Important Information
This website contains information designed to encourage people to join Medibank Private and to assist current members in deciding whether to change their level of cover. The following is a summary of important information relating to Membership of Medibank Private, rules relating to the payment of Benefits, and a Glossary of words and phrases used throughout this website. Please make sure you are familiar with the following information and the Glossary.
Like to find out more?
Further information is contained in the Membership Guide, which is sent to you with your Membership card after joining or changing cover. The Membership Guide is also available at any of our Retail Centres, by phoning 132 331 or download here (pdf). In addition, our Fund Rules are available at any of our Retail Centres or download here (pdf).
30 day cooling-off period
If you are not entirely satisfied with the cover you have chosen within the first 30 days of joining or amending your cover, and no claims have been made against your policy, Medibank Private will transfer you to a more suitable cover or, if you choose, refund your premium in full.
State of residence
Members are required to hold Membership and pay the premium which is applicable to the State or Territory in which they reside. As premiums and some Benefits differ from State to State, when Members move interstate they must notify Medibank Private within 2 months.
Cover all year round
You receive Benefits under your cover all year round, provided you obtain medical certification for ongoing acute care after 35 continuous days in hospital.
Things to consider before choosing your cover
Excess
An Excess is an amount that you agree to pay if admitted to hospital in exchange for lower premiums. Your Excess is deducted from the Benefits we pay when you make a hospital claim.
When you choose your hospital cover, think about how you're going to use it and choose the level of Excess that suits you. The higher the level of Excess, the lower the amount you'll pay in premiums.
With First Choice Hospital, First Choice Saver Hospital, Smart Choice Hospital and Blue Ribbon Hospital, the Excess is applied to the Membership each Calendar Year. The Excess amount that you have chosen is deducted from the benefits payable for any hospital treatment. Once the Excess has been met, it will not be applied again in that Calendar Year.
With a packaged cover, the hospital Excess that applies is $200 for Single, Couple, Family and Single Parent Family Memberships and applies each time a Member is admitted to hospital. However, you will not pay more than $500 per Single Membership and $1,000 for Couple, Family and Single Parent Family Memberships each Calendar Year.
Note: The Excess does not apply to extras claims under the packaged covers. PremierPlus and MyOptions do not have an Excess.
Daily Co-payment
Under our First Choice Saver Hospital and Smart Choice Hospital covers, you pay part of the cost of your hospital accommodation in the form of a ‘a Daily Co-payment', if you are treated in a Members' Choice Hospital or a Contracted Hospital.
In a Members' Choice Hospital, the Daily Co-payment is:
- $50 a day for a shared room, or
- $80 a day for a private room.
For any one stay in a Members' Choice Hospital, you will not pay more than $280. A Daily Co-payment of $50 also applies to each Same Day Admission in a Members' Choice Hospital.
In addition to the Daily Co-payments listed above, in a Contracted Hospital you may be required to pay an extra contribution towards your stay.
If you are treated in a private hospital that is not a Members' Choice Hospital or in a private room in a public hospital, you might need to pay additional out-of-pocket costs, including part of the cost for your hospital stay. These costs vary between hospitals and are typically not subject to a maximum limit. If you are going to be treated in a non Members' Choice Hospital, please confirm any out-of-pocket expenses with both the hospital and Medibank Private before you're admitted.
Waiting Periods
A Waiting Period is a period of time a Member must wait before Benefits are payable. Waiting Periods apply to:
- New Members and Members rejoining Medibank Private.
- Members who change their level of cover. However, these Members will be entitled to Benefits under their new cover or Benefits under their old cover, whichever are the lesser during Waiting Periods.
- The difference between the Medibank Private Benefits and the former fund Benefits for Members transferring from another fund. For these Members, Benefits are payable at the former fund level or the Medibank Private level, whichever are the lesser during Waiting Periods.
Waiting Periods apply to the following:
| Waiting Period |
Item / Service |
| 2 months |
All services, except as specified below. |
| 6 months |
Optical items
PackageBonus |
| 12 months |
Pre-existing Ailments (However, the 12 month Pre-existing Ailment waiting period does not apply to hospital or hospital–substitute treatment for approved psychiatric treatment, approved rehabilitation treatment or palliative care)
Obstetrics-related Services. (However, Benefits are payable during this Waiting Period for premature births and complications arising from the pregnancy where a medical practitioner confirms that the baby was not expected to be born until after the Waiting Period.)
