Our Product Disclosure Statement (PDS)

Transcription

1 Our Product Disclosure Statement (PDS) Your HIF hospital and ancillary health cover in detail. The smart choice for health cover. Visit hif.com.au or call to get a quote and join (or switch) today. Australia s first certified Carbon Neutral health fund

2 What s inside? A bit about us, this PDS and health insurance A bit about us, this PDS and health insurance HIF Hospital Cover Options...4 GoldStarter Hospital...8 GoldSaver Hospital...10 Gold Hospital...12 GoldStar Hospital...14 About our ancillary cover...16 Ways to claim...17 Feedback, disputes and privacy...38 Frequently asked questions...40 Glossary...42 At HIF, we aim to make choosing smart health insurance simple and painless. With that in mind, we ll keep this Product Disclosure Statement (PDS) as short and sweet as possible. No unnecessary information. Just the must-know stuff. We want you to be able to make the right health insurance choice but we don t want you to fall asleep. So here we go

3 About us and you HIF is a not-for-profit private health insurer. That means we don t have shareholders, so any income we earn after paying for our members benefits and covering our operating expenses is available to pay bigger and better benefits. And that s a good thing. About this PDS You ll find lots of useful info about our health insurance in this brochure: what s and what isn t; details of different cover options; explanations about our services and the terminology we use. All the stuff you need to know when comparing, choosing and reviewing your health cover. Important Tip When you join HIF or change your level of cover, we will send you a Member Statement confirming your new level of cover. To avoid confusion, it s a good idea to keep your statement with this brochure. Keep Updated HIF is always reviewing and improving its services and benefits so to ensure you are claiming all possible benefits remember to regularly visit hif.com.au for an updated version of this PDS. The legislation or rules that affect your premiums, cover and membership obligations include: The Private Health Insurance Act 2007 (the PHI Act) Fairer Private Health Insurance Incentives Act 2012 Fairer Private Health Insurance Incentives (Medicare Levy Surcharge) Act 2012 Fairer Private Health Insurance Incentives (Medicare Levy Surcharge Fringe Benefits) Act 2012 Under the PHI Act, we are required to document our operating guidelines, known as Fund Rules or Business Rules. All private health funds have to do this. These rules detail our obligations as a private health insurer, as well as the obligations of our members. As such, when you become a HIF member, you agree to be bound by these rules. If you would like a copy of the rules, simply info@hif.com.au or call us on Want more information? Visit hif.com.au to find out more about our not-for-profit health fund. Alternatively, if you would like to know more about us or the rules and regulations around health insurance, please info@hif.com.au or call us on About Australian private health insurance All Australian private health insurers, and residents and non-residents who pay tax in Australia, have potential responsibilities, obligations and entitlements under Australian health insurance laws. These laws include directions about services that can or must be, entitlement to the private health insurance rebate and obligations to pay the Medicare Levy Surcharge (MLS) and the Lifetime Health Cover (LHC) loading. 3

4 HIF Hospital Cover Options Cover for in-hospital procedures GoldStarter GoldSaver Gold GoldStar Choice of Excess Private Room Private room (maternity) (3 days) (5 days) (uned) Shared room Intensive Care Theatre Care Same-day Accommodation Same-day Theatre Appliances Prostheses Pharmacy Drugs AccessGap Palliative Care (disease) Cardio Thoracic (heart/chest) Psychiatric Care & Treatment Joint Replacement Assisted Reproductive Technology (e.g. IVF) Eye Surgery (non-cosmetic) Some restrictions and exclusions may apply. 4

5 Restrictions and exclusions Product Restricted Excluded GoldStar Surgery by podiatrists Cosmetic services* Services not by Medicare Gold Surgery by podiatrists Cosmetic services* Services not by Medicare* GoldSaver Assisted reproductive technology Gastric banding and obesity surgery GoldStarter Cardiac and thoracic (heart and/ or chest) conditions, procedures or monitoring** Eye surgery Joint replacement Psychiatric Palliative care Psychiatric Rehabilitation Cosmetic services* Services not by Medicare* Surgery by podiatrists Gastric banding and obesity surgery Cardiac and thoracic (heart and/or chest) conditions, procedures or monitoring** Eye surgery Joint replacement Assisted reproductive technology Obstetrics (maternity) Cosmetic services* Services not by Medicare Surgery by podiatrists For restricted services HIF will pay a basic benefit known as the public hospital rate, toward accommodation charges. All other charges raised by the hospital during the stay will be paid by the member. An excluded service means all charges raised during the stay will be paid by the member. * Where a service is deemed by Medicare to be cosmetic and/or does not attract a Medicare rebate, all charges raised in association with the hospital stay will not be eligible for payment. ** Some examples of cardiac and thoracic surgery treatment or monitoring are: heart bypass, angiograms, coronary care, lung surgery, chest conditions such as pneumonia, bronchitis, asthma and emphysema. Contact us prior to admission to confirm benefits payable. 5

