This brochure has been written to. help you make the right choice of personal. health cover. To help you, we d like to

Transcription

1 Hospital Cover

2 Why HBF?... 4 What about the public hospital system?... 6 Why private health insurance?... 8 Choices to suit every body Top Hospital Intermediate Hospital Healthy Saver Hospital This brochure has been written to help you make the right choice of personal health cover. To help you, we d like to explain why HBF is different. Different to other private health insurers. And different to the public health system. 4. Young Singles Saver Hospital Compare levels of cover Everything you need to know about Hospital cover Detailed information on HBF Hospital Cover HBF Participating Hospitals Hospital Benefits and Excess Medical Gap Minimising out-of-pocket expenses Hospital co-payments & accommodation benefits Maternity Theatre benefits Details on specific services Additional cover available to you GapSaver Ambulance Plus Join HBF today How to join HBF Ways to Pay Cooling off period How soon can you claim? Glossary... 29

3 More participating hospitals When in hospital you will want to have a choice over where, when and by whom you get treated. If you re an HBF member you will have more choice. We have arrangements with 38 hospitals in WA that s more than any other health fund according to the latest State of the Health Funds report. Higher percentage of hospital related charges covered If you do find yourself in a private hospital, even though you have private health cover, you may still have some out-of-pocket expenses. HBF covers an average of 93.6% of hospital related charges in WA that s a higher percentage of these charges than any other major health fund, according to the Government s State of the Health Funds Report Why HBF? Someone to talk to Another thing you might notice if you end up in hospital is that you have a few questions. So HBF has dedicated personal Hospital Liaison Officers in most WA private hospitals to help you understand your HBF cover, the sometimescomplicated hospital bills and claims paperwork, and what is involved in being a patient in hospital. Western Australian and not-for-profit Unlike most of our competitors, HBF only focus on taking care of West Australians. And because we re not-for-profit, 87.9% of premiums go straight back in member benefits. That s above the industry standard according to the Government s State of the Health Funds Report Every HBF member s health cover is covered If something happens and you re unable to work, HBF won t abandon you. HBF will give you complimentary cover for up to nine months. Because the last thing you need to think about at a time like that is paying your health cover. Some conditions do apply so please ask us for more details. 4 5

4 What about the public hospital system? The truth is WA s population is among the fastest growing in the country and increasingly, those dedicated doctors and nurses simply cannot attend to everyone s needs immediately. This is why HBF private health insurance exists: to give you access to a fast personal health service when you need it most. Because of all the things you can spend your money on, your health is the most important. Faster when you need it to be Sometimes it s hard to think of times when you might need to use hospital cover. So here s a list of common medical procedures that HBF members avoid being put on public hospital waiting lists for: Injuries sustained in an accident (eg: broken bones) Hernia repair Ear, nose and throat procedures (eg: removal of tonsils) Skin grafts (medically necessary) Shoulder reconstruction surgery Appendicitis treatment Removal of gall bladder Hysterectomy Heart surgery Joint replacements Special care nursery Cancer treatment Please Note: Heart surgery and joint replacements are not covered on Young Singles Saver Hospital and Healthy Saver Hospital. HBF also provides all Hospital members with unlimited cover for urgent ambulance transport. 6 7

5 You avoid public hospital waiting lists Urgent or not, HBF hospital members get access to prompt medical attention in a private hospital. So you get the best possible treatment as soon as possible. You get to choose your doctor Choose your doctor and get the peace of mind that HBF has arrangements with the majority of medical practitioners in WA. Save 30% on your health insurance Why private health insurance? If you re eligible for Medicare benefits, you can receive a saving of 30% or more with the Federal Government 30% Rebate on private health insurance. For more information on how you can apply go to page 29. Australians aged 65 and over are eligible for higher rebates. Reduce your tax You could save at least $800 in tax each year, depending on your income, just by taking out private hospital cover. For more information on avoiding the Medicare Levy Surcharge just call us on Join early and save Avoid having to pay the Lifetime Health Cover loading by taking out hospital cover by the 1st July following your 31st birthday. For all the details see page