Major Dental services
Endodontic Services (eg. root canal treatment)
Dental surgical procedures and surgical extractions (eg. extraction of wisdom teeth)
Nebulisers
Peak flow meters
Spacing devices
Approved Jenny Craig weight loss services
|
| 24 months |
Blood glucose monitors. |
| 36 months |
Hearing aids |
Waiting Periods may apply to betterhealth Programs.
The 2 month Waiting Period is waived for treatment arising from an Accident (excluding a School Accident) occurring after joining or changing cover. However, the applicable longer Waiting Periods specified still applied.
Benefit Replacement Period
A Benefit Replacement Period applies to certain extras items. This means that, once you have been paid a Benefit for a particular item, you must wait for a certain period of time from the date of purchase of the item before you are entitled to a Benefit for the replacement of that item. Where a Benefit is payable under your extras cover, the following Benefit Replacement Periods will apply. These Benefit Replacement Periods apply per Member except where shown.
| Benefit Replacement Period |
Item/Service |
| 2 years |
Wigs
Hip protectors
Insulin delivery pens |
| 3 years |
Blood glucose monitors
Breathing appliances
- nebulisers
- peak flow meters (per Membership)
- spacing devices
Mouthguards (a Benefit may be payable for a replacement mouthguard each calendar year for Members up to 18 years of age)
Other health appliances and external prostheses (except as specified below)
|
| 5 years |
Hearing aids
Sleep Apnoea - Continuous Pressure Devices and other similar approved Sleep Apnoea appliances under all hospital covers detailed in this website (excluding MyOptions).
|
Restricted Services
If you choose our First Choice Hospital, First Choice Saver Hospital, HealthyPlus, SmartPlus or MyOptions, you will receive lower Benefits for Restricted Services in a private hospital. There are no Restricted Services if you choose Smart Choice Hospital, Blue Ribbon Hospital, AdvantagePlus or Premier Plus.
Under MyOptions cover, Restricted Services are services for which benefits are payable and which are not Included Services or Excluded Services.
- When you receive a Restricted Service in a private hospital, the Benefits we pay towards your hospital accommodation (including intensive care charges) will not exceed the relevant Default Benefit. For non-Restricted Services, the Benefits we pay are higher than the relevant Default Benefit. Further, for Restricted Services, we do not pay any Benefits towards the costs of using labour wards or operating theatres.
- When you have First Choice Hospital, HealthyPlus, SmartPlus or MyOptions, you will be fully covered for overnight accommodation charges for Restricted Services in a public hospital in either a shared or private room, less any applicable Excess.
- When you have First Choice Saver Hospital, you'll be fully covered for accommodation charges for Restricted Services in a public hospital in a shared room only (both for overnight accommodation and Same Day Admission), less any applicable Excess.
If you receive treatment as a private patient in a private room (in a public hospital), you may have to pay an additional amount towards your hospital accommodation.
If there's anything you don't understand, please call us on 132 331 or drop into one of our Retail Centres and we'll be happy to talk you through it.
Extras Annual Limits and Sub-limits
An Annual Limit is the maximum amount of Benefits you can claim for extras services or items within a particular category (eg. optical items) within a Calendar Year.
Some extras services also have Sub-limits. Sub-limits restrict the amount you can claim for a particular extras service or item (eg. spectacle frames).
Once the Annual Limit (or Sub-limit) has been reached, no further Benefits are payable for those extras services for that person until the next Calendar Year. Annual Limits vary according to the level of cover.
Before you choose your cover, you should make sure you are aware of any Annual Limits and Sub-limits that apply.
Federal Government Rebate
The Federal Government 30% Rebate on private health insurance makes health cover more affordable by reducing your premiums.
Medicare Levy Surcharge
A 1% surcharge payable by Australian residents for tax purposes who do not have an appropriate level of hospital cover. Find out more.
Medically Necessary Ambulance Transport
General
In WA, eligible residents aged 65 or over are entitled to either free or subsidised ambulance services. For those Members who are entitled to subsidised ambulance services, the remaining cost may be claimable from Medibank Private if they are entitled to ambulance transport Benefits under their cover.
Hospital covers
Benefits for Medically Necessary Ambulance Transport are included in all hospital covers, except where there is an entitlement to Benefits under third party arrangements such as State Government ambulance transport schemes or ambulance subscription services, such as those operating in the ACT, NSW, Qld and Tas.