6 Things you need to know about our hospital cover When selecting hospital cover, it s important to ensure that you understand how each level of cover will apply to you, as well as being aware of details such as ations, restrictions or exclusions that might also apply to your chosen cover. AccessGap Cover AccessGap Cover applies to medical accounts for members undergoing in-patient hospital procedures. It s designed to reduce or eliminate out-of-pocket expenses by allowing doctors to use the scheme on a patient-by-patient basis. If a doctor uses the scheme, he/she agrees to charge you a set fee for each item and will then receive a payment from HIF and Medicare combined, which is more than the Medicare Schedule Fee. To be eligible for AccessGap Cover, doctors must be willing to participate for your particular surgery and the account must be lodged directly with HIF (not Medicare). To find out more about specific payment amounts for upcoming procedures, or for your doctor to register for the scheme, please call us on Healthcare providers HIF covers ancillary, medical and hospital providers throughout Australia. To confirm if a provider is approved by HIF, go to hif.com.au, us at info@hif.com.au or call us on Benefits will not be paid for any hospital services provided outside Australia, or for services purchased or provided within Australia from a non-australian recognised provider. Ambulance services HIF is required under New South Wales and Australian Capital Territory legislation to financially contribute toward the cost of operating state or territory-provided emergency ambulance services on behalf of any person who is a permanent state or territory resident and holds any level of HIF hospital cover. Under this arrangement, our members who are residents of NSW or ACT and hold HIF hospital cover may submit their resident state or territory emergency ambulance invoice to HIF to claim a benefit toward the fees charged. Please note that ambulance benefits may not be claimable under a NSW or ACT HIF hospital cover if the service was not provided by your local statecontrolled ambulance service, or if the service was not deemed by the ambulance attendant to be an emergency (medically necessary). For more information about this, see page 18 or visit hif.com.au and visit the Ambulance Cover page within the Health section. Medical Gap Different medical providers may charge different prices for the same procedure. If you are planning a procedure, we recommend that you ask your medical provider and any associated health provider (e.g. anaesthetist or assistant) if they will participate in our AccessGap scheme to help you avoid or minimise your out-of-pocket expenses. If your health provider does not confirm your out-of-pocket expenses, we recommend you contact us with your provider s details, item numbers and charges and we will provide you with a benefit estimate. 6

7 The Pre-existing Ailment Rule This standard rule is applied across the health insurance industry. It is designed to ensure that long-term members are not financially disadvantaged by new members who join and claim benefits immediately for pre-existing conditions. A pre-existing ailment is defined as an ailment or condition for which the signs or symptoms were evident or known at any time during the 6 months prior to when the member joins HIF, or upgrades to a higher level of cover or the same cover with a reduced or nil excess. HIF is not required to pay benefits for a pre-existing ailment during the first 12 months of a new member s hospital cover. Where an existing member upgrades to a higher level of cover or the same cover with a reduced or nil excess, any services related to the pre-existing ailment will be paid out at the previous level of cover for the first 12 months. Restricted services Where services are noted as restricted in your hospital cover, this means that if you receive them in a private hospital, you will only be at the basic public hospital benefit rate, which includes: The cost of a shared room in a public hospital A benefit towards the cost of surgically implanted prosthesis AccessGap for in-patient medical services Workers Compensation and Dual Insurance Benefits cannot be claimed and are not payable by HIF where you have or can claim benefits or compensation (in full or in part) for treatment, goods or services from a third party including Workers Compensation or Public Liability sources, your employer or any other Insurance policy. Transferring and upgrading your cover New members who transfer hospital cover from another Australian health fund to an equivalent level of HIF hospital cover will not have any waiting periods applied, providing these were served with the previous fund. New members who transfer hospital cover from another Australian health fund to a higher level of hospital cover, or equivalent level of cover with a reduced or nil excess, will have qualifying periods applied for the higher level of cover and/ or benefits. During these periods benefits will be payable at the equivalent level of cover to that of your previous fund. Current HIF members who transfer hospital cover to a higher level of hospital cover, or equivalent level of cover with a reduced or nil excess, will have qualifying periods applied for the higher level of cover and/or benefits. During these periods benefits will be payable at the lower level of cover. No other benefits are payable for restricted services, unless specifically listed in the individual product description within this brochure. Excluded services Where services are noted as excluded in your hospital cover, this means that you are not and you must pay all costs. 7