6 Choices to suit every body Everyone needs hospital cover for different reasons and at different times in their lives. Which is why HBF have created 4 choices of Hospital cover. The two main things that every Hospital policy includes are: Your choice of your own doctor whether you re in a private or public hospital as a private patient Unlimited urgent ambulance transport, covering circumstances classified by St John Ambulance as requiring urgent attention 1. Top Hospital 2. Intermediate Hospital 3. Healthy Saver Hospital 4. Young Singles Saver Hospital Around $103.90* per month Equates to $1, per year. You ve reached a time in your life when you feel you need comprehensive cover and would benefit from full cover for a shared room and substantial cover for a single room. Around $86.10* per month Equates to $1, per year. You feel you need comprehensive cover, however want to save on your premiums by having substantial cover for a shared room. Around $82.20* per month Equates to $ per year. Ideal for younger couples or families, this option again gives you the choice of your own doctor, but allows you to make further savings on your premium by paying only for the health services you feel you re likely to need (including maternity). This option doesn t include cover for heart surgery, joint replacements (including partial and total) and cataract and eye lens procedures.it provides restricted cover for psychiatric treatment. Around $46.20* per month Equates to $ per year. You re young, single, don t have any children and you want to choose your own doctor. You save money on your premium by not being covered for services you decide you re not likely to need, like joint replacements (including partial and total), heart procedures, cataract and eye lens procedures, IVF and maternity. It provides restricted cover for psychiatric treatment. For a complete listing of what is included under each cover, see the table on the following page. To find out the exact cost per fortnight/month/year, you can go to hbf.com.au and use our product selector, call us on or visit one of the Branches listed at the back of this brochure. *Price based on WA rates for single premium paid annually by direct debit after deducting the Federal Government 30% Rebate on private health insurance with no Lifetime Health Cover loading

7 Compare levels of cover To help you choose the right cover, the table below shows you how the different levels compare. A general rule of thumb is: the fewer services covered by a product, the lower its premium. Waiting periods apply before you can receive hospital treatments and can be found on page 28. Benefits Substantial cover towards a single room in an HBF Participating Hospital Top Hospital Intermediate Hospital Healthy Saver Hospital Young Singles Saver Hospital^ Substantial cover for a single room for maternity patients in an HBF Participating Hospital Fully covered for a shared room in an HBF Participating Hospital Substantial cover for a shared room in an HBF Participating Hospital HBF Medical Gap cover Hospital excess options Assisted reproductive services (including IVF) Cataract and eye lens procedures Heart procedures Joint replacement surgery (including partial and total) Maternity and birth-related services Psychiatric care * * Theatre fees Urgent Ambulance Waiting periods apply. No benefit is payable for hospital treatment where a Medicare benefit is not payable (except certain dental and podiatry surgery where HBF will pay a benefit for accommodation and hospital costs). ^Only available for singles or couples. For more information on HBF Participating Hospitals please refer to page 15 or contact us for a copy of the Hospital Policy Details brochure. No benefit for procedures that are excluded or restricted on your level of cover. Urgent Ambulance transport covers circumstances classified by St John Ambulance as requiring urgent attention. *Please note: Limited hospital benefits apply which are similar to the cost of a shared room in a public hospital. Significant out-of-pocket costs may be incurred

8 Everything you need to know about Hospital cover. Detailed information on HBF Hospital Cover Getting the right health cover for you is in the details. On the following pages we go into a lot more detail about our Hospital policies. If you have the time it s well worth you reading through. You can also call us on , visit your nearest branch or visit hbf.com.au HBF Participating Hospitals HBF Participating Hospitals are hospitals that HBF has negotiated special agreements with that provide better value for our members. These agreements ensure that when you need hospital treatment, you ll be covered for accommodation and theatre fees, less any co payments or agreed excess (co-payments are pre-determined payments that you make towards your stay). Why is this important? If you visit a non-participating Hospital you may incur a significant out-of-pocket expense. We recommend that before arranging a hospital stay, you call one of our Member Service Advisors on or visit hbf.com.au to find out if you re being admitted into an HBF Participating Hospital. Please also remember, all benefits are subject to various restrictions or exclusions on your chosen level of cover. Hospital Benefits and Excess Hospital benefits When you re admitted to hospital, a lot of things happen that incur costs. Here is a guide to the services that HBF pays a benefit towards: Medical benefits Accommodation benefits Theatre and labour ward benefits Pharmacy benefits Prostheses Includes the fees charged by your surgeon, anaesthetist and pathologist. Includes the fees charged for your room in a private or public hospital. Includes the fees charged for the theatre in which your procedure was performed. Includes the fees for some of the pharmaceuticals administered during your hospital stay. Includes the fees charged for any prostheses used during your procedure