Members in the ACT and NSW pay an ambulance levy as part of their hospital cover premiums, and are entitled to cover under their State scheme. When these Members receive an account for ambulance transport, they should take it to a Medibank Private Retail Centre for endorsement, then send it to the administrator of the relevant scheme.
Note: Members in the ACT and NSW who hold a Commonwealth concession card may be exempt from paying the ambulance levy and should contact Medibank Private on 132 331 for a premium quote.
Extras covers
For residents of all States, except Qld and Tas, Benefits for Medically Necessary Ambulance Transport are included in all extras covers.
Packaged covers
Benefits for Medically Necessary Ambulance Transport are included in all packaged covers, except where there is an entitlement to Benefits under third party arrangements such as State Government ambulance transport schemes or ambulance subscription services.
Lifetime Health Cover (LHC)
Lifetime Health Cover is a Federal Government initiative designed to encourage people to take out hospital cover early in life and maintain it, by allowing them to pay lower premiums compared with others who take out hospital cover when they're older, or who allow their cover to lapse for long periods.
Pre-existing Ailment Rule
What is a Pre-existing Ailment?
A Pre-existing Ailment is an ailment, illness, or condition, the signs or symptoms of which existed at any time during the six months before you purchased a new cover or transferred to a cover with higher Benefits. The only person authorised to decide whether you have a Pre-existing Ailment is a medical or other health practitioner appointed by Medibank Private. The practitioner must consider any information as to signs or symptoms that your treating practitioner(s) provide.
Explanation of the Pre-existing Ailment Rule
Health funds can apply a special Waiting Period to new Members who have Pre-existing Ailments. This Waiting Period also applies to existing Members who have recently amended their cover to include higher Benefits.
The 12 month Pre-existing Aliment Waiting Period can be applied to all hospital or hospital substitute treatment for which we pay benefits. However, a two month waiting period applies to the following services:
- approved psychiatric treatment
- approved rehabilitation treatment, or
- palliative care.
If the ailment, illness or condition is considered pre-existing:
- new Members must wait 12 months for any Benefits
- Members transferring to Medibank Private or amending their Medibank Private cover to include higher Benefits must wait 12 months to get the higher Benefits including Benefits for services not previously covered.
The 12 month Waiting Period for the treatment of a Pre-existing Ailment can also apply to extras services (except General Dental).
Other assessment rules
- Benefits are only payable for services rendered by Recognised Providers.
- Restrictions apply to some individual Benefits. For example, for an initial consultation for an extras service, the higher Benefit (if any) is generally payable once only in a course of treatment.
- Benefits are not payable for services or treatments where you have, or may have, an entitlement to receive compensation and/or damages.
Medibank Private's GapCover Scheme
GapCover is available to doctors for medical services provided to inpatients of hospital and day hospital facilities (doctors' services provided out of hospital are not eligible for GapCover). Members of First Choice Hospital, First Choice Saver Hospital, Smart Choice Hospital and Blue Ribbon Hospital, or any packaged covers are automatically entitled to GapCover.
However, whether or not you benefit depends on your doctor's willingness to use this scheme. Practitioners are free to use the GapCover Scheme on a case-by-case or episode-by-episode basis. Search our listing of specialists who have participated in GapCover in the past.
If you anticipate being admitted to hospital for treatment or a procedure, we recommend that, before proceeding, you ask your doctor whether he or she participates in GapCover. Confirm with them whether they will be charging in accordance with our GapCover arrangements for the treatment you are about to have.
Participating doctors are required to give you a written estimate of out-of-pocket expenses prior to you receiving treatment. The standard 25% Benefit for in-hospital medical expenses, or any extra Benefit payable under Gapcover, is not payable where Medicare benefits are not payable for a procedure.
Transferring to Medibank Private from another registered health fund (Portability)
You can join or leave Medibank Private at any time. The Private Health Insurance Ombudsman has published a brochure called The Right to Change, which describes the rules that apply when you transfer between funds.
Provided you join Medibank Private within two months of leaving your former fund, and you have served the equivalent Medibank Private Waiting Periods with your former fund, from the date you join you will be eligible for those Benefits under your new cover for those services that were payable under your old cover. Benefits will not be paid for treatments you receive before joining Medibank Private.
However, if you are transferring to a higher level of cover with Medibank Private you will need to serve the applicable Waiting Periods before you are entitled to the higher Benefits.