8 GoldStarter Hospital This is our entry-level private hospital insurance cover a smart choice if you re younger and less likely to require things like maternity and cardio-thoracic procedures. It covers all the essentials and is great value for money too. GoldStarter Hospital No maternity cover Restrictions and exclusions apply Full cover for the cost of a shared room, theatre fees and charges in a HIF contracted hospital anywhere in Australia for approved services Full AccessGap Cover for inpatient medical procedures for approved services Includes an excess to reduce the premium Hospital waiting periods General hospitalisation two months All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 12 months Restricted services Benefits for the following services will include basic public hospital rate (only) for accommodation. However, full AccessGap coverage for inpatient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient: Psychiatric care or attention Palliative care Rehabilitation Surgery by podiatrists No benefits will be payable for other charges related to these services (e.g. theatre or some pharmaceutical costs), so significant out-of-pocket expenses may apply for these procedures if you are admitted as a private patient. Exclusions Benefits are not payable for any charges raised for the following services: Assisted reproductive technology (e.g. IVF) Cardio and thoracic (e.g. conditions of the heart and chest requiring surgery, monitoring or other procedures such as heart or lung surgery, treatment for asthma, emphysema, etc) Eye surgery (any procedure on the surface or within the structures of the eye) Gastric banding and obesity surgery Joint replacement Obstetrics Services deemed cosmetic by Medicare and services that do not attract a Medicare rebate Services GoldStarter Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check with us prior to admission to ensure that the hospital is a HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The listed benefits are offered to members who are admitted to those hospitals. 8

9 Accommodation charges including day patient, intensive care and neonatal care Theatre fee and labour ward charges Pharmaceutical drugs (does not include discharge drugs) Prostheses and consumables Outpatient theatre fees (not emergency department fees) Medical Gap For more details, please refer to the AccessGap Cover section in this brochure, or or call us on Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital All hospitals and approved day care facilities Full cover in a shared or private room. The full cost of a shared room. If you occupy a private room you will be up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge. Charges are not raised for this service. Full cover for theatre charges. Charges are not raised for this service. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Prostheses items used in relation to relevant exclusion services are not. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses items used in relation to relevant exclusion services are not. No charge raised. Full cover for outpatient theatre fees. Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. Applicable excess A mandatory excess is applied to GoldStarter hospital cover to reduce premium costs: GoldStarter $200 per person to a max of $400** * Therapeutic Goods Administration ** Excesses are paid once per person per admission under the policy in a calendar year up to the maximum. Excesses apply to all hospital treatments. 9

10 GoldSaver Hospital This is our intermediate hospital cover and is a step up from GoldStarter. It s great for young couples and families who are likely to need things like maternity cover but not services such as cardio-thoracic and joint replacement surgery. GoldSaver Hospital Intermediate hospital cover Includes maternity services Full cover for the cost of a shared room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia for approved services Private room for up to 3 days for management of labour and delivery of child Full AccessGap cover for inpatient medical procedures Includes an excess to reduce the premium Some restricted services Hospital waiting periods General hospitalisation 2 months All obstetric related services 12 months All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 12 months Restricted Services Benefits for the following services will include basic public hospital rate (only) for accommodation. However, full AccessGap coverage for in-patient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient: Joint replacement Cardio and thoracic (e.g. conditions of the heart and chest requiring surgery, monitoring or other procedures such as heart or lung surgery, treatment for asthma, emphysema, etc) Eye surgery (any procedure on the surface or within the structures of the eye) Psychiatric care or attention Assisted reproductive technology (e.g IVF) Surgery by a podiatrist No benefits will be payable for other charges related to these services (e.g. theatre or some pharmaceutical costs), so significant out-of-pocket expenses may apply for these procedures if you are admitted as a private patient. Exclusions Benefits are not payable for any charges raised for the following services: Gastric banding and obesity surgery Services deemed cosmetic by Medicare and services that do not attract a Medicare rebate Services GoldSaver Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The listed benefits are offered to members who are admitted to those hospitals. 10

