CBHS Health Fund Ltd.

Transcription

1 Fund Product Template Fund Name: CBHS Health Fund Ltd Postal Address: Locked Bag 5014 Parramatta NSW 2124 Telephone: Facsimile: (02) (02) Chief Executive Officer: Mr Paul Gladman Claims Enquiries: Membership Enquires: Patient Eligibility Checks: HELPER is an online service for hospitals to perform patient eligibility checks. If you do not have a password please call our Member Care Centre on and ask to be transferred to the Data and Technical Team to begin the registration process. Registration is effective immediately. Patients eligibility checks via fax available to hospitals who do not have access to the internet ONLY.

2 Table: Excess: Excess: Hospital 'a,' Comprehensive, Overseas Visitors Cover and CBHS Prestige Private Hospital covers Comprehensive, Overseas Visitors Cover and CBHS Prestige Nil Nil Hospital 'a' Excess cover $350 per person for an overnight hospital admission up to a maximum of $700 for a family membership per calendar year A Co-payment of $100 per day is payable for every Hospital service as an Admitted Patient that does not include an overnight stay. This is an uncapped amount and is payable on every occasion by the member. Comprehensive 100 or Comprehensive 70 hospital cover $100 or $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per family). Table: Excess: Hospital 'b' & Limited Private Hospital cover (with Minimum Benefits in a private hospital for some treatments) see attached for more details Hospital 'b' Excess hospital cover $350 per person for an overnight hospital admission up to a maximum of $700 for a family membership per calendar year A Co-payment of $100 per day is payable for every Hospital service as an Admitted Patient that does not include an overnight stay. This is an uncapped amount and is payable on every occasion by the member. Limited 100 or Limited 70 hospital cover $100 or $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per family). Table: Excess/ Basic Hospital This level of cover receives Minimum Benefits in a private hospital as specified in PHI Benefit Requirement Rules. Nil Table: Basic Hospital 500 This level of cover receives Minimum Benefits in a private hospital as specified in PHI Benefit Requirement Rules.

3 Excess: $ per person with a maximum of $1000 per family per calendar year. Nil

4 Table: Co-payment Table: Table: LiveLife Private Hospital cover $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per family) applies to all Members covered by the membership. This co-payment is waived for children under 13 years. StepUp Private Hospital cover (with Minimum Benefits in a private hospital for some treatments) see attached for more details $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per family) applies to all Members covered by the membership. This co-payment is waived for children under 13 years. Kickstart Hospital Private Hospital cover (with benefit restrictions for some treatments) - see attached for more details. $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per couple) Table: Excess/ Global Mobility Basic Hospital Cover No Benefit shall be payable for treatment received by a Member in a Private Hospital (including a private day surgery facility). The Benefit payable for treatment received in a Public Hospital shall be the Minimum Default Benefit for that treatment. Nil

5 CBHS Prestige, LiveLife, Comprehensive Hospital, Overseas Visitors Cover & Hospital a Excess Excess/Co-payments Nil for CBHS Prestige, Comprehensive Hospital and Overseas Visitors Cover Hospital 'a' Excess hospital cover Excess -$350 per person for an overnight hospital admission up to a maximum of $700 for a family membership per calendar year Co-payment - $100 per day is payable for every Hospital service as an Admitted Patient that does not include an overnight stay. This is an uncapped amount and is payable on every occasion by the Member. Comprehensive 100 or Comprehensive 70 Hospital cover $100 or $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per family). LiveLife $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per family). This co-payment is waived for children under 13 years. Restricted Benefits (Services) not fully covered The services listed below, 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 the Minimum Default Benefit and the bed charge raised by the hospital. The services listed below are also eligible for hospital benefits in a public hospital at a shared room rate. - cosmetic surgery - podiatric surgery - laser eye surgery - other services for which a Medicare benefit is not payable All other hospital services receive benefits up to the amount listed in the Hospital Purchaser-Provider Agreement. (Hospital Contract) Claims for undetermined compensable services should be accompanied with a completed Accident/Injury/Illness form. Hospital admissions for Compensation, Accidents or Injuries MUST have the relevant form completed on admission and sent to CBHS with the hospital claim. For compensable services where liability has been accepted by another party, please direct claim to relevant party.

6 StepUp Co-payments $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person) applies to all Members covered by the membership. This does not apply to a Dependent under the age of 13 years old. Claims for undetermined compensable services should be accompanied with a completed Hospital admissions for Compensation, Accidents or Injuries MUST have the relevant form completed on admission and sent to CBHS with the hospital claim. For compensable services where liability has been accepted by another party, please direct claim to relevant party. MINIMUM DEFAULT BENEFITS as specified in the relevant Schedule of the Private Health Insurance (Benefit Requirement) Rules MINIMUM DEFAULT BENEFITS as specified in the relevant Schedule of the Private Health Insurance (Benefit Requirement) Rules Joint Replacement Services hip, knee, ankle, shoulder and other joint replacements Major Eye Surgery Services corneal transplant, cataract surgery, other lens related Sterilisation & Reversal of Sterilisation Services Bariatric Services gastric banding, sleeve gastrectomy, gastric by-pass and associated procedure items ie etc (see note 2) (see note 3) Explanation of Notes Note Plastic & Reconstruction Surgery Services Clinical notes required - see Note 1 Item Plastic and Reconstructive Surgery items (see Full Contract Rate - clinical notes required for all services listed below Services associated with trauma, burn, cancer or other accidental mutilation that was not present at the time this level of cover was taken Where required for treatment of cancer, requires an arthrodesis and is not a pre-existing condition When the procedure is for a revision of a total hip replacement where only part of the original total hip is required - ie the tibia or the femur and is not a pre-existing condition Cardiothoracic services including medical admissions Ministers Default Rate If performed within 12 months of end of pregnancy or if performed with item numbers 45564, 45565, or Services associated with joint replacement Services associated with total hip replacement Psychiatric, Rehabilitation or Palliative Care Services & services for which there is no Medicare Benefit Schedule Fee payable All other hospital services receive benefits up to the amount listed in the Hospital Purchaser-Provider Agreement. (Hospital Contract)

