Things worth knowing

Understanding private health insurance can be tricky. This section is designed to help make things a little easier for you. It contains some important information about our covers along with explanations of terms you may not be familiar with. It also gives you an overview of some of our key rules. Medibank recommends that you should carefully read our fund Rules, the information on the website and any brochures or Standard information Statement available to you, and you should retain this information for future reference.

About your membership with us

  • Do you have a 'cooling-off' period?
  • If you join but then decide you'd like to either cancel your membership or move to another cover, we have what is known as a ‘cooling-off' period. This also applies if you're already a member and have recently changed your cover.

    As long as you tell us within 30 days of joining or changing your cover, and no claims have been made against your policy there's no problem. We can either transfer you to a more suitable cover or refund your premium in full.

  • How often should I review my cover?
  • You may have different health needs at different stages of your life, so it makes sense to review your health cover regularly. This is especially important if your situation changes. For example, if you're planning to start a family, the kids have grown up or either you or someone in your family has developed a health issue. Whatever your situation, it's a good idea to call us to discuss your options on 134 190 or drop into one of our stores. Alternatively you can log into Online Member Services and compare covers.

  • What is the difference between a member, a membership and a policy holder?
  • There are three terms we use when we're talking about membership: member, membership and policy holder. As a starting point, it's good to be clear on all three.

    A member is simply any person covered under a Medibank Private membership.

    A membership is made up of one or more members and can consist of:

    • just one person, (single membership)
    • a couple membership which covers you (the policy holder) and your partner
    • single parent* membership, which covers you and
      • any of your child dependants and/or
      • any student dependants
    • family membership*, which covers you and your partner and
      • any of your child dependants and/or
      • any of your student dependants
    • family with adult children* membership option, which can, for an additional cost, extend a single parent or family membership to include any of your children who:
      • have reached the age of 21 but are under 25,
      • are not studying full-time, and
      • are neither married nor living in a de facto relationship

    *These membership categories do not apply to Young Hospital cover.

    The term policy holder refers to the person who ‘owns' the membership. This is the person we contact when we need to communicate important information.

  • Can my partner manage my membership too?
  • Although you as the policy holder ‘own' the membership, your partner (if he or she is also covered by the same membership) can automatically manage most aspects of the membership too, including: making claims, adding or removing dependants, changing cover, suspending the membership and changing contact and bank account details.

    However, as the policy holder you're the only one who can remove yourself from the membership or cancel the membership. It's important to be aware that this means we may disclose registered membership details to both of you. If at any time you want to be the only person who can manage the membership or you require further information about the handling of personal information, please call us on 134 190.

  • If I transfer to Medibank from another registered Australian health fund, am I covered immediately?
  • In some cases yes, in other cases no. You'll be covered for services on your new cover from the date you join if: (i) those services were also included on your cover with your former fund, (ii) you join us within two months of leaving your former fund and (iii) you've already served the applicable waiting periods. So although we'll recognise any waiting periods you've served with your former fund, if you haven't fully served the applicable waiting periods, you'll need to serve the balance with us before you're eligible for benefits.

    Additional waiting periods will also apply if you've switched to a higher level of cover with Medibank or if you wait more than two months after leaving your former fund before you join Medibank. More information.

    Any loyalty bonus or other similar entitlements built up with your former fund (for example, orthodontic entitlements) will not transfer to Medibank. If you transfer to Medibank or to another Medibank cover, any benefits that may have been paid under your previous cover will be taken into account in determining the benefits payable under your new cover.

  • What if I want to add my partner to my single membership?
  • It's easy to change from a single to a couple membership, but you should be aware that higher premiums apply to a couple membership and additional waiting periods may apply to your partner.

  • Can I add a dependent child to my membership?
  • If you're on a single membership:

    To add a dependent child to your membership you'll need to change from a single to a family or single parent membership. If you do this within two months from the date of their birth or inclusion in your family unit (eg. through marriage, adoption or fostering) your child won't have to serve any additional waiting periods. The change will be backdated to the date of birth or the date of inclusion in your family unit. Also, this change of membership means you'll pay higher premiums.

    If you're on a couple or family membership:

    You can add a dependent child to your membership at any time and they won't need to serve any waiting periods already served on the membership. Your premium doesn't increase if you change from a couple to family membership, or add a dependent child to a family membership.

    As Young Hospital is only available as a single or couple membership, you can't add a dependent child to that cover.