9 Exclusions on benefits There are a few circumstances under which HBF will not pay a benefit: If your membership is unfinancial at the time of treatment or service (that is, if you have not been paying your premiums by the due dates) On claims covered by Worker s Compensation, Third Party or other legal right For treatment or services required by your employer or potential employer to be provided to you as a condition of your employment or by your insurer as a condition of your policy For treatment or services provided outside of Australia For care and accommodation in nursing homes Before a treatment or service has been received. This simply means we don t pay in advance for future treatments If a claim is not lodged within two years of the date of service For hospital treatment that is not eligible for a Medicare benefit, such as cosmetic surgery Hospital excess options If you decide to go on to Top or Intermediate Hospital cover, you have the option of taking out an excess. An excess is a simple and effective way to reduce your health cover premiums without reducing your level of cover. If you choose to add an excess, you ll only pay it if you stay in hospital overnight and you ll only pay it once per member (to a maximum of twice per family policy), per calendar year, regardless of how many times you may need to stay in hospital. Your options are: Cover Intermediate Hospital Top Hospital Level 1 Top Hospital Level 2 Single Couple/ Family $140 $280 $200 $400 $500 $1000 Please note: The excess is payable in addition to any accommodation and procedure co-payments that may apply. You won t be required to pay an excess for any dependant children on your family policy. Medical Gap What is the medical gap? The medical gap isn t easy to explain but it s important for you to understand should you ever find yourself in hospital. Medical practitioners may charge more than the amount listed on the Medicare Benefit Schedule (MBS). This difference between the fee charged and what is listed on the schedule is known as the medical gap. For example, if an HBF member undergoes a knee reconstruction with a Medicare Schedule fee of $5000 and the practitioner s fee is $8000, the member s out-of-pocket will be $3000, which is the difference between the Medicare Schedule fee and the practitioner s fee. Medical practitioners registered with HBF (ie. doctors) fall into three categories: 1. Fully covered no out-of-pocket expense. 2. Known gap option there may be an out-of-pocket expense. 3. No agreement with HBF there will be an out-of-pocket expense. Fortunately, HBF has fully covered arrangements with more than 1200 doctors in WA. This means that more often you won t have an out-ofpocket expense. Minimising out-ofpocket expenses Being treated in hospital is worrying enough without the added concern of having to pay out-ofpocket expenses. There are two ways to minimise your out-of-pocket expenses: 1. Check if your medical practitioner has a fully covered arrangement with HBF beforehand (if possible) 2. Take out HBF s GapSaver for those times when you may use a doctor who isn t fully covered. For the full details on how you can reduce your out-of-pocket expenses with GapSaver see page 23. Hospital co-payments & accommodation benefits In most cases, you ll be charged for a hospital room when you go into hospital, regardless of whether you have a procedure or not. Depending on your level of HBF Hospital cover, you may be required to pay a co-payment

