Extras. It s the little things we do, that make a big difference.

Transcription

1 Extras It s the little things we do, that make a big difference.

2 Contents Welcome to ahm Health Insurance...3 We ve got the right cover for you...4 Waiting periods...7 Basic Extras...9 Lifestyle Extras...10 Family Extras...12 Super Extras...14 Claiming your Extras benefits...16 a healthy me...19 Health improvement benefits...23 Online member services...25 You could save on premiums...26 Your membership...27 How to pay...29 Important information and definitions you need to know...30 Feedback...34 ahm Privacy Statement...35 Private Health Insurance Code of Conduct We adhere to the Private Health Insurance Code of Conduct. This is a self-regulatory code that promotes informed relationships between private health insurers, consumers, agents and brokers. Our documents display the PHI Code of Conduct logo. This shows that we comply with the Code and have been authorised by the Code Compliance Committee to use the logo. If you d like more information about the Code or if you d like your own copy of the Code call one of our friendly staff on or go to ahm.com.au Important note The information contained in this document is current at the time of issue October 2012 and supersedes previously published material. Please ensure you read this document thoroughly and retain a copy for your reference. Membership of ahm Health Insurance is subject to our Fund Rules and policies which are summarised in this document. Premiums, benefits, Fund Rules and policies change from time to time. The information in this document only applies to ahm Health Insurance branded products. Policies of insurance issued under, or on the terms of, any products described in this publication are referable to the Medibank Private Limited (ABN ) health benefits fund. ahm Health Insurance Extras cover 2

3 Welcome to ahm Health Insurance At ahm Health Insurance we understand that health insurance can sometimes be confusing, with so many different options, benefits and rules. By choosing ahm Health Insurance you can be assured that our Cover Specialists will help you choose a level of cover that matches your needs and help you understand what you re covered for. More value from your cover At no extra cost, you can access an integrated suite of health management programs, to help improve and maintain your heath and wellbeing. You can receive personalised advice, support and motivation online, by phone or and save time managing your health with a trusted team of qualified consultants and experts. You don t have to wait No waiting periods apply on some of our most popular extras services like Physiotherapy, Optical, or Routine Dental. So you can join today and claim today.* You can count on us to help you use your extras We want to make sure you re getting the most of your Extras cover, so from time to time we contact our members if we notice they re not claiming. You can come to us for easy, friendly and helpful advice The ahm Health Insurance team have been looking after the health of Australians for more than 40 years and each of our recognised health providers are accredited in their field. Our friendly staff are just a phone call away to help you understand, make the most of your insurance and make sure your level of cover is right for you. You can manage your health insurance 24/ / 2012 Voted best health insurer ahm Health Insurance (formally Australian Health Management) was named Best Health Insurer in the Australian Financial Review s Smart Investor SMILES Survey 2011/2012. Already covered? No worries! If you re switching private health insurers, we will recognise any waiting periods served for comparable benefits. Plus there are no two or six month waiting periods on any ahm Extras covers! Note: Other waiting periods may apply, please see page 7 for details. Our online member services allow you to claim for most paid ahm Extras, pay your premiums, check your benefit limits and more. You re rewarded the longer you stay with us Some of our Extras covers include loyalty limits which means the longer you re with us, the more you can claim. *Other waiting periods apply. Extras are subject to benefit limits. You can only claim once you have paid your first premium ahm.com.au

4 We ve got the right cover for you At ahm Health Insurance, we offer a range of different Extras covers to meet your individual needs. Whether you just want the basics covered on our most popular extras services or higher benefits on a larger range of services, we can keep you and your family covered in a way that suits you. Our Extras covers have set benefits for services so that you know exactly how much you ll get back each time you visit a service provider. Generally, the higher your level of cover the more you ll be able to get back. Our Extras covers Basic Extras pays benefits on our most popular extras services such as routine dental, optical, physiotherapy and remedial massage plus a range of health improvement benefits. Lifestyle Extras our most popular Extras cover includes all the benefits you get on Basic Extras plus also covers you for complex and major dental, psychology and 17 different complementary and alternative therapies. Family Extras perfect if you have a growing family, this cover has all our most popular benefits with higher limits so that the whole family can claim more on the services they use. Super Extras our highest level of cover is perfect for those that want to receive the most back. It includes benefits for all services covered on our other covers with the best benefits and highest limits. ahm Health Insurance Extras cover 4

5 Choose a cover that suits you best Your ahm Extras policy covers you for things like dentist visits, prescription glasses or physiotherapy. However if you want peace of mind knowing that you re covered if you need to go to hospital or if you re looking to avoid paying the Medicare Levy Surcharge or Lifetime Health Cover loading, you ll need hospital cover. Like our Extras covers, we offer a range of Hospital covers that are designed to suit different needs. You can combine any of our Hospital covers with any Extras cover so that you choose a cover that s just right for you. Extras cover One of Basic Extras Lifestyle Extras Family Extras Super Extras Hospital cover One of Budget Hospital Basic Hospital Family Hospital Essential Hospital Top Hospital The right cover for you For more information on ahm Hospital covers, please call us on ahm.com.au