If you have not fully served the equivalent Medibank Private Waiting Periods with your former fund, then you will need to serve the balance of these Waiting Periods with Medibank Private before you are eligible for Benefits.
Unless specifically permitted, any loyalty bonus or other entitlements accrued with your former fund, such as increased Annual Limits for dentures and crowns, will not transfer to your Medibank Private Membership.
Portability and Lifetime Health Cover (LHC)
If you are transferring your hospital cover to Medibank Private we recommend you keep your cover with your former fund until the date your transfer to Medibank Private. This will ensure that you are not without cover and do not use any of your permitted days without hospital cover under Lifetime Health Cover.
If transferring from another registered fund you will need to complete a Transfer Certificate Request.
Adding a Dependent Child to your Single Membership
Your Membership can be changed from a Single to a Family or Single Parent Family Membership without additional Waiting Periods:
- following the birth of your baby, or
- at the time of adopting or fostering a child.
He or she must be added within two months of the birth or being included in your family unit. The effective date will be the date on which the child was born, adopted or fostered.
If applicable, Waiting Periods will apply to any other family members added at this time.
Note: Higher premiums apply to Family and Single Parent Family Memberships. If you change your type or level of cover to one with a higher Excess (eg. Single to Family) the higher Excess applies from the date of the change.
When a newborn baby is in hospital with the mother, no accommodation charges should be raised by the hospital in respect of the baby, unless the baby becomes an admitted patient in its own right.
This happens when the baby:
- requires admission to a neo-natal intensive care unit, or
- is the second or later child of a multiple birth.
Adding a Spouse or Partner to your Single Membership
Your Membership can be changed from a Single to a Couple Membership. Waiting Periods may apply to your Spouse or Partner. Higher premiums apply to a Couple Membership.
Families with Adult Children
With our Families with Adult Children Membership option, you can extend the time your children can remain on your Membership. Even though you'll pay a higher premium, generally it's a more economical option than taking out their own individual Membership at the same level of cover.
Private Patients' Hospital Charter
The Private Patients' Hospital Charter is a booklet prepared by the Federal Government to inform Members about what they can expect from their health fund, doctors and hospitals as a patient with private hospital cover. A copy of this Charter is available at our Retail Centres.
Surgically Implanted Prostheses
Most of the common items on the Federal Government's Prostheses Schedule will be fully covered under your hospital cover (we call these No-Gap Prostheses). However, there will be some Surgically Implanted Prostheses and other items for which you will have to pay an amount towards the costs (we call these Gap Prostheses). For every relevant procedure listed in the Medicare Benefits Schedule there will be at least one No-Gap Prosthesis available.
It is important that you discuss with your doctor the item that best suits your medical needs and ask them to provide you with an estimate of any out-of-pocket expenses. Members' Choice Hospitals are required to give you an estimate of any out-of-pocket expenses prior to you receiving treatment where practical.
Customer feedback
At Medibank Private, we value your comments on our products and services. If you have any feedback for us or require further explanation on any matter affecting your Membership, you can contact us by:
- emailing us at ask_us@medibank.com.au
- asking us a question
- calling us on 132 331, or
- visiting one of our Retail Centres.
Resolution of Issues
We are committed to efficient and fair resolution of complaints, and to using the information we receive to ensure our products, policies and service continue to adequately address our Members' needs.
We aim to resolve any complaint you may have the first time you raise it with us and encourage you to contact us with your issue through the contact points listed above.
In most instances, we will be able to resolve the issue to your satisfaction. If, despite our best efforts, you believe your complaint has not been satisfactorily dealt with, please let us know and we will escalate your complaint to the appropriate manager, or you can write to Medibank Private Customer Resolutions, GPO Box 9999, Melbourne, VIC 3000.
When you have considered our response, if you feel that we have still not adequately addressed your concerns, free, independent advice is also available from the Private Health Insurance Ombudsman on 1800 640 695.
Private Health Insurance Code of Conduct
Medibank Private is proud to be a signatory to the Private Health Insurance Code of Conduct.
The code was developed by the Health Insurance industry and aims to promote the standards of service to be applied throughout the industry.
The code is designed to help you by ensuring that:
- information which we provide to you is written in plain language
- Medibank Private employees are competently trained to deal with your enquiries
- Medibank Private protects the privacy of your information in line with Privacy Principles
- you have access to a reliable and free system of addressing complaints with Medibank Private.
A copy of the code is available at privatehealth.com.au/codeofconduct