10 These payments are necessary to keep our premiums as low as possible. Here are the details of the co-payments that may apply: Hospital room co-payments Top Hospital Top Hospital members staying in an HBF Participating Hospital may be required to contribute to the cost of a single room for up to six days of a hospital stay, after which the accommodation fee is 100% covered (except for psychiatric treatment). Intermediate Hospital Intermediate Hospital members staying in an HBF Participating Hospital may be required to contribute to the cost of a shared room for up to six days of a hospital stay, after which the accommodation fee for a shared room only is 100% covered (except for psychiatric treatment). Young Singles Saver Hospital and Healthy Saver Hospital Young Singles Saver and Healthy Saver members staying in a shared room in an HBF Participating Hospital are fully covered. Limited hospital benefits apply for Psychiatric Care and significant out-of-pocket costs may be incurred. Other out-of-pockets Other out-of-pocket costs include sundry items not included in your cover, such as extra meals for guests, TV hire, internet access and newspapers. Hospital boarders HBF will fully cover the charge for a hospital boarder whose presence is integral to the management of the patient s condition. Long stay patients After 35 days of continuous hospitalisation (and if you no longer need acute care) by law the hospital must classify you as a nursing home type patient. If this happens, HBF pays a smaller portion of the benefit per day and you re required to contribute towards the cost of your care. If you re in a private hospital these costs may be quite substantial. Maternity Hospital room co-payments Top Hospital and Healthy Saver Hospital For members who are Top Hospital or Healthy Saver Hospital maternity patients, accommodation fees are 100% covered for the first three days of a stay in a single room in an HBF Participating Hospital. After this time, members may be required to contribute towards the cost of the next six days. Intermediate Hospital For Intermediate Hospital members who are maternity patients, accommodation fees are 100% covered for the first three days of a stay in a shared room in an HBF Participating Hospital. After this time, the member may be required to contribute towards the cost of the next six days. Cover for your newborn baby Newborn babies are not considered to be patients in a hospital for the first nine days unless they are admitted to a special care facility or the baby is part of a multiple birth. You may be required to contribute to the cost of your baby s stay in a special care facility for the first six days of their stay in most hospitals, or if you have Intermediate Hospital cover and the baby is part of a multiple birth.. If you re on a single policy and you want your baby to be covered for benefits from birth, an application for family cover must be made within one month of your baby s birth date. The family premiums will apply from the baby s date of birth. Labour ward benefits When you re admitted into hospital for a procedure, there is a charge for the theatre used for that procedure. HBF provides 100% cover for labour ward costs charged by HBF Participating Hospitals. Public hospitals do not charge labour ward fees. Theatre benefits Top and Intermediate Hospital HBF provides theatre cover in HBF Participating Hospitals. A co-payment of $50 is payable in some hospitals for procedures such as colonoscopies and gastroscopies

11 Healthy Saver Hospital HBF provides 100% theatre cover in HBF Participating Hospitals. This excludes joint replacement, heart procedures, cataract and eye lens procedures and psychiatric where no benefit is payable by HBF. Young Singles Saver Hospital HBF provides 100% theatre cover in HBF Participating Hospitals. This excludes joint replacement, heart procedures, cataract and eye lens procedures, psychiatric, maternity and assisted reproductive services (including IVF), where no benefit is payable by HBF. Please note that for all our levels of cover, out-of-pocket expenses are payable for procedures being performed using robotics. This is because the consumable equipment and materials used in robotic surgery cost thousands of dollars more than non-robotic procedures. And now, some details on specific services Pharmacy benefits When you re admitted to hospital for a procedure, it s more than likely that pharmaceuticals will be administered. The Government subsidises the cost of some pharmaceuticals under the Pharmaceutical Benefits Scheme (PBS). HBF will pay a benefit towards the cost of non-pbs prescription pharmaceuticals administered during a hospital stay. This benefit is limited to $1400 per hospital episode, with a co-payment of $100 ( episode is an industry term that means any period of hospital care or stay; this can also include breaks in treatment and time in, or out, of hospital). The number of patient episodes payable per year is unlimited, however readmissions within 7 days may be considered continuous and therefore one limit applies to both. Prostheses benefits Prostheses are the surgically implanted devices you may need if you have a procedure such as joint replacement, cataract surgery and some heart procedures. All levels of HBF Hospital cover entitle you to a benefit for prostheses as long as you re admitted to hospital for the procedure and the item is listed on the Federal Government Prostheses List. No benefit is payable for prostheses implanted during a procedure that is specifically excluded from your level of cover. Most prostheses are fully covered, however there are some prostheses that may attract an out-ofpocket expense. We suggest you discuss the choice of prosthesis with your medical practitioner. How do you find out if you re fully covered for a prosthesis? It s important to talk to your medical practitioner to find out whether a prosthesis will be used during your procedure. Once you have confirmed this, you ll need to know the item number and charge for the prosthesis you need and the item number of the procedure you ll be having. When you have this information, simply contact HBF. Psychiatric treatment HBF will pay psychiatric benefits for treatment in hospitals with approved programs. However, this is not usually 100% covered and HBF s usual 100% cover after six days of hospitalisation does not apply. Urgent Ambulance Urgent ambulance transport covers all circumstances classified by St. John Ambulance as requiring urgent attention. HBF does not pay any benefit for air ambulance services