  • What if I want more information on adding a dependent child?
  • Call us on 134 190.

  • What happens if my newborn baby needs hospital treatment?
  • When a newborn baby is in hospital with its mother, no accommodation charges apply for the baby unless the baby becomes an admitted patient in their own right. This happens when the baby requires admission to a neo-natal intensive care unit or it is the second or later child of a multiple birth.

  • If I have children, how long can they be insured on my cover?
  • As your children grow older they can still be covered at no additional cost on your family or single parent membership until they turn 21 or, if they are full-time students, until they turn 25, provided they're not married or in a de facto relationship. This is because we consider them to be your dependent children.

    If you have unmarried children aged 21 to 24 who aren't studying full-time and are not in a de facto relationship we also have a membership option called families with adult children. Although you'll pay a higher premium, it can prove to be a more economical option for your children than if they were to take out their own cover at the same level. Waiting periods may apply.

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About Lifetime Health Cover (LHC)

  • What is LHC?
  • This is a Federal Government initiative where a loading can be applied to your premium if you take out hospital cover later in life. It’s aimed at encouraging people to take out hospital cover early in life and maintain it.

  • When does the loading apply?
  • The loading generally applies if you don’t have hospital cover on the 1 July following your 31st birthday. This means for every year you don’t have hospital cover, you’ll pay a 2% loading on top of a base rate on your premium (or on your share of a couple or family premium) up to a maximum loading of 70%. The loading applies only to hospital cover or the hospital component of your cover – not to extras covers. Any loading that applies to your premium will be removed after you’ve held hospital cover continuously for 10 years. However, the loading may be reapplied if you then cease to hold a hospital cover and subsequently take it up again.

  • Does the LHC loading apply to everyone?
  • No, the LHC loading doesn't apply to people born on or before 1 July 1934. There are also special rules that apply to people who fall under a LHC exemption category. For more information please refer to the Department of Health and Ageing website – www.health.gov.au

  • What if I drop my hospital cover?
  • You can drop your hospital cover for a sum total of three years (1,094 permitted days) during your lifetime without any change to your LHC loading status. If you drop your hospital cover for longer than this, in most circumstances you’ll have to pay an LHC loading (or, if you were already paying the loading, it will be higher) once you take out hospital cover again. The following are additional permitted days without hospital cover that won’t count towards your 1,094 permitted days without hospital cover:

    • if you’ve been overseas continuously for more than one year (this includes visits back home of less than 90 days at a time)
    • if your health fund has agreed to a period of suspension.
  • What happens if I change health funds?
  • If you switch to us from another fund we recommend you keep your cover with your old fund until the date you transfer to us. This way you avoid using up any of the 1,094 permitted days you can be without hospital cover during your lifetime. Also, if you already have a LHC loading, it will move with you.

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About waiting periods

  • What is a waiting period?
  • All health funds have waiting periods. In short, a waiting period is a period of time you need to wait after taking out your cover before you can receive benefits for services or items covered.

    You’re not able to receive benefits for any items or services you might have obtained while you’re serving a waiting period or before you joined Medibank.

  • How do I know if a waiting period applies to me?
  • Waiting periods will apply if you're a new member, you're rejoining Medibank after not having health cover for some time or you're changing to a higher level of cover (either within Medibank or transferring from another registered Australian health fund). If you're changing to a higher level of cover, you'll still be entitled to benefits at the level of your former cover while you're serving any waiting periods on your new cover if:

    • those services were included under your old cover; and
    • you've already served the waiting periods that applied under your old cover.

    Waiting periods may apply to some of our betterhealth programs.

  • How long is the waiting period?
  • That depends on the types of services or items included on your cover. Have a look at the following table for a guide:

    2 months* All services (including ambulance services) - except those set out below
    6 months Optical items
    Ultra bonus
    12 months Pre-existing conditions. However, the 12 month pre-existing condition waiting period does not apply to hospital or hospital substitute treatment for psychiatric treatment, rehabilitation treatment or palliative care
    Obstetrics-related services
    Major dental services
    Orthodontic treatment
    Dental surgical procedures and surgical extractions (eg. wisdom teeth)
    Nebulisers
    Peak flow meters
    Spacing devices
    24 months Blood glucose monitors
    36 months Hearing aids
    Laser eye surgery
    * If you have an accident after joining us or changing cover and require treatment, we'll waive the 2 month waiting period.

