Level 4, 260 Elizabeth Street SYDNEY NSW 2000 SYDNEY NSW Brad Joyce

Transcription

1 Fund Name: Address: UniHealth Insurance (brought to you by Teachers Health Fund.) Level 4, 260 Elizabeth Street SYDNEY NSW 2000 Postal Address: GPO Box 9812 SYDNEY NSW 2001 Telephone: Ph: Facsimile: Fax: Chief Executive Officer: [email protected] Brad Joyce Claims Enquiries: Membership Enquiries: Patient Eligibility Checks: Patient eligibility and membership level of cover should be confirmed prior to patient admission. UniHealth Insurance is Eclipse enabled. All eligibility checks should be conducted through Eclipse using identification code NTF Where a hospital is not eclipse enabled, eligibility and member level of cover can be confirmed at Patient Eligibility Checks: Pre-existing Conditions - 12 months Pregnancy and Related Conditions - 9 months

2 Psychiatric/Rehabilitation/ Palliative Care - 2 months All other hospital services - 2 months Excluded Benefits: No benefits are payable for any services which no Medicare benefit is payable including cosmetic surgery and Laser Eye Surgery. This applies to all levels of cover. The only exception is psychiatric care, rehabilitation and palliative care. Restricted Benefits: Prostheses Benefits: Services listed as Restricted, when provided in a private hospital, are eligible for Minimum Default Benefits prescribed by Private Health Insurance Legislation. These benefits relate to hospital bed charges and are unlikely to cover the fees charged for a private hospital admission. Members may incur large out of pocket expenses for theatre fees together with the difference between Minimum Default Benefit and the bed charge raised by the hospital. Benefits for Prostheses are payable for non-cosmetic surgically implanted items that are Government approved up to the listed benefit specified by the Prostheses List.

3 Table Top Hospital, Top Hospital 300 and Top Hospital 500 (K,X,I,N &S) Description Private Hospital Covers Top Hospital Top Hospital 300 $300 per person per admission up to a maximum of $600 for a family per calendar year No excess payable for dependants under 21 No excess payable for public hospital admission Top Hospital 500 $500 per person per admission up to a maximum of $1000 for a family per calendar year No excess payable for dependants under 21 No excess payable for public hospital admission Table Mid Hospital 300 and Mid Hospital 500 (G & F) Description Private Hospital Cover (with Minimum Benefits in a private hospital for some treatments) see attached for more details Mid Hospital 300 Apply refer attached product table below $300 per person per admission up to a maximum of $600 for a family per calendar year Mid Hospital 500 Apply refer attached product table below $500 per person per admission up to a maximum of $1000 for a family per calendar year

4 Table Description Basic Hospital (H) Private Hospital Cover (with Minimum Benefits in a private hospital for some treatments) see attached for more details $300 per person per admission up to a maximum of $600 for a family per calendar year Table StarterPak (P) Description Private Hospital cover (with Minimum Benefits in a private hospital for some treatments and benefits in public and private hospital for some treatments) see attached for more details All services not excluded are treated as restricted with the exception of items actually covered and listed on attached product schedule below Nil

5 Top Hospital, Top Hospital 300 and Top Hospital 500 (K,X,I,N &S) Top Hospital excess for Top Hospital Top Hospital 300 $300 per person per admission up to a maximum of $600 for a family per calendar year No excess payable for dependants under 21 No excess payable for public hospital admission Top Hospital 500 $500 per person per admission up to a maximum of $1000 for a family per calendar year No excess payable for dependants under 21 No excess payable for public hospital admission Excluded Services (No benefits available) Services for which a Medicare Benefit is not payable receive benefits for Teachers Health fund in a private or public hospital Claims subject to a COMPENSABLE injury Hospital Admissions for Accidents or Injuries MUST have the relevant form completed on admission and sent to Teachers Health Fund with the hospital claim. Payment delays may be experienced where this does not accompany the claim submitted. For compensable services where liability has been accepted by another party, please direct claim to relevant party.