11 Accommodation charges including day patient, intensive care and neonatal care Theatre fee and labour ward charges Pharmaceutical drugs (does not include discharge drugs) Prostheses and consumables Outpatient theatre fees (not emergency department fees) Medical Gap For more details, please refer to the AccessGap Cover section in this brochure, or or call us on Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital All hospitals and approved day care facilities Full cover in a shared or private room. Full cover in a shared room. A private room will be fully for up to 3 days for maternity stays relating to the management of labour and delivery. If you occupy a private room for maternity stays greater than 3 days, for the fourth and additional days you will be up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge. Charges are not raised for this service. Full cover for theatre and labour ward charges. Charges are not raised for this service. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Prostheses items used in relation to relevant exclusion services are not. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Full cost of the charge raised. Full cover for outpatient theatre fees. Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. Applicable excess A mandatory excess is applied to reduce premium costs: GoldSaver $200 per person to a max of $400** * Therapeutic Goods Administration ** Excesses are paid once per person per admission under the policy in a calendar year, up to the maximum. Excesses apply to all hospital treatments. 11

12 Gold Hospital This is our award-winning top shared room hospital insurance cover. You re fully for theatre fees, ward fees and all other services. It s especially great if you re planning on having a baby, because our maternity cover includes up to five days in a private room at no extra cost. Gold Hospital Top hospital cover Comprehensive cover for all Medicare approved items Includes maternity services Private room for up to 5 days for management of labour and delivery Full cover for the cost of a shared room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia Full AccessGap Cover for inpatient medical procedures Choice of excesses to reduce cost Hospital waiting periods General hospitalisation 2 months All obstetric related services 12 months All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 12 months Restrictions Surgery performed in a hospital by registered podiatrists is not eligible for Medicare rebates. However, under this level of cover HIF will pay ed benefits toward the podiatrist s charges. Hospital accommodation and theatre charges will also be ed. Exclusions No benefit is payable for services deemed as cosmetic by Medicare and/or services that do not attract a Medicare benefit. Services Gold Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The listed benefits are offered to members who are admitted to those hospitals. 12

13 Accommodation charges including day patient, intensive care and neonatal care Theatre fee and labour ward charges Pharmaceutical drugs (does not include discharge drugs) Prostheses and consumables Outpatient theatre fees (not emergency department fees) Medical Gap For more details, please refer to the AccessGap Cover section in this brochure, or or call us on Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital All hospitals and approved day care facilities Full cover in a shared or private room. The full cost of a shared room. A private room will be fully for up to 5 days for maternity stays relating to the management of labour and delivery. If you occupy a private room for maternity stays greater than 5 days, for the sixth and additional days you will be up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge. Charges are not raised for this service. Full cover for theatre and labour ward charges. Charges are not raised for this service. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. No charge raised. Full cover for outpatient theatre fees. Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. Excess options Optional excesses to reduce premium costs: Gold Excess 100/200 $100 per person to a max of $200** Gold Excess 200/400 $200 per person to a max of $400** Gold Excess 400/800 $400 per person to a max of $800** * Therapeutic Goods Administration * * Excesses are paid once per person per admission under the policy in a calendar year, up to the maximum. The excess is not applied to same-day surgery or to child dependants under the age of

14 GoldStar Hospital This is our premium hospital insurance cover, with all the bells and whistles. You re fully for everything, including a private room for all services, theatre fees and all ward fees. No worries. Just total peace of mind for you and your family. GoldStar Hospital Cover Top hospital cover Comprehensive cover for all Medicare approved items Includes maternity services Full cover for the cost of a private room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia Full AccessGap Cover for inpatient medical procedures Choice of excesses to reduce cost Exclusions No benefit is payable for services deemed as cosmetic by Medicare and/or services that do not attract a Medicare benefit. Services GoldStar Hospital will cover the following services provided in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The listed benefits are offered to members who are admitted to those hospitals. Hospital waiting periods General hospitalisation 2 months All obstetric related services 12 months All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 12 months Restrictions Surgery performed in a hospital by registered podiatrists is not eligible for Medicare rebates. However, under this level of cover HIF will pay ed benefits toward the podiatrist s charges. Hospital accommodation and theatre charges will also be ed. 14

15 Accommodation charges including day patient, intensive care and neonatal care Theatre fee and labour ward charges Pharmaceutical drugs (does not include discharge drugs) Prostheses and consumables Outpatient theatre fees (not emergency department fees) Medical Gap For more details, please refer to the AccessGap Cover section in this brochure, or or call us on Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital Public hospital Private hospital All hospitals and approved day care facilities Full cover in a shared or private room. Full cover in a shared or private room. Charges are not raised for this service. Full cover for theatre and labour ward charges. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. No charge raised. Full cover for outpatient theatre fees. Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap Cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. Excess options Optional excesses are available to reduce premium costs: GoldStar Excess 200/400 $200 per person to a max of $400** GoldStar Excess 400/800 $400 per person to a max of $800** GoldStar Excess 500/1000 $500 per person to a max of $1000** * Therapeutic Goods Administration ** Excesses are paid once per person per admission under the policy in a calendar year, up to the maximum. The excess is not applied to same-day surgery or to child dependants under the age of