6 The services available for each of our cover types The following table provides a summary of what each Extras cover includes, for more detail including the benefits and annual limits that apply to each service, please refer to the enclosed ahm Extras Benefit Chart. Basic Lifestyle Family Super Routine dental Physiotherapy, chiropractic and osteopathy Complementary and alternative therapies (naturopathy, homeopathy, acupuncture, herbalism and remedial massage) Optical (frames, lenses and repairs) Diet and nutrition (dietitian and nutritionist, weight loss 1 ) Health improvement benefits (quit smoking, Cancer Council UV products, disease management association fees, health checks) Stress management courses, preventive tests, exercise classes 2 Pharmacy 3 Major and complex dental Orthodontics Psychology and hypnotherapy Laser eye surgery (sight correcting) Complementary and alternative therapies (reflexology, feldenkrais, rolfing, bowen therapy, alexander technique, kinesiology, biochemistry, traditional Chinese medicine, shiatsu, myotherapy and aromatherapy) Speech therapy, occupational therapy and eye therapy Podiatry and orthotics Swimming lessons and training 0-17 years 4 Hearing aids Pre and post natal services and birthing courses Medical gases and joint fluid replacement injections Audiology Outpatient procedure room fees, post operative and medical aids 1 ahm recognised providers only. Medical evidence of a BMI of 26 or over required for adult claims and an unhealthy BMI for children s claims. 2 Where part of an ahm or recognised health management program and provided by an ahm recognised provider. 3 Doesn t include dentures. 4 By an Austswim or Swim Australia accredited swim school with evidence of asthma, diabetes, an unhealthy BMI or a doctor s recommendation to undertake this activity due to their condition. ahm Health Insurance Extras cover 6

7 Waiting Periods When you take out Extras cover or change your level of cover, you may have to wait a set period of time before you can claim for services and benefits you weren t previously covered for. The good news is that there are no two or six month waiting periods on any ahm Extras covers so you ll be able to start claiming straight away on many benefits including routine dental, optical, physiotherapy, chiropractic and osteopathy and complementary and alternative therapies including naturopathy and remedial massage. If you change your cover and your new level of cover has additional or higher benefits on services where waiting periods of 12 months or more apply, you will still have to serve these waiting periods. The following table outlines the waiting periods that apply to our Extras policies. Please note, some services may not be available on all covers, please refer to pages 9-15 to confirm whether a benefit is paid on your level of cover. 1 day 12 months 2 years > Emergency ambulance > ahm Health Management Programs > Complex dental benefits >Major dental benefits >Orthodontics >Podiatric surgery >Orthotics and orthopaedic shoes >Hearing aids >Pre and post natal services >Medical gases >Joint fluid replacement injections >Refractive sight correcting laser eye surgery (You need to have held Lifestyle Extras or Super Extras for 2 years before you re entitled to this benefit) ahm.com.au

8 Extras covers Basic Extras... 9 Lifestyle Extras Family Extras...12 Super Extras...14 ahm Health Insurance Extras cover 8

9 Basic Extras Basic Extras is a great choice if you want cover that pays benefits towards some of the most popular services such as routine dental, optical and physiotherapy. What you re covered for To find out what benefits and limits you receive for each of the services below please refer to the ahm Extras Benefit Chart included with this policy document. > Routine dental > Optical Frames, lenses and repairs > Physiotherapy > Chiropractic > Osteopathy > Complementary and alternative therapies Remedial massage Naturopathy Homeopathy Acupuncture Herbalism Exercise physiology > Diet and nutrition* Dietitian and nutritionist consultations Weight loss classes > Health improvement benefits* Quit smoking benefits Cancer Council UV products Preventive tests Health checks Stress management courses Disease management association fees Exercise classes > Pharmacy > Emergency ambulance *Special conditions apply, see pages ahm.com.au

10 Lifestyle Extras Looking for a cover that gives you great value and lets you claim for 17 different complementary and alternative therapies? Then our popular Lifestyle Extras is for you. It includes all our most popular extras services with higher benefits than Basic, plus you can also claim for complex and major dental (excluding dentures), psychology and sight correcting laser eye surgery. A number of the services also include loyalty limits which means that the longer you stay with us, the more you can claim. What you re covered for To find out what benefits and limits you receive for each of the services below please refer to the ahm Extras Benefit Chart included with this policy document. > Routine dental > Complex and Major dental (excluding dentures) > Orthodontics > Optical Frames, lenses and repairs Refractive sight correcting laser eye surgery > Physiotherapy > Chiropractic > Osteopathy > Complementary and alternative therapies Remedial massage Naturopathy Homeopathy Acupuncture Herbalism Exercise physiology Reflexology Feldenkrais Rolfing Bowen therapy Alexander technique Kinesiology Biochemistry Traditional Chinese medicine Shiatsu Myotherapy Aromatherapy > Psychology and hypnotherapy > Diet and nutrition* Dietitian and nutritionist consultations Weight loss classes > Health improvement benefits* Quit smoking benefits Cancer Council UV products Preventive tests Health checks Stress management courses Disease management association fees Exercise classes > Pharmacy > Emergency ambulance *Special conditions apply, see pages ahm Health Insurance Extras cover 10

