Mail: Locked Bag 25, Wollongong NSW 2500 - Phone: 1800 148 626 - Fax: 1300 673 406 Email: info@onemedifund.com.au - Web: www.onemedifund.com.au Private Plus Hospital - $250/$500 Excess & Basic Extras Effective 1 September 2014 This package combines: Private Plus Hospital - $250/$500 Excess, and Basic Extras Hospital Cover Private Plus provides comprehensive private hospital cover Australia wide. Private Plus Hospital Cover Service Coverage Public hospital bed - shared or private room (if available) Private hospital bed - shared or private room Same day patient Individual and family excess maximums Co-payments No Theatre fees Labour Ward Intensive Care Surgical prosthesis Are certain treatments excluded? Services not covered by Medicare In-hospital psychiatric treatment In-hospital rehabilitation treatment Cardio-thoracic surgery (heart surgery) Major eye surgery Hip and knee joint replacement Obstetrics related services Assisted reproductive services Plastic and reconstructive services (excludes cosmetic) Access Gap Cover Australia-wide coverage Dependants covered up to 18 years (or 25 years if a full time student) Ambulance Please keep in mind that waiting periods, including pre-existing condition waits, might apply. Excess You will pay an up-front Excess as specified below: Day surgery or public hospital admission Overnight admission in private hospital Financial year maximum Excess per person Financial year maximum Excess per family $125 $250 $250 $500 Page 1 of 8
Excess Bonus 1. Per person excess maximums also apply to family cover. Excess example: A person belonging to a family with the Excess $250 / $500 option, who goes into a private hospital for an overnight stay, will pay a maximum excess of $250 in a financial year instead of $500. If another contributor of the family also is admitted to a private hospital for an overnight stay they will pay a separate excess to a maximum of $250. Other contributors of the family admitted to hospital in the same year will pay no excess. The financial year excess limit for family health cover is a maximum of $500 2. Excess applies to hospital services only, not Extras services. Hospital Cover 1. 100% cover for most private and public hospital services nationwide (after payment of the up-front excess) with access to an extensive range of quality services and approved programs in contracted private hospitals. The fund has agreements with the vast majority of private hospitals in all States and Territories of Australia. Our hospital agreements total more than 450 Australia wide. Call us on 1800 148 626 for more information 2. The services listed in the previous table are applicable in all private hospitals that have entered into an agreement with onemedifund. There are a small number of private hospitals that do not have agreements with the fund. In these cases a limited personal payment may apply 3. We do not have any treatment exclusions on services eligible for Medicare benefits. Access Gap Cover onemedifund has Access Gap arrangements with over 19,000 doctors Australia wide These arrangements maximise the financial benefits for our contributor s in-hospital medical bills. The ultimate aim is to minimise or eliminate contributors out of pocket expenses when our contributors are treated as hospital inpatients We understand that being admitted to hospital can be a very stressful and uncomfortable experience and we are working very hard to minimise or eliminate the financial impact of this experience What is great about these Access Gap arrangements is that you will have either no out-of-pocket expenses to pay or will know exactly how much you will have to pay before treatment begins, and be unlikely to have to lodge a claim for benefits as your doctor can bill onemedifund direct, making it even easier for you Call 1800 148 626 for information about a specialist that has Access Gap arrangement with onemedifund. Health programs onemedifund has a range of health options for contributors, free with your Hospital cover. My Health Online gives you access to a range of health and wellbeing tools through our My Health Online web portal. You can store e-health information about yourself and share it with your doctor, keep a calendar of healthcare appointments, access a health library and more. You also have the option to complete a Health Risk Assessment, which asks you for your health information across a range of areas that can be updated at any time. If your assessment indicates risk areas that we can assist you with, our health professionals may contact you to discuss your options. It s important to know that your Health Risk Assessment is completely confidential. It is stored with our partners at Medikeeper, onemedifund staff do not have access to your health information and it will not affect your health cover contributions. Strive for Health helps contributors with chronic conditions manage their health at home with the help of expert telephone and face-to-face health support. This program gives you access to a health coach (who s a registered nurse or allied health professional) for support, education and advice about your health condition - 24 hours a day, 7 days a week. Hospital @ Home makes it easy to get out of hospital earlier and receive short-term personal care in your home. In some cases, you can even avoid a hospital stay altogether if the services you need can be provided at home. If you and your doctor think recovering at home is right for you, we provide in-home nursing, health aids and equipment to help you get around and help with meals and showering. We also provide the option of 24 hour phone access to healthcare professionals after you have left hospital. Rehab @ Home helps you recover in the comfort of your own home with short-term therapy after joint replacements, fractures, spinal conditions, stroke, respiratory conditions, cardiac conditions and mobility problems. We offer physiotherapy, occupational therapy and more. Page 2 of 8