16 Things you should know about our ancillary cover Here at HIF, we pride ourselves on enabling member choice. So, unlike some health fund insurers who pay lower benefits if you don t go to their preferred providers, with HIF you re free to visit any ancillary provider in Australia. Our only requirement is that members must visit healthcare providers who are legally qualified to practise in Australia (and approved by HIF). So as long as your preferred doctor, dental provider, optical provider, physiotherapist, chiroprator or other type of healthcare provider is approved by HIF, you re free to use whichever one you want. Our Member Loyalty Program HIF recognises and rewards members who retain their ancillary cover each year by providing increasing benefits or annual s. Our dental s increase every year from commencement until the maximum is available in your sixth year of membership. Benefits or s for services like optical, physiotherapy, occupational and speech therapy increase after 5 years and benefits or s increase for complementary therapies, chiropractic, osteopathic and pharmacy after 3 years. Where a policy is upgraded to a higher level of ancillary cover, annual s and benefits will automatically move to the next highest loyalty benefit on the new level of cover and progress each year until all maximum benefits and s are reached. Annual s HIF ancillary covers have an annual for most services, which means there is a on how much HIF will pay toward your claims. Most s are for the calendar year (January to December) but each January your benefit s will be refreshed, allowing you to claim benefits again for ancillary services provided in the new year. Claiming timeframe ation Claims must be made within two years of the service being provided. Approved consultations Unless stated, to be eligible for HIF benefits all services must be provided by a HIF approved health provider at that provider s registered practice address in a face-to-face setting, or as otherwise approved by HIF. Video, telephone or online facilitated services, with the exception of HIF approved Hospital Substitute treatment or Chronic Health Disease Management programs, are not approved consultations. Workers Compensation and Dual Insurance Benefits cannot be claimed and are not payable by HIF where you have or can claim benefits or compensation (in full or in part) for treatment, goods or services from a third party including Workers Compensation or Public Liability sources, your employer or any other Insurance policy. 16

17 Ways to claim Electronic Claiming Providers with electronic claiming technology (HICAPS or IBA) can settle your account with you on the spot. Simply swipe your HIF membership card and pay any difference. SmartClaim for mobile Members who own an Apple or Android mobile device can now submit paid ancillary accounts of $700 or less by using their mobile s in-built camera to photograph receipts and invoices. To find out more, visit hif.com.au or download HIF SmartClaim now from the Apple App Store or the Android Market. By post Complete a claim form and post it to: HIF GPO Box X2221 Perth WA 6847 Claim forms can be downloaded from hif.com.au or mailed to you on request. For more information on the different ways to make a claim, check out the How to Claim page on hif.com.au Fast-Track e-claiming ( /fax) For paid ancillary accounts of $700 or less, try our quick and easy Fast-Track option. Simply scan your completed HIF claim form and associated receipts and invoices, and a copy to claims@hif.com.au or fax a copy to (08) To find out more, visit hif.com.au Hospital and AccessGap Accounts Your doctor may send the accounts to HIF direct. If not, you can send the unpaid account to us for processing the HIF and Medicare benefits payable. We will then send the payment direct to your doctor or hospital on your behalf. Please call us before you go into hospital so we can assist you with your claims. 17

18 Ambulance benefits Benefit is paid on charges raised for approved ambulance services. HIF fully covers the cost of emergency ambulance transport for cases classified by approved ambulance service providers as requiring urgent attention and where the patient is admitted to the emergency department of a hospital. A patient co-payment of $50 per service applies to non-emergency call-outs and transportation. Benefits are not payable for transportation from a hospital to your home, nursing home or other hospital, or for transportation for ongoing medical treatment. Benefits are not payable for off road or air ambulance. Where a member is eligible for a state or Federal government subsidy, HIF will pay a benefit, less this entitlement. e: Ambulance services, charges and levies vary significantly across Australian states and territories: QLD & TAS Residents are for uned emergency services provided by their respective state governments. Interstate ambulance service charges for these residents may not apply if reciprocal agreements are in place with the other states where the ambulance service was required. NSW and ACT Residents who hold HIF hospital cover are for uned emergency ambulance services provided in their home state by their state government or territory ambulance service. Interstate emergency services may also be if under a reciprocal state agreement. Premium Options Super Type of service Additional information Benefit Person Membership Benefit Pers Ambulance As above Emergency: 100% Nonemergency call-outs and transportation: 100% with a $50 co-payment Interhospital transfers: No benefit N/A N/A Emergency: 100% Nonemergency call-outs and transportation: 100% with a $50 co-payment Interhospital transfers: No benefit N/A 18