6 Mid Hospital 300 and Mid Hospital 500 (G&F) Mid Hospital 300 $300 per person per admission up to a maximum of $600 for a family per calendar year Mid Hospital 500 $500 per person per admission up to a maximum of $1000 for a family per calendar year Excluded Services (No benefits available) Services for which a Medicare Benefit is not payable receive benefits for Teachers Health fund in a private or public hospital Claims subject to a COMPENSABLE injury Hospital Admissions for Accidents or Injuries MUST have the relevant form completed on admission and sent to Teachers Health Fund with the hospital claim. Payment delays may be experienced where this does not accompany the claim submitted. For compensable services where liability has been accepted by another party, please direct claim to relevant party. The below services are RESTIRCTED on Mid Hospital and only attract the MINIMUM DEFAULT BENEFITS as specified in the Private Health Insurance (Benefit Requirement) Rules Pregnancy & Related Services Infertility Treatment Coronary Care & Cardiothoracic Dialysis Joint replacement Major Eye Surgery Glaucoma Bariatric Surgery Psychiatric Rehabilitation / Palliative Care Sterilisation & Reversal of Sterilisation

7 Basic Hospital (H) Basic Hospital excess $300 per person per admission up to a maximum of $600 for a family per calendar year Excluded Services (No benefits available) Services for which a Medicare Benefit is not payable receive benefits for Teachers Health fund in a private or public hospital Restricted Services (Minimum Benefits) AL MBS items NOT LISTED below receive Minimum Default Benefits only as specified in the Private Health Insurance (Benefit Requirements) rules for accommodation in a private hospital. Benefits for prostheses are payable for noncosmetic surgically implanted items that are Government approved up to the minimum specified by legislation The below services are COVERED in a Private Hospital or Day Surgery that has an agreement with Teachers Health Fund Tonsils and Adenoids Knee Investigations and Reconstructions Shoulder Investigations and Reconstructions Appendicitis Treatment Hernias Removal of Wisdom Teeth D001* D002* D042* D043* Claims subject to a COMPENSABLE injury Hospital Admissions for Accidents or Injuries MUST have the relevant form completed on admission and sent to Teachers Health Fund with the hospital claim. Payment delays may be experienced where this does not accompany the claim submitted. For compensable services where liability has been accepted by another party, please direct claim to relevant party. * Removal of Wisdom Teeth(cover for hospital charges only no cover for dental items).

8 StarterPak (P) StarterPak excess Nil Restricted Services (Minimum Benefits) AL MBS items NOT LISTED below receive Minimum Default Benefits only as specified in the Private Health Insurance (Benefit Requirements) rules for accommodation in a private hospital. Benefits for prostheses are payable for noncosmetic surgically implanted items that are Government approved up to the minimum specified by legislation The below services are COVERED in a Private Hospital or Day Surgery that has an agreement with Teachers Health Fund Tonsils and Adenoids Knee Investigations and Reconstructions Shoulder Investigations and Reconstructions Appendicitis Treatment Hernias Removal of Wisdom Teeth D001* D002* D042* D043* * Removal of Wisdom Teeth (cover for hospital charges only limited cover for dental items ADA item 323 pays $70 for Tooth IDs 18 and 28 only, ADA item 324 pays $100 for Tooth IDs 38 and 48 only).

9 Excluded Services (No Benefits available) The services LISTED below and all services for which a Medicare Benefit is not payable receive benefits from Teachers Health fund in a private or public hospital Pregnancy & Related Services Infertility Treatment Coronary Care & Cardiothoracic Dialysis Glaucoma Joint Replacement Hip Joint Replacement Knee Sterilisation & Reversal of Sterilisation Claims subject to a COMPENSABLE injury Hospital Admissions for Accidents or Injuries MUST have the relevant form completed on admission and sent to Teachers Health Fund with the hospital claim. Payment delays may be experienced where this does not accompany the claim submitted. For compensable services where liability has been accepted by another party, please direct claim to relevant party.