11 Get more the longer you stay with us Lifestyle Extras include loyalty limits which are based on the number of financial years you ve been a member of ahm Health Insurance. This means your annual claiming limit for some of our most popular extras benefits will increase after you ve been with us for over 5, 10 and 20 years. To find out more about how loyalty limits work, see page 18. For details on the limits see below. < 5 years 5+ years 10+ years 20+ years Complex Dental Per person limit combined $600 $700 $800 $900 Family limit $1,200 $1,400 $1,600 $1,800 Major Dental Per person limit combined $750 $900 $1,100 $1,300 Family limit $1,500 $1,800 $2,200 $2,600 Physiotherapy, Osteopathy and Chiropractic Per person limit per therapy $300 $350 $400 $450 Family limit per therapy $750 $875 $1,000 $1,125 Psychology and hypnotherapy Per person limit $250 $275 $300 $325 Family limit $500 $550 $600 $650 Pharmacy general items, hormonal implants, contraceptives and preventative/travel vaccines Per person limit combined $350 $400 $450 $500 Family limit $700 $800 $900 $1,000 Orthodontics Orthodontic benefits increase after you ve been with us after 3 and 5 years < 3 years 3-4 years 5+ years Per person limit $500 $600 $ ahm.com.au

12 Family Extras If the kids need braces or speech therapy or you need to attend pre or post natal classes then Family Extras is for you. It also gives you access to a wide range of services such as routine and major dental, optical, physiotherapy, other therapies and plus a range of health improvement benefits. What you re covered for To find out what benefits and limits you receive for each of the services below please refer to the ahm Extras Benefit Chart included with this policy document. > Routine dental > Complex and Major dental > Orthodontics > Optical Frames, lenses and repairs > Physiotherapy > Chiropractic > Osteopathy > Complementary and alternative therapies Remedial massage Naturopathy Homeopathy Acupuncture Herbalism Exercise physiology > Psychology and hypnotherapy > Speech therapy > Occupational therapy > Eye therapy (Orthoptics) > Podiatry > Orthotics and orthopaedic shoes > Hearing aids > Maternity options Pre and post natal consultations and classes Birthing courses (provided by a registered midwife) > Diet and nutrition* Dietitian and nutritionist consultations Weight loss classes > Health improvement benefits* Quit smoking benefits Cancer Council UV products Preventive tests Health checks Stress management courses Swimming lessons Disease management association fees Exercise classes > Travel and accommodation > Medical gases > Joint replacement injections > Pharmacy > Emergency ambulance *Special conditions apply, see pages ahm Health Insurance Extras cover 12

13 Get more the longer you stay with us Family Extras include loyalty limits which are based on the number of financial years you ve been a member of ahm Health Insurance. This means your annual claiming limit for some of our most popular extras benefits will increase after you ve been with us for over 5, 10 and 20 years. To find out more about how loyalty limits work, see page 18. For details on the limits see below. < 5 years 5+ years 10+ years 20+ years Routine Dental Per person limit combined $500 $550 $600 $650 Family Limit $1,250 $1,375 $1,500 $1,625 Complex Dental Per person limit combined $600 $700 $800 $900 Family Limit $1,500 $1,750 $2,000 $2,250 Major Dental Per person limit combined $750 $900 $1,100 $1,200 Family Limit $1,750 $2,250 $2,750 $3,000 Physiotherapy, Osteopathy and Chiropractic Per person limit per therapy $250 $275 $300 $325 Family limit per therapy $625 $675 $750 $850 Psychology and hypnotherapy, speech therapy, occupational therapy, eye therapy & podiatry Per person limit per therapy $250 $275 $300 $325 Family limit per therapy $625 $675 $750 $850 Pharmacy general items, hormonal implants, contraceptives and preventative/travel vaccines Per person limit combined $350 $400 $450 $500 Family limit $700 $800 $900 $1,000 Orthodontics Orthodontic benefits increase after you ve been with us after 3 and 5 years < 3 years 3-4 years 5+ years Per person limit $600 $750 $ ahm.com.au

14 Super Extras If you re after a top level of cover offering high limits and benefits then Super Extras is for you. It offers everything included on all our other Extras covers and more, with higher limits and the best benefits. What you re covered for To find out what benefits and limits you receive for each of the services below please refer to the ahm Extras Benefit Chart included with this policy document. > Routine dental > Complex and Major dental > Orthodontics > Optical Frames, lenses and repairs Refractive sight correcting laser eye surgery > Physiotherapy > Chiropractic > Osteopathy > Complementary and alternative therapies Remedial massage Naturopathy Homeopathy Acupuncture Herbalism Exercise physiology Reflexology Feldenkrais Rolfing Bowen therapy Alexander technique Kinesiology Biochemistry Traditional Chinese medicine Shiatsu Myotherapy Aromatherapy > Psychology and hypnotherapy > Speech therapy > Occupational therapy > Eye therapy (Orthoptics) > Podiatry > Audiology > Orthotics and orthopaedic shoes > Hearing aids > Post operative and medical aids > Outpatient procedure room fees > Maternity options Pre and post natal consultations and classes Birthing courses (provided by a registered midwife) > Diet and nutrition* Dietitian and nutritionist consultations Weight loss classes > Health improvement benefits* Quit smoking benefits Cancer Council UV products Preventive tests Health checks Stress management courses Swimming lessons Disease management association fees Exercise classes > Travel and accommodation > Medical gases > Joint replacement injections > Pharmacy > Emergency ambulance *Special conditions apply, see pages ahm Health Insurance Extras cover 14