19 All other emergency services In all other locations and circumstances, emergency ambulance services may be claimable from HIF Options covers, subject to the services being provided by the recognised St John or state government controlled ambulance organisation and the service being deemed as medically necessary by the attending ambulance officer. Options Special Options Saver Options on Membership Benefit Person Membership Benefit Person Membership N/A Emergency: 100% N/A N/A Emergency: 100% N/A N/A Nonemergency call-outs and transportation: 100% with a $50 co-payment Nonemergency call-outs and transportation: 100% with a $50 co-payment Interhospital transfers: No benefit Interhospital transfers: No benefit 19

20 Ancillary benefits Premium Options Super Options Type of service Additional information Benefit Person Membership Benefit Person Membership Asthmatic spacers N/A $18 2 per person per year No $18 2 per person per year No Auxiliary Home Nursing Benfits must be ordered by a medical practitioner. Contact us for conditions. $120 $1,800 per year No $75 $1,800 per year No Blood glucose or blood pressure monitor A letter of recommendation from the patient s treating practitioner is required. 75% of cost 1 of either monitor every 3 years Max: $200 No 75% of cost 1 of either monitor every 3 years Max: $200 No Chiropractic Benefits are paid for spinal manipulation or spinal adjustments carried out by a registered chiropractor approved by HIF. Spinal adjustment manipulation First visit: $30 Visits 2-10: $29 Visits 10+: $18 X-ray: $110 annual (chiropractic and osteopathic) Up to 3 years: $650 Over 3 years: $750 1 x-ray per year annual (chiropractic and osteopathic) Up to 3 years: $1300 Over 3 years: $1500 Spinal adjustment manipulation First visit: $28 Visits 2-10: $23 Visits 10+: $14 X-ray: $85 annual (chiropractic and osteopathic) Up to 3 years: $550 Over 3 years: $650 1 x-ray per year annual (chiropractic and osteopathic) Up to 3 years: $1100 Over 3 years: $

21 Special Options Saver Options Type of service Additional information Benefit Person Membership Benefit Person Membership Asthmatic spacers N/A N/A N/A No N/A N/A No Auxiliary Home Nursing Benfits must be ordered by a medical practitioner. Contact us for conditions. N/A N/A No N/A N/A No Blood glucose or blood pressure monitor A letter of recommendation from the patient s treating practitioner is required. N/A N/A No N/A N/A No Chiropractic Benefits are paid for spinal manipulation or spinal adjustments carried out by a registered chiropractor approved by HIF. Spinal adjustment manipulation First visit: $26 Visits 2-10: $21 Visits 10+: $10 X-ray: $70 annual (chiropractic, osteopathic, physiotherapy, podiatry and complementary therapies) $450 1 x-ray per year annual (chiropractic, osteopathic, physiotherapy, podiatry and complementary therapies) $900 Spinal adjustment - manipulation: First visit: $26 Visits 2-10: $21 Visits 10+: $10 X-ray: $65 annual (chiropractic, dietetics healthy lifestyle, complementary therapies, pharmacy, osteopathic, physiotherapy and podiatry) $350 annual (chiropractic, dietetics healthy lifestyle, complementary therapies, pharmacy, osteopathic, physiotherapy and podiatry) $700 1 x-ray per year 21

22 Ancillary benefits Premium Options Super Options Type of service Additional information Benefit Person Membership Benefit Person Membership Complementary therapies - Naturopathy - Homeopathy - Acupuncture - Traditional Chinese Medicine - Remedial massage therapy - Myotherapy Benefits are not payable on medicines provided by the practitioner. The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Visits 1-6: $25 Visits 7+: $17 Up to 3 years: $500 Over 3 years: $600 No Visits 1-6: $20 Visits 7+: $13 Up to 3 years: $250 Over 3 years: $350 $700 Dental See page 36 for more details Diabetics education For consultations or information sessions held by Diabetes Association in relation to diabetes. First visit: $36 Subsequent: $18 6 visits per year No First visit: $36 Subsequent: $18 6 visits per year No Dietetics Benefits are paid on consultations carried out by a registered dietician approved by HIF. First visit: $40 Subsequent: $20 Group: $12 $324 per year No First visit: $36 Subsequent: $18 Group: $10 $324 per year 22