12 This section details the additional cover available to you: GapSaver and Ambulance Plus. GapSaver What is GapSaver? Being treated in hospital is worrying enough without the added concern of unexpected hospital or medical expenses. So it s good to know you can further reduce most out-ofpocket expenses with GapSaver. GapSaver is a way to build up benefits to help cover out-of-pocket expenses. The best part is that you can accrue more GapSaver benefits than you ll pay in premiums. So you can keep more money in your pocket. Can be used for: Medical gap Prostheses gap Hospital excesses Accommodation co-payments Theatre co-payments Non PBS & PBS in-patient pharmaceutical out-of-pockets Robotic surgery charges Minor surgical appliances not on the Prostheses List Surgical stockings and slings Television, phone and other sundry hospital charges GapSaver can also be used for Essentials and Wellness out-of-pocket costs. If you have these products please see the Essentials cover brochure for more information. Can t be used for: Benefits towards MBS procedures that are not covered on your policy Charges for procedures with no MBS item number Any out-of-pocket costs incurred after your maximum entitlements have been reached How much can you accrue? There are two levels of GapSaver cover you can choose from: GapSaver Level GapSaver Level 1 GapSaver Level 2 Single policy (yearly accrual) $100 $200 $200 $400 Family policy (yearly accrual) GapSaver benefits are accrued to your membership quarterly, with the balance accumulating year after year until you use it. Even if you cancel your GapSaver cover, any accrued benefit will be available for as long as you remain an HBF member. However, it s important to note that the benefit is not refundable

13 Receive GapSaver benefits automatically when you claim You can opt-in to receive GapSaver benefits automatically. This means your GapSaver accrual would be automatically paid towards any out-of-pocket costs at the time your claim is processed. You can claim GapSaver manually if you prefer. GapSaver waiting periods apply, please refer to page 28. Ambulance Plus Every HBF Hospital member gets unlimited cover for urgent ambulance transport. When you take out HBF Hospital cover, you can also choose to add the extra protection of Ambulance Plus. This provides cover for elective ambulance services including pre-booked and non-urgent ambulance care. Please note: Benefits are capped at $3000 per person per calendar year. If you re an Aged Pensioner you may not need Ambulance Plus cover due to the WA State Government s provision of free ambulance services

14 Join HBF today. How to join HBF To get Hospital cover today, put ten minutes aside and give us a call, we ll join you up over the phone straight away. It s that easy. Our telephone number is Or you could join online by visiting: hbf.com.au Alternatively, come and see us in person we have 15 branches in and around Perth, plus another 4 in major regional centres. Their addresses are on the last page. Ways to Pay Direct debit Selecting this option will save you 4% on your health insurance premiums. It will also give you the convenience of having your payments automatically deducted from your chosen savings, cheque or credit card account. Statement HBF can send monthly, quarterly, half yearly or yearly statements for you to pay online at hbf.com.au, via Bpay, mailing a cheque, calling HBF on or visiting an HBF branch. Payroll deductions You may be able to have your health insurance premiums deducted directly from your pay. For details, please check with your payroll officer. Cooling off period If you take out any HBF Health policy you will have a 30 day cooling off period from the commencement date of the policy, in which time you may cancel your policy and receive a full refund of any premiums paid, provided that you have not made a claim against the policy