Extras Cover Basic Extras provides extras cover for the more essential services. Please keep in mind that each service has a limit and waiting periods may apply. General Dental Optical Pharmaceutical Basic Extras Cover Service Benefit Annual Limit Diagnostic / Preventative Extractions Oral surgery Restorations Endodontics Glasses / Frames Contact lenses Prescriptions 75% of cost $550 per person 100% of cost $180 per person 75% of balance in excess of PBS amount ($36.10 as at 1/1/2013) Max $50 per script $500 per person/ $1,000 per family Physiotherapy Physiotherapy 75% of cost $350 per person/ $700 per family Complementary Therapies Additional Benefits Natural Therapy (including remedial massage) Chiropractic Acupuncture Osteopathic Podiatry Health Management Programs 75% of cost $350 per person/ $700 per family 75% of cost $100 per single cover/ $200 per family cover Ambulance (Nationwide, all services) 100% of cost No annual limit Please Note: 1. Financial year is 1 July to 30 June and waiting periods may apply. 2. No benefits are payable by the fund when: The service is provided outside of the Commonwealth of Australia A Contributor is given treatment without charge The services received are not recognised by the fund and are not provided by providers registered with the fund An entitlement exists or may exist under any compensation, third party or sports club cover A claim for services is submitted more than 24 months after the date of service A claim is submitted for optical appliances where sight correction is not required The claim benefit is less than $5, although this can be accumulated with other claims Services are provided by family members, relatives, business associates or yourself The claim is for goods or services that are deemed to be primarily for the purposes of sport, recreation or entertainment. General Dental Cover 1. Benefits are payable for General Dental services and procedures such as Diagnostic, Preventative, Extractions, Oral Surgery, Restorations and Endodontic Treatment 2. Excludes High Cost Dental: Dentures, Orthodontic, Implants, Crowns and Bridgework 3. Benefits are paid at 75% of the item cost up to the annual limit 4. A 2 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but Contributors transferring from another fund that have lower General Dental limits than onemedifund must wait 2 months before they can claim more than the former funds General Dental limits. Page 3 of 8
Optical Cover 1. Benefits payable only on glasses or contact lenses that are prescribed by a registered optometrist or ophthalmic surgeon, where sight correction is necessary 2. A 6 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but Contributors transferring from another fund that have lower Optical limits than onemedifund must wait 6 months before they can claim more than the former funds Optical limits. Pharmaceutical Cover 1. Benefits payable only on non Pharmaceutical Benefits Scheme (PBS) prescriptions. No benefits payable on PBS prescriptions or items normally available over the counter. The PBS amount changes on 1 January every year and is $36.90 as at 1/1/2014. 2. A 2 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but Contributors transferring from another fund that have a lower Pharmaceutical limit than onemedifund must wait 2 months before they can claim more than the former funds Pharmaceutical limit. Ambulance Cover What we will cover 1. 100% reimbursement of the cost of service, irrespective of distance travelled within the Commonwealth of Australia 2. There is no annual claim limit on ambulance services and there is no waiting period What We Will Not Pay For 1. Ambulance subscription or state based ambulance levies 2. Ambulance costs that are covered under government legislation or other compensable sources 3. Ambulance services that are not medically necessary Complementary Therapy Cover 1. Benefits payable only on Fund recognised services and where the provider is recognised by the fund 2. A 2 month waiting period applies unless these waiting periods have already been served with another health fund (see waiting periods explanation), but Contributors transferring from another fund that have a lower Complementary Therapy limit than onemedifund must wait 2 months before they can claim more than the former funds Complementary Therapy limit. Health Management Programs 1. Benefits are paid for approved programs which aim to prevent or improve a specific health condition. Health screening services such as blood pressure testing, cholesterol checks, mammograms and hearing tests can be claimed with a written recommendation from your health professional. Please contact the fund for details 2. Under the National Health Act, onemedifund cannot pay benefits for goods and services that are for the purposes of sport, recreation or entertainment, such as gym memberships or sports shoes. Waiting Periods Months Claim Category 0 Ambulance 0 Accidents requiring hospitalisation Transfers from other funds or parent s cover for equivalent level of cover and if currently financial with the 0 other fund 2 On commencement of the fund or upgrading your level of cover (apart from these noted below) 2 General Dental, Pharmaceutical, Physiotherapy and Complementary Therapies 6 Optical and Health Management Benefits 12 High-cost dentistry including crowns, bridgework, implants, orthodontics and dentures Page 4 of 8