23 Special Options Saver Options Type of service Additional information Benefit Person Membership Benefit Person Membership Complementary therapies - Naturopathy - Homeopathy - Acupuncture - Traditional Chinese Medicine - Remedial massage therapy - Myotherapy Benefits are not payable on medicines provided by the practitioner. The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Visits 1-6: $16 Visits 7+: $11 Up to 3 years: $100* Over 3 years: $200* $400* Visit 1-6: $15 Visits 7+: $10 Up to 3 years: $50 # Over 3 years: $100 # $200 # Dental See page 36 for more details Diabetics education For consultations or information sessions held by Diabetes Association in relation to diabetes. N/A N/A No N/A N/A No Dietetics Benefits are paid on consultations carried out by a registered dietician approved by HIF. First visit: $36 Subsequent: $18 Group: $10 $252 per year No First visit: $36 Subsequent: $18 Group: $10 annual (chiropractic, dietetics healthy lifestyle, complementary therapies, osteopathy, pharmacy, physiotherapy and podiatry) $350 annual (chiropractic, dietetics healthy lifestyle, complementary therapies, osteopathy, pharmacy, physiotherapy and podiatry) $700 * Subject to combined overall person of $450 and membership of $900 for complementary therapies, chiropractic incl. 1 X-ray per year per person, osteopathic, physiotherapy and podiatry. # Subject to combined overall person of $350 and membership of $700 for complementary therapies, chiropractic incl. 1 X-ray per year per person, dietetics, healthy lifestyle, pharmacy, osteopathic, physiotherapy, and podiatry. 23

24 Ancillary benefits Type of service Additional information External prostheses Benefits are paid on HIF approved prosthetics items such as artificial limbs, wigs and external mammary prostheses. Contact us for details prior to purchasing item. First aid courses For first aid courses held by St John Ambulance or Royal Life Saving Association. Healthy Lifestyle - Health management program - Weight loss program - Quit smoking plan - Health assessments - Skin cancer screening Benefits are payable for HIF approved programs delivered by registered providers only. Please contact us prior to commencing the program or paying subscriptions to ascertain if the program is eligible for a rebate. Premium Options Super Options Benefit Person Membership Benefit Person Membership 75% of fee $1,500 per year. No 75% of fee $1,500 per year. No e: sub s apply depending upon item. e: sub s apply depending upon item. $70 1 every 3 years No N/A N/A No Single: $50 Single: $50 1 per year Single: $50 Single: $50 1 per year Family: $100 Family: $100 Family: $100 Family: $100 24

25 Type of service Additional information External prostheses Benefits are paid on HIF approved prosthetics items such as artificial limbs, wigs and external mammary prostheses. Contact us for details prior to purchasing item. First aid courses For first aid courses held by St John Ambulance or Royal Life Saving Association. Healthy Lifestyle - Health management program - Weight loss program - Quit smoking plan - Health assessments - Skin cancer screening Benefits are payable for HIF approved programs delivered by registered providers only. Please contact us prior to commencing the program or paying subscriptions to ascertain if the program is eligible for a rebate. Special Options Saver Options Benefit Person Membership Benefit Person Membership N/A N/A No N/A N/A No N/A N/A No N/A N/A No Single: $50 Family: $100 Single: $50 Family: $100 1 per year Single: $50 Family: $100 annual (chiropractic, dietetics healthy lifestyle, complementary therapies, osteopathic, pharmacy, physiotherapy and podiatry) $350 annual (chiropractic, dietetics healthy lifestyle, complementary therapies, osteopathic, pharmacy, physiotherapy and podiatry) $700 25

26 Ancillary benefits Premium Options Super Options Type of service Additional information Benefit Person Membership Benefit Person Membership Hearing aids Benefits are paid on replacement hearing aids after 5 years from date of supply. Up to 5 years: $550 5 to 10 years: $600 per ear Up to 5 years:1 Over 5 years: 1 per ear No Up to 5 years: $ years: $550 per ear Up to 5 years: 1 Over 5 years: 1 per ear No 10+ years: $700 per ear Humidifier or nebuliser A letter of recommendation from the patient s treating practitioner is required. 75% of cost 1 of either monitor every 3 years. Maximum $180. No 75% of cost 1 of either monitor every 3 years. Maximum $140. No Occupational therapy Benefits are paid on consultations carried out by a registered occupational therapist, approved by HIF. First Visit $60 Subsequent $27 Group $10 (orthoptics, physiotherapy and speech therapy) Up to 5 years: $1200 Over 5 years: $1500 No First visit: $45 Subsequent: $25 Group: $10 (orthoptics, physiotherapy and speech therapy) Up to 5 years: $900 Over 5 years: $1100 No Optical See page 34 for more details Orthotics Benefits are paid on items carried out by a registered podiatrist or orthotic supplier, approved by HIF #. 75% of cost $240 1 every 2 years from date of supply^ No 75% of cost $200 1 every 2 years from date of supply ^ No # e: benefits are not available for orthotics which are not specifically modified and fitted for the individual member s condition. ^ Orthotic includes associated services such as muscle testing, ROM testing and gait analysis. 26