15 Get more the longer you stay with us Super Extras include loyalty limits which are based on the number of financial years you ve been a member of ahm Health Insurance. This means your annual claiming limit for some of our most popular Extras benefits will increase after you ve been with us for over 5, 10 and 20 years. To find out more about how loyalty limits work, see page 18. For details on the limits see below. < 5 years 5+ years 10+ years 20+ years Complex Dental Per person limit combined $1,000 $1,100 $1,200 $1,300 Family limit $2,500 $2,750 $3,000 $3,250 Major Dental Per person limit combined $1,100 $1,300 $1,500 $1,700 Family limit $2,750 $3,250 $3,750 $4,250 Physiotherapy, Osteopathy and Chiropractic Per person limit per therapy $300 $350 $400 $450 Family limit per therapy $750 $875 $1,000 $1,125 Psychology and hypnotherapy, speech therapy, occupational therapy, eye therapy, podiatry and audiology Per person limit per therapy $300 $350 $400 $450 Family limit per therapy $750 $875 $1,000 $1,125 Optical frames, single lens, bi-focal, multi-focal, contact lenses, repair to frames or lenses Per person limit combined $250 $275 $300 $325 Family limit No limit No limit No limit No limit Pharmacy general items, hormonal implants, contraceptives and preventative/travel vaccines Per person limit combined $500 $550 $600 $650 Family limit $1,000 $1,100 $1,200 $1,300 Orthodontics Orthodontic benefits increase after you ve been with us after 3 and 5 years < 3 years 3-4 years 5+ years Per person limit $800 $1,000 $1, ahm.com.au

16 Claiming your Extras benefits We ve made claiming easy by providing a range of options so that you can choose the claiming method that suits you. There are some rules though, so we ve provided you with details of these and how to claim on the following pages. We can only pay a claim if: > the service is performed by an ahm recognised provider > the service date on the receipt is less than two years old > an original receipt or invoice is submitted to and kept by ahm > your claim is not payable or subsidised by a third party such as workers compensation unless an authority has been completed > your policy is financial on the date of service. How to claim Most extras service providers offer the convenience of HICAPS (Health Insurance Claiming and Processing System) using your member card. You just pay any remaining balance directly to the provider so there s no need to submit anything to us. If your service provider doesn t offer HICAPS you can use one of the following services we provide: Online You can make a claim any time you want if you ve already paid for the service by visiting the online members section at ahm.com.au. Claiming for most extras benefits is easy and can be completed in three easy steps. 1. Log in to the members section at ahm.com.au and enter your claim details 2. We ll deposit your benefit into your nominated account within two working days 3. We ll send you a letter to confirm your claim, so make sure your contact details are up to date. You need to attach your original receipt/s to this letter and send it back to us. If you ve lost your receipts, you can contact your service provider for duplicates. Over the phone If you d prefer to speak to someone, the ahm team can process most extras benefits over the phone as long as you ve already paid for the service. 1. Call us on to provide your claim details 2. We ll deposit your benefit into your nominated account within two working days 3. We ll send you a letter to confirm your claim, so make sure your contact details are up to date. You need to attach your original receipt/s to this letter and send it back to us. If you ve lost your receipts, you can contact your service provider for duplicates. NOTE: There s a $500 limit for claims made online or over the phone. If you reach this limit, you can t make any more claims online or over the phone until we have received your receipts. Once we ve received your receipts and verified your claims, you can start claiming again. ahm Health Insurance Extras cover 16

17 POSTAL Paid claims 1. Fill in a Claim form 2. Make sure you attach your original receipts (these won t be returned to you) 3. Mail to: ahm Health Insurance, Locked Bag 1006, Matraville NSW We can either deposit the benefit in your bank account or send you a cheque. If you ve lost your original receipts, contact your service provider for duplicates before you claim. POSTAL Unpaid claims 1. If you haven t paid the bill fill in a claim form, attach the bill and mail it to us 2. We ll send you a cheque that s payable to your service provider 3. When you receive the cheque, you must send it to the provider and include any additional amount that you may be required to pay. Claim forms can be downloaded from ahm.com.au or call us on to have them posted to you. Annual limits This is the maximum amount we ll pay for items or services in a 12 month period. Unless stated otherwise, annual limits on our ahm Extras are for the financial year period (1 July 30 June) and all benefit entitlements are renewed at the beginning of each financial year (unless you ve already reached your lifetime limit (where applicable)). We ve outlined the limits that apply to all our Extras covers in the ahm Extras Benefit Chart (included with this document) and you can check benefit limits online at any time. Claiming periods Financial year 1 July to 30 June. Your benefit entitlements are renewed at the beginning of each financial year. Rolling year Very few of our benefits have a rolling year however, a rolling year begins on the date a service was first provided with the limit applying to that 12 month period following the date of service. Limit types Per person limits Where applicable, each person on a policy can claim up to the per person limit for the claiming period except where the family limit has already been used by other members on the policy. Family limit Benefits are payable up to the family limit indicated in the benefits table for the claiming period (as subject to per person limits). Lifetime limit A benefit with a lifetime limit means that once you reach the limit, you can no longer claim that benefit in any future year of membership, even if you change your cover ahm.com.au

