgrade or downgrade their hospital cover policy under Lifetime Health Cover without affecting their premium rating. The usual rules for waiting periods will apply. The only circumstances under which a person s premium rating may be affected by a variation to their private health insurance cover could be if they changed from a policy that included hospital cover to a policy that did not. In this case the period of absence rules would apply. The rates quoted in this brochure do not take into account any potential Lifetime Health Cover loading. 16

18 YOUR RIGHTS Cooling Off Period It is Fund policy that new members to the Fund and existing members making any change to their level of cover will be granted a cooling off period of 30 days. Cancellation of new membership If you have second thoughts, and choose to cancel your new membership from the commencement date, you must advise us during the cooling-off period and any premium paid for the policy will be refunded in full, providing a claim has not been made. Upgrading members If you choose to revert to your previous level of cover within 30 days of upgrading, we will refund in full the additional premiums paid in relation the upgraded component of the cover. You must advise us during the cooling off period and must not have in the meantime generated any related claim on the Fund. Terminating or downgrading members - If you choose to revert to your previous level of cover within 30 days of terminating or downgrading your membership you must advise us and pay in full the arrears due on the premium on the former level of cover during the cooling off period. Privacy To provide our services to you, we need to hold certain personal information about you. We will respect your privacy. We are committed to ensuring that any personal information you entrust us with is protected against misuse. A copy of our privacy policy is available on our website: Alternatively, contact this office and we will provide you with a copy. Complaints, Disputes and Ombudsman If you ever have a complaint or dispute relating in any way to your membership, contact us directly so that it can be resolved as quickly as possible. If your complaint is not dealt with satisfactorily, you can also take the matter up with the independent, Governmentappointed, Private Health Insurance Ombudsman, whose duty it is to attempt to resolve health insurance complaints. Address: Suite 2, Level 22, 580 George Street, Sydney NSW info@phio.org.au Phone: State of the Health Funds Report Once a year, the Private Health Insurance Ombudsman conducts an independent assessment of the comparative performance and service delivery of Australia s private health funds. The resulting State of the Health Funds Report can be accessed on the Ombudsman s website: 17

19 AUSTRALIAN GOVERNMENT REBATES & MEDICARE LEVY SURCHARGE The Australian Government rebates are government initiatives that provide subsidies against the cost of private health insurance. When you take out hospital, ancillary or dental insurance, you can receive the rebate as a reduction on your premiums, as a tax offset claimable on your income tax return or as a cash rebate claimable from a Medicare office. Effective from 1 July 2012, the private health insurance rebate and the Medicare levy surcharge are income tested. The percentage of rebate you are entitled to is reduced on a tiered basis depending on your level of income (based on the new income test) and the age of the oldest person on the policy. If you do not hold an eligible hospital cover (or if you drop your hospital cover), and are considered to be a high income earner, you will have to pay additional tax on top of the standard Medicare Levy that applies to all Australian taxpayers. The ATO will determine the amount of your private health insurance rebate entitlement when you lodge your income tax return. This may result in a tax refund or a tax liability for you. Base Tier Tier 1 Tier 2 Tier 3 Singles $84,000 or less $84,001 $97,000 $97,001 $130,000 $130,001 or more Families $168,000 or less $168,001 - $194,000 $194,001 - $260,000 $260,001 or more Rebate < age 65 30% 20% 10% 0% Age % 25% 15% 0% Age % 30% 20% 0% Medicare levy surcharge Rate 0.0% 1.0% 1.25% 1.5% Note: Single parents and couples (including de facto couples) are subject to the family tiers. For families with children, the thresholds are increased by $1,500 for each child after the first. Who can claim the rebate? The payer of the policy will no longer be automatically entitled to the rebate. Each adult covered by the policy will be responsible for their share of the policy. How do you claim the direct reduction of your health insurance premium? To receive a direct reduction in your health insurance premium you must complete an Application to Receive or change the Australian Government Rebate on Private Health Insurance as a Reduced Premium form (see page 19), and lodge it with us. 18