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About pre-existing conditions

It's standard practice in the private health insurance industry to apply a waiting period of 12 months before benefits are payable for a pre-existing condition.

  • What's a pre-existing condition?
  • By pre-existing condition, we mean an ailment, illness or condition where signs or symptoms existed at any time during the six months before you either took out your new cover, or transferred to a higher level of cover.

    We'll appoint a medical or health practitioner to determine whether you have a pre-existing condition, based on information provided by the practitioner(s) treating you.

  • What if I have a pre-existing condition?
  • If you're a new member, you'll have to wait 12 months before you can receive benefits for items or services related to a pre-existing condition.

    If you're changing to a higher level of cover (either within Medibank or from another fund), you may have to wait 12 months to receive the higher benefits, including benefits for services not previously covered.

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About benefit replacement periods

  • What's a benefit replacement period?
  • It's a period of time you need to wait after purchasing an item covered by us before you can receive further benefits to replace the item. For example, if you received benefits for an insulin delivery pen, purchased on 1 July 2011, you can only receive benefits for another one purchased on or after 1 July 2013.

  • How long is a benefit replacement period?
  • This varies from item to item and generally applies per member unless specified in the following table.

    12 months External mammary prosthesis
    Repairs of external prosthesis and health appliances
    2 years Wigs
    Hip protectors
    Insulin delivery pens
    3 years Blood glucose monitors
    Breathing appliances
    • nebulisers
    • peak flow meters
    • spacing devices
    Mouthguards (Benefits for a replacement mouthguard are payable once every 12 months for members under the age of 18)
    Dentures, crowns and bridges
    Other health appliances and external prosthesis
    5 years Hearing aids
    Sleep Apnoea - continuous pressure devices and other similar approved appliances under our hospital cover (excluding Young Hospital)

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Other rules for paying benefits

  • Are there any other rules I need to know about?
  • Yes, here are some other important rules for you to be aware of:

    • We only pay benefits for items and services delivered by Medibank-recognised providers.
    • Restrictions may apply to the number of services you can claim in a particular period.
    • Some appliances may need to be ordered by a medical practitioner before benefits are payable eg. nebulisers.
    • To claim for a Sleep Apnoea device or similar device approved by Medibank, firstly, you'll need hospital cover (excluding Young Hospital). You'll also need to undergo an overnight investigation for Sleep Apnoea which is listed in the Medicare Benefits Schedule. Lastly, the device must be requested by a medical practitioner and purchased or hired within 12 months of undergoing the investigation.
    • Limitations apply to some benefits. For example, for an initial consultation for an extras service, we generally pay the higher benefit only once per person, per provider per calendar year (if any) only once in a course of treatment.
    • Limited hospital benefits apply to podiatric surgery (performed by an accredited podiatrist) and dental procedures that are performed in a non Members' Choice private hospital.
    • If you no longer need acute care and stay in hospital for more than 35 days, you'll be classified as a nursing home type patient. If this happens, we'll only pay a small portion of the daily hospital charges and you may need to pay the rest of the cost of your care. If you're in a private hospital, these costs may be substantial. Your doctor and hospital will be aware of this rule which applies to all health funds and they can advise you.
    • We don't pay benefits for services or treatments where you are, or may be, entitled to compensation and/or damages. For example State Government workers' compensation schemes, traffic accident schemes or public liability claims.
    • We don't generally pay benefits for hospital procedures not recognised for Medicare benefit purposes (such as cosmetic surgery).
    • To claim for Private room priority under Ultra Health Cover, you'll need to make sure you request a private room at least 24 hours before your stay as well as provide supporting documentation from the hospital about your request. Private Room Priority won't apply to:
      • same day admissions
      • admissions for sleep studies
      • nursing home type patients
      • where your doctor considers that you should be located in a shared room for clinical reasons
    • No Medibank benefit is payable under extras where there is an entitlement to a Medicare benefit (eg. allied health services).

    It's important you call us on 134 190 for information on recognised providers and the benefits you're entitled to before commencing treatment.

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About out-of-pocket expenses

  • What's an out-of-pocket expense?
  • It's any expense for a hospital or extras service or item for which you won't be reimbursed – by either us or Medicare.