18 Loyalty limits Our Lifestyle, Family and Super Extras covers include loyalty limits as a way of rewarding members for their ongoing membership. Loyalty limits are based on maintaining an ahm policy for a continuous period of time and apply to some of our most popular benefits. This means your benefit limit is dependent on how long the principal member has held an ahm policy. To confirm your loyalty limit entitlement, you need to know the number of years you have continuously held an ahm policy then refer to the benefits table. You can check your loyalty years online in our members section or by calling us. How loyalty limits work The loyalty date for the policy is determined by the principal member (see definition page 27). If your partner or dependant (see definition page 27) leaves the policy for any reason, they ll carry their own joining date as their loyalty date. We ve provided some examples below to help explain: 1. Betty (principal member) started an ahm family policy in 1980 and John was added to the policy in 1991 when he was born. John recently turned 21 and left the family policy to start his own single ahm policy. Because he s been covered under an ahm policy since 1991 he ll start a single policy with 21 years of loyalty (as at 2012). 2. Tom has held an ahm policy since 2002, he married Betty and he joined her policy in The policy stays in Betty s name so their loyalty date remains at 1980 and they re entitled to the highest limits. If the policy had transferred into Tom s name (he became the principal member) their loyalty date would be 2002 instead of 1980 and their loyalty years would be less. NOTE: If you have to make a change to your policy, it s important that you consider who will be the principal member as this may determine the loyalty limits that will apply. Moving into a higher limit category As loyalty limits apply to a financial year, the number of years the principal member has held an ahm policy as at 1 July each year determines which category of loyalty limit they re entitled to. For example, if a member has held an ahm policy continuously for 5 years in December 2011 (having joined in December 2006), they won t be entitled to their 5 years loyalty limits until 1 July ahm Health Insurance Extras cover 18

19 a healthy me learn more > take action > live well a healthy me is an integrated suite of health management programs, tools and resources available exclusively to our members to help improve and maintain their health and wellbeing. It s based on a continuous cycle of learning, taking action and living well. It will inspire you to make changes to your lifestyle and support you in managing your health issues, no matter how simple or complex. With a healthy me you can: > Empower yourself with our suite of integrated health tools, programs and online resources. > Receive personalised advice, support and motivation online, by phone or . > Save time managing your health from a central, reliable source of information and support. Some additional a healthy me services are also available if you have an ahm Hospital cover. Please refer to the Hospital policy document for details ahm.com.au

20 ahm Health Hub Achieving and maintaining good health takes planning and action. Now you can conveniently organise a healthy lifestyle from one secure online resource the ahm Health Hub. If you re an eligible member and you register for ahm Health Hub, you gain full and immediate access to an extensive range of motivational and interactive health information tools. The ahm Health Hub is available at no extra cost to all ahm Extras members who are at least 18 years of age. Wellbeing Assessment This comprehensive questionnaire provides you with an overview of your current health and lifestyle, including your real health age compared to your actual age. It outlines the risks to your health and recommends activity plans to improve your wellbeing. To help you stay informed, a fortnightly newsletter will be sent to you containing informative and timely articles. You can also revisit your assessment as often as you like to track and check your progress. Health Action Programs Once you have undertaken the Wellbeing Assessment you can sign up for Health Action Programs that have been designed to address your individual health needs. These educational courses, developed by experts in their field, are delivered to you via . A range of programs are available from sport and general fitness, diabetes management, heart and lung health, as well as weight loss and mental health management. Meal & Activity Planners The ahm Health Hub can help you design a daily meal plan tailored to your body shape and lifestyle. You can also create an unlimited number of customised workout plans to suit your goals, activity preferences and the time and equipment you have available. REGISTER for the ahm Health Hub at healthhub.ahm.com.au/register ahm Health Insurance Extras cover 20

21 ahm Health Coaching When it comes to your health, sometimes you just need someone to talk to, especially if you have a specific medical condition or multiple health issues to address. If you prefer one-on-one support, you can speak directly and confidentially over the phone to an experienced, qualified Health Consultant with ahm Health Coaching. Through the ahm Health Coaching program you ll receive the motivation, tools and techniques you need to sustain a healthy lifestyle. You will also receive support through regular phone calls from your Health Consultant over a six month period so that you can talk about your progress. Some of the health goals ahm Health Coaching can support include: > weight loss/management > exercise > blood pressure/stress > quit smoking > alcohol intake > cholesterol reduction > Arthritis management > Diabetes management > auto-immune conditions Depending on your health goals, your Health Consultant will be a qualified health professional, such as a Nurse, Dietitian, Psychologist, Occupational Therapist, Exercise Physiologist, Health Educator or Nutritionist. ahm Health Coaching is available to all members on an ahm Extras policy who are at least 18 years old. Each member on the policy can enrol once every six months. To apply call or visit ahm.com.au/health-coaching ahm.com.au