20 Application/Change of Details form HEALTH INSURANCE SINCE 1929 I am applying to Join Mildura District Hospital Fund ( MDHF ) Add a person/persons to this membership Change my level of cover Remove a person/persons from this membership Change my payment options Transfer to MDHF - A Transfer Certificate request Receive or change rebate as a reduced premium form will need to be completed. Change my contact details Add a delegated authority Other - please provide details Your details Title Given Names Membership Number Surname Date of Birth M/F Medicare Number Home Ph. Work Ph. Mobile Ph. Postal Address Residential Address Address Other family members to be covered Title Given Names Surname Date of Birth M/F Relationship Student Yes/No Family/Couple Membership Single Cover Application to receive or change the Australian Government Rebate on Private Health Insurance as a reduced premium Complete this section to receive the Australian Government Rebate as a reduced premium. All the people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced premium. If at any stage you wish to stop receiving the Australian Government Rebate as a reduced premium, you must notify MDHF as soon as possible. Are you covered by this policy? Yes No Medicare No. Valid to / Your Full Name as it appears on your Medicare card Date rebate and/or rebate tier nomination to commence from: / / Level of rebate you belive you are entitled to: Base Tier Tier 1 Tier 2 Tier 3 Are all the people on the policy listed on a Medicare card? Yes No 19 H4 F1 F2 F3 H1 D A A1 Employers and trustees of organisations cannot claim the Australian Government Rebate on policies paid on behalf of employees. You are entitled to a Medicare card if: You are a person who lives in Australia; You are an Australian citizen; You are a holder of a permanent resident visa; You are a New Zealand citizen; or, in some cases an applicant for a permanent resident visa. Any inquiry about Medicare eligibility can be made at any Department of Human Services office or by phoning for the cost of a local call. Declaration I declare that the information provided is correct. I understand that there are penalties for giving false or misleading information. Signature Date / / AUSTRALIAN GOVERNMENT REBATE ON PRIVATE HEALTH INSURANCE The information provided on this form will be used for the purpose of registering you for the Australian Government Rebate. Its collection is authorised by law, and information collected may be disclosed to the Department of Health and Ageing, Department of Human Services, and the Australian Taxation Office.

21 Payment Details Method of payment I wish to pay my health cover membership contributions by the option selected below. 1 Direct Debit (provides peace of mind as your contributions are always up to date and entitles you to receive a 2.5% discount off the cost of your premium) Details of my Financial Institution Account Name of Financial Institution Account Name BSB Number Account Number Frequency of Payment Fortnightly Monthly Quarterly Half Yearly Yearly I/we would like my/our first Direct Debit to commence on I/we request Mildura District Hospital Fund (user I.D. no 18530) until further notice in writing to debit from my/our nominated bank account, any amounts payable under my/our selected cover details. Signature Date 2 Account Notice (received by mail) Frequency of Payment Quarterly Half Yearly Yearly 3 Salary Deduction - Name of Employer 4 Other Arrangement - Branch/Agent Frequency of Payment Fortnightly Monthly Quarterly Half Yearly Yearly Delegated Authority For your own convenience, we suggest you consider nominating a spouse or other authorised representative/s below. Nominated person/persons Title Surname Given Names Date of Birth Relationship to Member Address Signature/s of nominated representative/s I hereby authorise the above named person/persons to claim benefits on my behalf until further notice in writing. I hereby authorise the Mildura District Hospital Fund to release information (other than sensitive personal information) in relation to my policy to the above named person/persons until further notice in writing. Signature Date Transfer Certificate Request Form Title Surname Given Names M/F Date of Birth Address Name of existing health fund Member Number Cover Name I hereby authorise Mildura District Hospital Fund to terminate my membership with your organisation as at and request that you forward a Transfer Certificate to Mildura District Hospital Fund, PO Box 5046, Mildura VIC Please refund to me any subscription amount paid beyond the above transfer date. Signature Date I agree to the collection and storage of private/sensitive information by Mildura District Hospital Fund Limited for private health insurance purposes, and accept the rules, Privacy Policy, and Disclosure Statement of Mildura District Hospital Fund Limited, and undertake to inform all persons of consent age covered by this policy of the above. I understand the conditions of membership, waiting periods and Pre-Existing Conditions (please refer to the Pre-Existing Conditions rule in the brochure). I also agree to become a member of Mildura District Hospital Fund Limited and to be bound by the constitution and rules of the Company. Signature Date 20

22 MDHF CONTACT DETAILS 79 DEAKIN AVENUE, P.O. BOX 5046, MILDURA, 3502 TELEPHONE (03) Facsimile (03) Website District Agents Subscriptions may be paid and membership or claim forms obtained at any one of the following agents (our agents are not authorised to provide advice or any other service on our behalf ): BURONGA: Buronga Post Office, Shop 5/6, 10 Sturt Highway, Buronga. Phone CARDROSS: Cardross Store, 412 Dairtnunk Avenue, Cardross. Phone DARETON: Dareton Post Office, 24 Tapio Street, Dareton. Phone GOL GOL: Gol Gol Post Office, Adelaide Street, Gol Gol. Phone IRYMPLE: Irymple Post Office, 2133 Fifteenth Street, Irymple. Phone MERBEIN: Walder Real Estate, 87 Commercial Street, Merbein. Phone RED CLIFFS: Red Cliffs Newsagency, 42 Indi Avenue, Red Cliffs. Phone ROBINVALE: Robinvale/Euston Tourist Information Centre, Bromley Road, Robinvale. Phone WENTWORTH: Wentworth Post Office, 60 Darling Street, Wentworth. Phone