  • What out-of-pocket expenses can I expect if I receive an extras service and how can I reduce them?
  • The out-of-pocket expense will be the difference between the provider's charge and the benefit we pay. To help reduce your out-of-pocket expenses, visit a Members' Choice extras provider where you can access capped and/or discounts and generally receive higher benefits than you would with a non Members' Choice provider.

  • What kind of out-of-pocket expenses can I expect if I go to a private hospital?
  • Although hospital cover helps reduce the cost of your private hospital visit, you'll still have out-of-pocket expenses for things like your excess and any difference between what the hospital charges and the benefit we pay for the hospital services.

    You can also expect to pay the difference between the charge for in-hospital medical services (eg. doctors' services, pathology and radiology) and what you receive from Medibank and Medicare. To explain it further, the benefits you're entitled to for the medical services you receive while you're in an overnight or day hospital facility are based on the Medicare Benefits Schedule (MBS) fee. The MBS is a list of all the services Medicare pays benefits for and the rules that apply to payment of those benefits.

    Medicare pays 75% of the MBS fee and Medibank pays 25% (if the treatment is covered under your policy).

    When a doctor charges more than the MBS fee, you'll have out-of-pocket expenses. These can vary and may be significant. This is what's referred to as a ‘gap'. Have a look at the diagram below – it shows you the amount Medicare takes care of and the amount we cover for in-hospital medical services. It also shows you the gap.

  • How can I reduce my hospital out-of-pockets?
  • Hospital charges

    If possible, go to a Members' Choice hospital where our agreement with the hospital limits what you can be charged.

    This means your out-of-pockets for hospital charges should be limited to things like:

    • Any excess you may have with your cover
    • Any pharmaceuticals not covered by our agreement with the hospital. This includes the cost of any drugs issued on discharge from hospital
    • Any gap for surgically implanted prostheses and other items on the Federal Government's Prostheses Schedule
    • Costs for services not covered, or not fully covered, by our agreement with the hospital or under your cover
    • Costs for treatment in an emergency department in a private hospital. Note, with Ultra Health Cover you can claim benefits on the facility fee charged (subject to annual limits).

    If you go to a non Members' Choice private hospital, you're likely to have significant out-of-pocket expenses.

    Doctors' charges

    Before you go to hospital, try to arrange to see a doctor who'll participate in our GapCover scheme. This is because GapCover can help reduce or eliminate your out-of-pocket expenses for doctors' services received in a private hospital. It's important to be aware that doctors can choose to participate in GapCover on a claim-by-claim basis and more than one doctor may be involved in your treatment

    GapCover doesn't apply to pathology and radiology services, any applicable excess payment, services not included under your cover or out-of-hospital consultations.

    Ultra Health Cover

    Ultra Health Cover includes additional features to help reduce or eliminate your out-of-pocket costs when you are admitted to hospital. For example, if your doctor agrees to participate in GapCover there will be no out-of-pockets for your doctor's charge. There is also an Ultra bonus which is automatically applied to reduce any eligible out-of-pockets costs for in-hospital medical treatment and hospital related costs. Call us to find out more on 134 190.

  • Rule of thumb before you go to hospital
  • Call us first on 134 190 so we can help you understand what's involved and the types of questions you need to ask your doctor or specialist.

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Other important information

  • What's the best way for me to give feedback?
  • If you have any feedback on our products and services, or you'd like further explanation on anything to do with your membership, please contact us:

    • call 134 190
    • email ask_us@medibank.com.au
    • visit any of our Medibank stores
    • write to us at Medibank Private GPO Box 9999 in your capital city.
  • What if I have a complaint?
  • We'll try to resolve any complaint you may have the first time you raise it with us – please contact us with any issues through the contact points listed above. If you believe your complaint has not been satisfactorily dealt with, let us know and we'll escalate your complaint. You can also write to our Customer Resolutions team at Medibank Private, GPO Box 9999, Melbourne, VIC 3000.

  • Private Health Insurance Ombudsman
  • Free, independent advice is also available from the Private Health Insurance Ombudsman.

    HOTLINE 1800 640 695 (free call anywhere in Australia; mobile charges may apply)

    Telephone (02) 8235 8777

    Facsimile (02) 8235 8778

    email: info@phio.org.au

    www.phio.org.au

  • Private Patients' Hospital Charter
  • Prepared by the Federal Government, this booklet is designed to advise you on what you can expect from your health fund, doctors and hospitals as a patient with hospital cover. A copy is available from any Medibank store.