22 News & info The first step to improving and managing your health is through education. You need to stay informed about potential risks to your health and learn how to lead a healthy lifestyle. We provide our members with reliable and current health information that has been clinically verified, including nutritional advice for everyday eating, tips from exercise experts and mouth watering recipes. Plus we keep you up to date with how to get the most from your health cover. a healthy me Magazine a healthy me is a printed magazine that is posted to all members. To find out more and view previous editions visit ahm.com.au/ahealthyme/magazine a healthy me enewsletter The enewsletter can be delivered straight to your inbox every two months. To subscribe you need to sign up for online member services on the ahm Health Insurance website. Visit ahm.com.au/members to register, then follow the links to the a healthy me enewsletter. ahm Health Library A comprehensive range of articles is available on the ahm website, covering topics such as nutrition, exercise, lifestyle and mental health. Visit the ahm Health Library at ahm.com.au/articlelibrary ahm Health Insurance Extras cover 22

23 Health improvement benefits To help you better manage your health, all ahm Extras policies include benefits for a range of health improvement benefits. It s important to note that in some cases we re only able to pay benefits if proof is provided that the service is to assist in helping a medical condition, so please read through all the information carefully and call us before you send in a claim if you re unsure whether you ll be covered or not. Cancer Council UV products We ll pay benefits for approved Cancer Council UV sun protection from the sunscreen, hats, swimwear, and sunglasses range. Items from the cosmetics, clothing, shade or accessories range aren t covered. Special conditions - Your receipt must identify the item as Cancer Council approved. Disease management association fees We ll pay a benefit for association fees paid to the Arthritis Foundation, the Asthma Foundation, the Coeliac Society, Diabetes Australia, the Heart Foundation, the Crohn s and Colitis Association and Ostomy Associations to help manage and receive support for these diagnosed chronic diseases. Doctor s health checks and Healthy Heart checks We ll pay a benefit for health checks to assist with early diagnosis and/or prevent an illness or condition. Special conditions - The benefit isn t payable when your health check is claimable through Medicare, is related to employment (such as pre-employment health checks) or when you can claim it through a third party insurer. Exercise classes We ll pay a benefit for exercise classes including gym, yoga, pilates and exercise physiology sessions to assist in the management of a condition. Special conditions - An Exercise Approval form or letter completed by your health provider, or evidence of participation in ahm Health Coaching, must be provided specifying the condition being managed and dated prior to the date of service of any claim. Gym classes must be provided by a Fitness Australia accredited gym or personal trainer. You can download a copy of the Exercise Approval form at ahm.com.au/downloads ahm.com.au

24 Preventive tests, scans and screenings We ll pay a benefit to assist with early diagnosis and/or to prevent an illness or condition. Special conditions - We can t pay a benefit if the test is claimable through Medicare. Quit smoking We pay benefits for laser therapy, hypnotherapy and nicotine replacement therapy (patches, gum, lozenges and inhalers) where not claimable under the Pharmaceutical Benefits Scheme (PBS) to assist in quitting or reducing smoking with the aim to help improve or prevent an associated health condition. Stress management courses To manage and prevent health conditions associated with high levels of prolonged anxiety. Special conditions - Course must be provided by a recognised psychologist or as part of an ahm Health Coaching program. Weight loss classes and courses We pay a benefit if the class or course is provided by ahm recognised providers Weight Watchers, Jenny Craig or Fernwood. Special conditions - Medical evidence of a Body Mass Index (BMI) (see definition on page 31) of 26 or over must be provided. This can be in the form of a doctor s certificate, an ahm health profile (provided after completion of an online ahm Wellness Assessment) or a certificate from an ahm recognised weight loss provider. If the claim is for a child, evidence of an unhealthy BMI must be provided in the form of a doctor s certificate/letter prior to claiming benefits. Swimming lessons (Family and Super Extras only) A benefit is payable for children 0 17 years of age if provided by an Austswim or Swim Australia accredited swim school if they have asthma, diabetes or an unhealthy BMI (see definition page 31). Special conditions - Medical evidence of one of these conditions must be provided or a doctor s recommendation to undertake this activity due to their condition. ahm Health Insurance Extras cover 24

25 Online member services Online member services allows you to manage your cover online when it suits you best. You can log on, any time of day to review your cover details and confirm they re correct or to make a claim. You can also access a range of information relating to healthy living including hundreds of healthy recipes. As soon as you ve registered you ll be able to: > view your claims history > change your level of cover > request a replacement member card > search for recognised providers > view and update your personal information > make a payment > access information on healthy living and dental and eyecare health > claim for most Extras benefits > check your benefits limits > and more ahm.com.au