27 Special Options Saver Options Type of service Additional information Benefit Person Membership Benefit Person Membership Hearing aids Benefits are paid on replacement hearing aids after 5 years from date of supply. N/A N/A No N/A N/A No Humidifier or nebuliser A letter of recommendation from the patient s treating practitioner is required. N/A N/A No N/A N/A No Occupational therapy Benefits are paid on consultations carried out by a registered occupational therapist, approved by HIF. N/A N/A No N/A N/A No Optical See page 34 for more details Orthotics Benefits are paid on items carried out by a registered podiatrist or orthotic supplier, approved by HIF #. N/A N/A No N/A N/A No # e: benefits are not available for orthotics which are not specifically modified and fitted for the individual member s condition. 27

28 Ancillary benefits Premium Options Super Options Type of service Additional information Benefit Person Membership Benefit Person Membership Orthoptics (eye therapy) Benefits are paid on items carried out by a registered podiatrist or orthotic supplier, approved by HIF #. Initial: $50 Subsequent: $25 with occupational physiotherapy and speech therapy No Initial $50 Subsequent $25 with occupational physiotherapy and speech therapy No Up to 5 years: $1200 Up to 5 years: $900 Over 5 years: $1500 Over 5 years: $1100 Osteopathic Benefits are paid on items carried out by a registered osteopath, approved by HIF. First visit: $30 Visits 2-10: $29 Visits 10+: $18 annual (chiropractic and osteopathic) annual (chiropractic and osteopathic) First visit: $28 Visits 2-10: $23 Visits 10+: $17 annual (chiropractic and osteopathic) annual (chiropractic and osteopathic) Up to 3 years: $650 Up to 3 years: $1300 Up to 3 years: $550 Up to 3 years: $1100 Over 3 years: $750 Over 3 years: $1500 Over 3 years: $650 Over 3 years: $1300 Peak Flow Meter N/A $30 1 per year No $30 1 per year No # e: benefits are not available for orthotics which are not specifically modified and fitted for the individual member s condition. 28

29 Special Options Saver Options Type of service Additional information Benefit Person Membership Benefit Person Membership Orthoptics (eye therapy) Benefits are paid on items carried out by a registered orthoptics supplier, approved by HIF #. N/A N/A No N/A N/A No Osteopathic Benefits are paid on items carried out by a registered osteopath, approved by HIF. First visit: $26 Visits 2-10: $21 Visits 10+: $16 annual (chiropractic, physiotherapy, osteopathic and podiatry) $450 annual (chiropractic, physiotherapy, osteopathic and podiatry) $900 First visit: $26 Visits 2-10: $21 Visits 10+: $16 annual (chiropractic, dietetics, healthy lifestyle, complementary therapies, osteopathic, pharmacy, physiotherapy & podiatry) $350 annual (chiropractic, dietetics, healthy lifestyle, complementary therapies, osteopathic, pharmacy, physiotherapy and podiatry) $700 Peak Flow Meter N/A N/A N/A No N/A N/A No # e: benefits are not available for orthotics which are not specifically modified and fitted for the individual member s condition. 29

30 Ancillary benefits Type of service Additional information Pharmacy payable on contraceptives or NHS (PBS) prescriptions or over the counter items purchased with or without a prescription. Physiotherapy Benefits are paid on items carried out by a registered physiotherapist, approved by HIF. Premium Options Super Options Benefit Person Membership Benefit Person Membership Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item. Up to 3 years: $200 Over 3 years: $400 No Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item. Up to 3 years: $200 Over 3 years: $400 No First visit: $45 Visits 2-10: $40 Visits 10+: $30 Hydrotherapy: $15 Antenatal: $15 Group: $15 (physiotherapy, occupational, orthoptics and speech therapy) Up to 5 years: $1200 Over 5 years: $1500 No First visit: $35 Visits 2-10: $29 Visits 10+: $20 Hydrotherapy: $13 Antenatal: $13 Group: $13 (physiotherapy, occupational, orthoptics and speech therapy) Up to 5 years: $900 Over 5 years: $1100 No $600 sub for hydrotherapy, antenatal and group. $500 sub for hydrotherapy, antenatal and group. 30