10 NOTES Table K & X (Top Hospital): No front end deductible Tables I, N (Top Hospital 300) are equal to tables K & X minus the front end deductible. The front end deductible for tables I & N is $300 per member or dependant with a maximum of $600 per family, per calendar year. Tables S (Top Hospital 500) are equal to tables K & X minus the front end deductible. The front end deductible for tables S is $500 per member or dependant with a maximum of $1000 per family, per calendar year Table P (StarterPak) allows benefit equal to tables K & X for a limited number of services. They are: Accidents, Removal of Wisdom Teeth, T s & A s, Knee investigations & reconstructions, Shoulder investigations and reconstructions, Appendix treatments and Hernias. Table P excludes any benefit being paid for services or procedures relating to: Pregnancy and related birth, Infertility investigations and treatments (including IVF), Coronary and cardiothoracic, Dialysis, Glaucoma, Hip and Knee Joint replacements, Cosmetic treatments or procedures designed to enhance appearance. Table P pays a benefit equal to the Government prescribed Default Benefit for all other services eligible for benefit under this agreement. Table M (CoreElect $300)- : The following services attract default public hospital benefits: Pregnancy and related services, Infertility investigations and treatments, Joint replacement (hip, knee, shoulder and elbow), Cataract and eye lens procedures, Cardiothoracic surgery, Obesity surgery, Dialysis, psychiatric, rehabilitations and palliative care. All other services that are covered by Medicare are covered at AHSA negotiated private hospital rates. Please note that a private room benefit is payable. An excess of $300/ person/ $600 max under a couples/family/single parent policy per calendar year applies for private and public hospital inpatient treatment. Table R (CoreElect $500) - : The following services attract default public hospital benefits: Pregnancy and related services, Infertility investigations and treatments, Joint replacement (hip, knee, shoulder and elbow), Cataract and eye lens procedures, Cardiothoracic surgery, Obesity surgery, Dialysis, psychiatric, rehabilitations and palliative care. All other services that are covered by Medicare are covered at AHSA negotiated private hospital rates. Please note that a private room benefit is payable. An excess of $500/ person/$1000 max under a couples/family/single parent policy per calendar year applies for private and public hospital inpatient treatment. Table F (Mid Hospital 300)- : The following services attract default public hospital benefits: Pregnancy and related services, Infertility investigations and treatments, Joint replacement (hip, knee, shoulder and elbow), Cataract and eye lens procedures, Cardiothoracic surgery, Obesity surgery, Dialysis, psychiatric, rehabilitations and palliative care. All other services that are covered by Medicare are covered at AHSA negotiated private hospital rates. Please note that a private room benefit is payable. The front end deductible for tables F is $300 per member or dependant with a maximum of $600 per family, per calendar year. Table G (Mid Hospital 500)- : The following services attract default public hospital benefits: Pregnancy and related services, Infertility investigations and treatments, Joint replacement (hip, knee, shoulder and elbow), Cataract and eye lens procedures, Cardiothoracic surgery, Obesity surgery, Dialysis, psychiatric, rehabilitations and palliative care. All other services that are covered by Medicare are covered at AHSA negotiated private hospital rates. Please note that a private room benefit is payable. The front end deductible for tables G is $500 per member or dependant with a maximum of $1000 per family, per calendar year. Table H (Basic Hospital) allows benefit equal to tables K & X for a limited number of services. They are: Accidents, Removal of Wisdom Teeth, T s & A s, Knee investigations & reconstructions, Shoulder investigations and reconstructions, Appendix treatments and Hernias.

11 Table H pays a benefit equal to the Government prescribed Default Benefit for all other services eligible for benefit under this agreement The front end deductible for tables H is $300/ person/ $600 max under a couples/family/single parent policy per calendar year applies for private and public hospital inpatient treatment.