26 You could save on premiums The Australian Government Rebate on Private Health Insurance is the amount that the Australian Government contributes to your health insurance premium to help make it more affordable. If you re eligible, you can reduce your premium by up to 30% and as you get older it can reduce even further. The rebate is income tested which means that the amount the Australian Government contributes towards your private health insurance premium will be determined by your income tier. Income tiers are based on income for Medicare Levy Surcharge purposes which includes things like taxable income, exempt foreign employment income, reportable fringe benefits, reportable superannuation contributions and total net investment losses. Once you ve advised us of your chosen income tier, the amount that you have to pay towards your premiums will be adjusted based on what the Government will contribute. You ll need to tell us what income tier you think you should be on, so if you re not sure, speak to your accountant or financial advisor. Visit ahm.com.au/rebate for more information including a table with current income levels for each tier. ahm Health Insurance Extras cover 26

27 Your membership Who s on your cover At ahm Health Insurance our policies are designed to suit the different lifestyle needs of our members. All covers listed in this document can be purchased in any of the membership categories listed below. Single a policy that covers one person only (the principal member) Single parent a policy that covers one adult (the principal member) and any child or student dependants Family a policy that covers one adult (the principal member), their partner and any dependants Members on your cover Principal member this is the first person listed on the membership. They are responsible for the payment of premiums and have full authority to make any changes to the membership Partner means a person who lives with the principal member in a marital or bona fide domestic relationship Child dependant means a child of the principal member who doesn t have a partner and is under the age of 21 Student dependant means a child of the principal member who doesn t have a partner, has reached the age of 21 but is under the age of 25, and is undertaking full-time education Adult dependant means a child of the principal member who doesn t have a partner; has reached the age of 21 but is under the age of 25; isn t a student dependant; and is a member of an eligible cover or combination of eligible covers. Changing your cover As your life changes, so do your health insurance needs. It s important to know when changing your level of cover it may impact the benefits you re entitled to receive, and you may have to serve waiting periods for any additional services or higher benefits that were not on your previous level of cover. The good news is that we don t have any two or six month waiting periods on any extras covers so for many services you ll be able to claim the higher benefit straight away. Changing your cover may affect your eligibility or participation in ahm Health Coaching and Health Hub programs. Switching private health insurers If you ve switched private health insurers, we ll recognise the waiting periods you ve already served for comparable benefits. In accepting a transfer from a private health insurer, we reserve the right to treat any benefits paid by the previous insurer in the current financial year as already being used under the limits of your new cover ahm.com.au

28 Suspending your policy We recognise that we all need to get away sometimes, so if you re travelling overseas for more than 30 days, you can suspend your policy (to a maximum of two years at any one time) without it affecting your loyalty. The period of suspension will still count towards the years of continuous cover. To suspend your policy just send us a written or request before your holiday with a copy of your official itinerary or e-ticket which includes the dates of travel. We ll contact you on your return to confirm reinstatement of your policy and advise you of the need to reactivate your premium payments. NOTE: You ll still need to serve any waiting periods you may have had before leaving the country and no benefits will be paid for services provided during the suspension period. If you also have an ahm Hospital cover, suspending your policy may result in you being charged the Medicare Levy Surcharge. We suggest you speak to your accountant, tax agent or the Australian Taxation Office for further advice. ahm Health Insurance Extras cover 28

29 How to pay We offer a number of convenient payment options to make sure you re covered when you most need it. All you need to do is pick the one that s right for you. Direct debit The easiest way to pay and our most popular payment method. There s no need to think about when your premium is due because we ll just withdraw the premiums from your nominated bank account or credit card at a frequency chosen by you. Simply call us on to set this up or download a Payment form from ahm.com.au BPAY You can pay any time of day, over the phone or online if you re registered for phone or internet banking with your financial institution. Simply use the biller code and your member number as the customer reference number. Online One off payments can be made using your Visa or MasterCard credit card. Just log in to the members section and select Make a payment. Phone You can pay your premiums by Visa or MasterCard credit card over the phone on Mail Make cheques payable to ahm Health Insurance. Please ensure you clearly print your name and member number on the back of the cheque and send it to: ahm Health Insurance, Locked Bag 1006, Matraville NSW 2036 Over the counter We accept Visa and MasterCard credit cards, EFTPOS, cheques and cash over the counter at 77 Market St, Wollongong NSW. Our fund rules for ahm products require that all members who pay their premiums by direct debit, cheque, cash or by BPAY must pay their premium so that it remains at least one premium frequency in advance at all times. If you pay by group payroll deductions, you must be paid up to the same date as your group. Payments in advance You can pay your premiums up to a maximum of 12 months in advance ahm.com.au