15 How soon can you claim? Once you re an HBF Hospital member, there are waiting periods that apply before you can receive benefits. Why is this a standard arrangement in private health insurance? Imagine you ve been paying your health insurance premiums for years, then a new member comes along, pays Waiting Periods Pre-existing ailments or conditions^ 12 month waiting period Maternity and birth related services 12 month waiting period Other hospital treatments 2 month waiting period Urgent Ambulance 7 day waiting period Is an illness or condition which, in the opinion of a medical practitioner (appointed by HBF), was known to exist, or where signs or symptoms were evident during the six month period before you became an HBF member or transferred to a product that may have higher benefits. Including surgical. Waiting Periods for Additional Covers Ambulance Plus # 30 day waiting period GapSaver Pre-existing ailments or conditions^ 12 month waiting period Maternity 12 month waiting period Other hospital treatments 2 month waiting period # For further ambulance information, see page 24. ^ Does not apply for psychiatric, rehabilitation and palliative care. just enough premiums to cover their treatment period, claims and then leaves. You and other long-term members will have, in effect, paid for their treatment. While they have contributed almost nothing to any treatment you may need in the future. It simply wouldn t be fair. These waiting periods also apply when transferring to a product that may have higher benefits, or when moving from a level of cover with an excess to a level of cover without an excess. Cover for urgent ambulance transport Cover for elective ambulance services A small additional premium lets you build a safety net of benefits that you can use to pay some out-of-pocket costs for eligible hospital stays. Glossary Accommodation Co-payment HBF hospital co-payments are a negotiated difference between the amount the hospital charges for accommodation and the amount we pay. The co-payment therefore varies between hospitals depending on the agreed charge. Which means, for some hospitals and treatments, there might be no co-payment at all. Benefit This is the amount that HBF will pay eligible members following a health service. Excess This is a simple way to reduce your premium without reducing your level of cover. An excess is only paid when you need to stay in hospital overnight and is only paid once per member (to a maximum of twice per family policy), per calendar year. This means if you don t have an overnight hospital stay, you don t have to pay the excess. Or if you re admitted to hospital several times in one year, you ll still only pay the excess once. You don t need to pay an excess for any dependant children on your policy. Federal Government 30% Rebate on private health insurance If you have private health cover and everyone covered under your policy is eligible for Medicare benefits, you re eligible for the Federal Government 30% Rebate on private health insurance. The Rebate entitlements are as follows: Age Rebate Example Under 65 30% 65 to 69 35% 70 and over 40% For every $100 in premium the Government pays $30. For every $100 in premium the Government pays $35. For every $100 in premium the Government pays $40. This Rebate is not means tested. The easiest way to receive your Rebate is through a reduced premium. You can, however, claim your Rebate when you lodge your tax return or as a cash payment at any Medicare office. To apply for the Rebate as a reduced premium, simply call an HBF Member Service Advisor on or visit an HBF branch

16 Hospital Episode An industry term that means any period of hospital care or stay; this can also include breaks in treatment. Lifetime Health Cover loading Lifetime Health Cover (LHC) was introduced by the Federal Government. It was designed to encourage people to take out hospital cover early in life and maintain their membership. Any person taking out hospital cover by 1 July in the year following their 31st birthday will lock in the lowest premiums for as long as they maintain hospital cover. Any time after this, they will pay an extra 2% on their hospital cover for each year they are over the age of 30 up to a maximum of 70%. Once they have paid hospital cover with loading for 10 years, the loading will no longer apply for as long as they continue to hold hospital cover. Premium Premium is a health insurance term that refers to how much you need to pay for your health insurance. 30

17 Telephone Enquiries Monday to Friday: 8am to 6pm Saturday: 9am to 12pm hbf.com.au Head Office GPO Box C101 Perth 6809 HBF Branch Hours Monday to Friday: 9am to 5pm * Saturday: 9am to 12.30pm Regional Branches Albany 21 Albany Highway Telephone Bunbury 12 Arthur Street Telephone Busselton 2/90-92 Queen Street Telephone Geraldton Northgate Shopping Centre Telephone Metropolitan Branches Perth 96 William Street Belmont Belmont Forum Shopping Centre Booragoon Garden City Shopping Centre * Cannington Carousel Shopping Centre * Fremantle 82 High Street Hillarys Whitford City Shopping Centre Innaloo Innaloo Shopping Centre Joondalup 115 Grand Boulevard Karrinyup Karrinyup Shopping Centre * Mandurah 32 Pinjarra Road Midland 18/53 The Crescent Morley Galleria Shopping Centre * Rockingham Rockingham Shopping Centre Subiaco 513 Hay Street Success Cockburn Gateway Shopping Centre HBF Health Limited ABN This policy information should be read carefully and retained for your future reference. The information in this brochure is correct on 22 November Minor changes may have occurred since that date. If major changes occur, the brochure will be replaced. Details of any minor changes can be obtained from HBF on request. 22/11/11 HI-550