7 Limited Hospital & Hospital b Excess Hospital 'b' Excess $350 per person for an overnight hospital admission up to a maximum of $700 for a family membership per calendar year Co-payment - $100 per day per person for every hospital admission, except an overnight admission. This is an uncapped amount (no yearly maximum). Limited 100 or Limited Co-payments - $100 or $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per family). Claims for undetermined compensable services should be accompanied with a completed Accident/Injury/Illness form. Hospital admissions for Compensation, Accidents or Injuries MUST have the relevant form completed on admission and sent to CBHS with the hospital claim. For compensable services where liability has been accepted by another party, please direct claim to relevant party. Restricted Benefits (Services) not fully covered The services listed below, 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 the Minimum Default Benefit and the bed charge raised by the hospital. The services listed below are also eligible for hospital benefits in a public hospital at a shared room rate. MINIMUM DEFAULT BENEFITS as specified in the relevant Schedule of the Private Health Insurance (Benefit Requirement) Rules MINIMUM DEFAULT BENEFITS as specified in the relevant Schedule of the Private Health Insurance (Benefit Requirement) Rules Plastic & Reconstruction Surgery Services Cardiothoracic services Pregnancy Related Services Joint Replacement Services Assisted Reproductive Services Major Eye Surgery Services Sterilisation & Reversal of Sterilisation Services Bariatric Services hip, knee, ankle, shoulder and other joint replacements corneal transplant, cataract surgery, other lens related surgery services gastric banding, sleeve gastrectomy, gastric by-pass and associated procedure items (see note 4) ie etc (see note 4) (see note 2) (see note 3) Explanation of Notes Note Item Full Contract Rate - clinical notes required for all services listed below Ministers Default Rate 1 Clinical notes required - see Note 1 Plastic and Reconstructive Surgery items (see above) Services associated with trauma, burn, cancer or other accidental mutilation that was not present at the time this level of cover was taken including medical admissions If performed within 12 months of end of pregnancy or if performed with item numbers 45564, 45565, or including medical admissions Psychiatric, Rehabilitation or Palliative Care Services & services for which there is no Medicare Benefit Schedule Fee payable Where required for treatment of cancer, requires an arthrodesis and is not a pre-existing condition Services associated with joint replacement , When the procedure is for a revision of a total hip replacement where only part of the original total hip is required - ie the tibia or the femur and is not a pre-existing condition Analysis and Storage where not associated with assisted reproduction Services associated with total hip replacement Services associated with Assisted Reproduction All other hospital services receive benefits up to the amount listed in the Hospital Purchaser-Provider Agreement. (Hospital Contract)

8 KickStart Copayment $70 per day of hospitalisation per Calendar Year (maximum of 6 days per person or 12 days per couple) Please note that any MBS Items NOT LISTED below or any Cosmetic Surgery, Surgical Podiatry, Laser Eye Surgery and all other procedures that have NO MBS item number receive 'Minimum Benefits' only according to the Schedule of the Private Health Insurance Benefit Requirements Rules for accommodation in a Private Hospital. Benefits for Prostheses are payable for non-cosmetic surgically implanted items that are Government approved up to the minimum amount specified by legislation. The following MBS item numbers below ARE covered in a Private Hospital or Day Hospital that has a Hospital Agreement Investigations, Repairs and Reconstructions Removal of Removal of Removal of Appendix Tonsils & Wisdom Teeth Shoulder Hip Knee D D002 - see note D003 - see note D015 - see note D D043 - see note D051 - see note D052 - see note Explanation of Notes Note 1: dental extractions covered for wisdom teeth only (tooth ID 18, 28, 38 & 48) Claims for compensable services should be accompanied with a completed Accident/Injury/Illness form. Hospital admissions for Compensation, Accidents or Injuries MUST have the relevant form completed on admission and sent to

9 Basic Hospital Basic Hospital Excess/Co-payment - Nil Basic Hospital 500 Co-payment - Nil Excess - $ per person per admission with a maximum of $1000 per family per calendar year. All services when provided in a private or public 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 the Minimum Default Benefit and the bed charge raised by the hospital. Fees raised by public hospitals that exceed Minimum Default Benefits set by the Department of Health and Ageing for shared room accommodation will be the member's out of pocket expense. Hospitals should provide patients with an estimate of fees in order for the patient to make an informed decision. Claims for undetermined compensable services should be accompanied with a completed Accident/Injury/Illness form. Hospital admissions for Compensation, Accidents or Injuries MUST have the relevant form completed on admission and sent to CBHS with the hospital claim. For compensable services where liability has been accepted by another party, please direct claim to relevant party.

10 Global Mobility Basic Hospital Cover Excess/Co-payment - Nil No Benefit shall be payable for treatment received by a Member in a Private Hospital (including a private day surgery facility). The Benefit payable for treatment received in a Public Hospital shall be the Minimum Default Benefit (Minister's Default Benefit) for that treatment. Claims for undetermined compensable services should be accompanied with a completed Accident/Injury/Illness form. Hospital admissions for Compensation, Accidents or Injuries MUST have the relevant form completed on admission and sent to CBHS with the hospital claim. For compensable services where liability has been accepted by another party, please direct claim to relevant party.

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