30 Important information and definitions you need to know ahm Recognised Providers It is important that we recognise service providers so that you receive quality health care from the providers you choose. Recognising a provider means we get specific details and credentials from them to make sure they meet both legislative and our criteria for benefit payment. All service providers must be recognised by ahm Health Insurance before we can pay benefits. Recognition of a provider means that we may check with the provider on the goods or services supplied to any person on a policy to ensure that appropriate claims and benefits are being paid. Benefits won t be paid for services performed or goods supplied by unrecognised practitioners or by a provider on themselves, their partner or dependants, business partners or business partners partner or dependants. To find out if your service provider is recognised by us call or use the online provider search tool at ahm.com.au If your preferred provider isn t recognised by ahm Health Insurance, they can find out more information on the requirements by visiting ahm.com.au/provider Disclaimer: ahm Health Insurance encourages its Recognised Providers to offer high-quality products and services at competitive prices to its members. Where ahm Health Insurance recognises a provider, to the fullest extent allowed by the law, such advertising or reference should not be construed as: > an endorsement by ahm Health Insurance > an acknowledgement or representation by ahm Health Insurance as to fitness for purpose; or > a recommendation or warranty by ahm Health Insurance; of, for, or in relation to, the product and/ or service of the recognised provider. Accordingly, to the fullest extent allowed by law, ahm Health Insurance neither takes nor assumes any responsibility for the product and or services provided. Members should make and rely on their own enquiries and seek any assurance or warranties directly from the recognised provider of the services or product. ahm Health Insurance Extras cover 30

31 Ambulance transportation If you have ahm Extras cover on its own, your policy only covers you for emergency transportation. This means a sudden or unexpected need for hospitalisation where the only practical way of getting to a hospital is by ambulance. NOTE: We don t pay benefits for ambulance subscriptions and we don t cover you for non-essential transportation such as: > transfer between a public and private hospital > changing hospitals to be closer to home > travelling from home to hospital for tests. If you have ahm Hospital cover, you re covered for all medically necessary ambulance transportation, please refer to the ahm Hospital policy document for more detail. Body Mass Index (BMI) The BMI is used to estimate your total amount of body fat. It s an approximate measure of the best weight for health. To calculate your BMI, divide your weight in kilograms by your height in metres squared. For example, if you weigh 70kg and you re 1.7 metres tall, your BMI would be (1.7 x 1.7) = 24.2 A BMI between 18.5 and 25 is within the normal range. A BMI less than 18.5 means you may be underweight and a BMI of 26 and over means you may be considered overweight. A BMI above 30, is considered obese. A child s BMI can only be determined by a medical practitioner as the child s age and sex is also taken into account. Broken appointments Your ahm Extras cover doesn t pay benefits towards broken appointments, so if you ve been charged for not attending or cancelling an appointment, you won t be able to claim for it. Consultations You re able to claim for one face to face consultation with a provider on a given day. This means that if you have two or more consultations with the same provider on the same day, even if they re for different types of services, you ll only be able to claim for one. Telephone or video consultations aren t eligible for benefits except where preapproved by ahm. Dental Dental benefits are paid by the type of service and according to the category as detailed below. Different benefits are not paid for the type of provider except orthodontics. Routine Includes x-rays, examinations or consultations, preventive procedures such as clean and polish, oral surgery for tooth extractions and minor restorative services. Complex Includes periodontics (root planing, oral surgery for prostheses, jaw injuries or non-tooth related surgery) and endodontics (root canal therapy). Major Includes indirect restorations, all crowns, bridgework and implants and dentures (dentures not available on ahm Lifestyle Extras). Orthodontics We ll pay benefits for orthodontic services by a General Practitioner (GP) or specialist dentist provided claims are accompanied by a detailed treatment plan. NOTE: Benefits paid for services provided by a General Practitioner are lower than benefits paid for services performed by a specialist ahm.com.au

32 Orthotics and orthopaedic footwear We ll pay benefits for orthotics and orthopaedic footwear only if custom made and supplied by an ahm recognised podiatrist or orthopaedic footwear supplier. Make sure you include a referral from an ahm Recognised Provider with your claim. We accept referrals from ahm recognised physiotherapists and chiropractors for orthotic devices. Outpatient procedure room fees Benefits will be paid towards the charge incurred for the use of a facility or procedure room for an outpatient medical service. The cost of the doctor s fee for the medical service isn t claimable. Overseas claims Your Extras policy doesn t cover you for any services received or goods purchased outside of Australia, including online purchases from overseas companies. If you re travelling overseas, call us on so that the ahm team can help you arrange travel insurance at discounted rates. NOTE: If you re planning to be out of the country for more than 30 days, you can suspend your policy for the time you re away up to a maximum of two years at any one time (see Suspending your policy page 28). Pharmaceutical Benefits Scheme (PBS) The PBS is the national pharmaceutical benefits scheme funded by the Australian Government where patients pay a set amount towards the cost of a subsidised drug. The PBS is only available to persons with Medicare eligibility. Pharmacy We ll pay benefits for non-pbs pharmacy items that are: > prescription only and prescribed by a medical practitioner, including contraceptives for medical conditions, and > essential to treat a particular illness, injury or condition. We ll pay a benefit for each eligible pharmacy item after you pay the set PBS general patient amount as a co-payment. Items available without a prescription including over the counter, off the shelf, herbal medicines and vitamins can t be claimed. Policy in arrears (unfinancial) Benefits are not payable for services provided during the period in which a policy is in arrears until the premium is fully paid and accepted by us. Our fund rules for ahm products require members to be at least one premium payment frequency in advance. We have the right to refuse to accept premiums if more than two months have elapsed since the financial date of the policy. NOTE: If a member is more than two months in arrears then the policy will be terminated by notice in writing to the principal member, effective from the last financial date of the policy. ahm Health Insurance Extras cover 32