12 Pre-existing conditions Any ailment, illness, or condition that you had signs or symptoms of (in the opinion of a medical practitioner appointed by the health insurer) that existed during the 6 months prior to you commencing hospital cover or upgrading to a higher Hospital cover. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed. A condition can still be classed as pre-existing even if you had not seen your doctor about it before commencing Hospital cover or upgrading to a higher Hospital cover. Note: This waiting period applies to Hospital cover only, and does not apply to Extras cover. 24 Laser eye surgery and hearing aids Please note: If a person is transferring to onemedifund from another fund with an equivalent or higher level of cover, is financial and waiting periods from the previous fund have been served, waiting periods will be waived, but: 1. Contributors transferring from another fund that have used all or part of their annual limits with this other fund will only receive the difference between the onemedifund limit and the amount already claimed from the other fund in the first financial year of cover, and 2. Contributors transferring from another fund that have lower limits than onemedifund must serve the waiting periods listed above before they can claim more than the former funds limit. 3. Contributors transferring from another fund will not be entitled to continuity for any Health Management benefits i.e. the normal 6 months waiting period must be served before any benefits are payable. Dependants Children are covered as dependants on a family cover to age: 1. 18 years, even if they are working full time or not, however they must not be married, or 2. 25 years if they are full time students and documentation is provided annually confirming this, however they must not be married. Once dependants cease to be covered under the family cover they are then entitled and strongly encouraged to take their own cover with us and continue to enjoy the exceptional benefits, competitive rates and first class service that we offer. Other Services Electronic "eftpos style" claiming using your onemedifund card is available at more than 21,000 dentists, physiotherapists, optical dispensers, chiropractors, osteopaths and podiatrists Australia wide. Privacy Statement onemedifund respects your privacy and is committed to keeping your personal information safe through compliance with the Privacy Act and the National Privacy Principles. We only collect information that is necessary to assist the fund in providing its services. We do not collect personal information unless we first ask the contributor or individual for it. onemedifund exercises great care to protect the personal information that is held. If you wish to obtain additional information regarding our Privacy Statement please contact the fund Privacy Officer on 1800 148 626 or email us at info@onemedifund.com.au Cooling off Period We are committed to ensuring that you choose the health cover that is right for you. If for any reason you decide that your choice was not suitable then we will provide a refund of your payment (provided no claims have been made). You will need to contact us within the first 30 days of commencement of the fund or changing your level of cover for this cooling off period to be available. Complaints If you have a complaint about onemedifund please contact the fund on 1800 148 626 and our staff will help to resolve your issue. Failing this, an escalation process is also available. Full details are included in our complaints resolution statement. If your complaint is not resolved you are entitled to seek the services of the Private Health Insurance Ombudsman (PHIO). PHIO provides free independent services to private health fund contributors. PHIO (www.phio.org.au) can be contacted on 1800 640 695 and they are located at Level 7, 362 Kent Street, SYDNEY, NSW 2000. Code of Conduct Page 5 of 8
This Code was developed by Private Healthcare Australia (PHA) and HIRMAA (representing restricted and regional health funds). As well as promoting improved standards in clarity of information given to contributors, it aims to solve problems between contributors and onemedifund through internal dispute resolution. The Code also ensures that funds inform their members of their entitlement to seek assistance from an external dispute resolution body, such as the Private Health Insurance Ombudsman (PHIO). Page 6 of 8
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Please Note: This document should be read carefully and retained for future reference. For further information, please call 1800 148 626 or email info@onemedifund.com.au. National Health Benefits Australia Pty Ltd (trading as onemedifund). A registered private health insurer. ABN 67 122 255 396 Page 8 of 8