  • Private Health Insurance Code of Conduct
  • We're proud to be a signatory to the Private Health Insurance Code of Conduct. The code was developed by the private 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
    • Our employees are competently trained to deal with your enquiries
    • We protect the privacy of your information in line with the privacy legislation
    • You have access to a reliable and free system of addressing complaints with us.

    A copy of the code is available online at privatehealth.com.au/codeofconduct

  • Disclaimer
    • Medibank Private encourages providers to offer high quality products and services at competitive prices to its members.
    • Where Medibank Private recognises a provider, advertises on behalf of a provider, or appears by reference or logo or otherwise in an advertisement of any provider, to the fullest extent allowed by the law, such advertising or reference should not be construed as:
      • an endorsement by Medibank Private;
      • an acknowledgment or representation by Medibank Private as to fitness for purpose; or
      • a recommendation or warranty by Medibank Private,
      of, for, or in relation to, the product and/or service of the provider. Accordingly, to the fullest extent allowed by law, Medibank Private neither takes nor assumes any responsibility for the product and/or service provided.
    • Members should make and rely on their own enquiries and seek any assurance or warranties directly from the provider of the service or product.
  • Note
  • Policies of insurance issued under, or on the terms of, any products described in this website are referable to the Medibank Private Limited (ABN 47 080 890 259) health benefits fund.

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Ambulance services

What is covered?

Benefits are payable for the full cost of medically necessary ambulance services if, due to the nature of your medical condition, you could not have been transported by any other means. Benefits are payable when the services are provided by an ambulance provider approved by Medibank Private, in the following circumstances:

  • When you need to be transported in an ambulance to a hospital or other approved facility in order to receive immediate professional attention.
  • When, as an admitted patient, you are transferred to another hospital (excluding transfers between public hospital facilities as an admitted patient).
  • When an ambulance is called to attend to you, but having received immediate professional attention, transport by ambulance is not subsequently required.
  • Air ambulance where pre-approval has been obtained from Medibank.

What is not covered?

Benefits are not payable:

  • Towards any ambulance costs that are fully covered by a third party arrangement such as an ambulance subscription scheme or a State/Territory ambulance transportation scheme (benefits may be payable, however, for any ambulance costs not fully covered by such schemes).
  • When you are transferred by ambulance between public hospital facilities whilst an admitted patient.
  • For ambulance transfers once you have been discharged from hospital.
  • When you are transferred to another hospital for treatment at the request of the admitting hospital because they do not have the medical facilities available to treat you (the admitting hospital may pay for this service).
  • When you’re aged 65 or over and live in WA, and are eligible for free or subsidised ambulance services. If eligible for subsidised services, you may be able to claim the remaining cost from Medibank.
  • When you live in NSW or the ACT and pay an ambulance levy as part of your hospital cover premium, and you’re entitled to cover under your state scheme. If you have a Commonwealth concession card you might be exempt from paying the ambulance levy.
  • When you live in Qld or Tas and are entitled to cover for ambulance transport under the State Government scheme. If you live in Qld or Tas and you have extras cover only, no benefits are payable.

For more information call us on 134 190.

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How do orthodontic benefits work?

Your orthodontic entitlement starts with an opening balance, which you can access once your 12 month waiting period is served. The balance is then topped up with an additional amount each 1 January (following the completion of your waiting period) up to a maximum lifetime limit.

The benefit you can claim (after waiting period) = Opening Balance + Any top ups -+ Any benefits ever claimed
  • Orthodontic entitlements available on each relevant product:
  • Cover Opening balance Additional annual top ups Top ups Lifetime limit
    Top Extras 55 $400 $200 $1,200
    Top Extras 70 $800 $400 $2,400
    Top Extras 85 $1,000 $500 $3,000
    Ultra Health Cover $1,500 $500 $3,500
  • Example of orthodontic entitlements on Top Extras 85:
  • Dates What you get towards orthodontics each year Your available balance if no claim has been made
    Date joined –
    30 Jun 2011
    $1,000
    (opening balance)
    x
    Waiting Period ends –
    30 Jun 2012
    x $1,000
    1 Jan 2013 $500
    (top up)
    $1,500
    1 Jan 2014 $500
    (top up)
    $2,000
    1 Jan 2015 $500
    (top up)
    $2,500
    1 Jan 2016 $500
    (top up)
    $3,000
    (lifetime limit)

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