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 from the original commencement date or refund your premium in full.

During the cooling off period, you cannot generally return to a cover that Medibank has closed.

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 1300 560 309 or drop into one of our stores. Alternatively you can log into MyMedibank and compare covers.

Some of the terms we use when we're talking about membership are: member, membership, and policy holder. As a starting point, it's good to be clear on all three.

A member is simply any person included on a Medibank membership.

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

• just one person, (single membership)
• a couple membership which includes you (the policy holder) and your partner
• single parent family* membership, which includes you and
  • any of your child dependants and/or
  • any student dependants
• family membership*, which includes 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

*Not all membership categories are available on all our products.

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

Although you as the policy holder ‘are responsible' for the membership, your partner (if he or she is also included on the same membership) can (unless you otherwise advise) manage most aspects of the membership too, including (but not limited to): making claims, adding or removing dependants, changing cover and suspending the membership.

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 1300 531 726.

In some cases yes, in other cases no. We’ll pay towards services included on your new cover from the date you join if: (i) those services were also included on your cover with your former fund, and (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 for any increased benefits, where you have chosen a lower excess, or if you wait more than two months after leaving your former fund before you join Medibank.

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.

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.

If you're on a single membership:

To add a dependant child to your membership you'll need to change from a single to a family or single parent family membership. If you do this within two months from the date of their birth or inclusion in your family unit (e.g. through marriage, adoption or fostering) your child won't have to serve any waiting periods the policy holder has already served. The change must be backdated to the date of birth or the date of inclusion in your family unit and will affect the premiums you’ll need to pay. Where a child is added outside two months, they’ll have to serve all waiting periods applicable to the cover.

If you're on a couple or family membership:

You can add a dependant child to your membership within 12 months of their birth or inclusion into the family unit and they generally won't need to serve any waiting periods the policy holder already served on the membership. This change can be backdated or commence from the date of application or any future date you choose. Where a child is added outside of 12 months, they will be subject to the regular waiting periods.

Adding a dependant child may affect the premiums you’ll need to pay.

Call us on 1300 531 726.

Generally, a healthy newborn isn’t separately admitted to hospital as an inpatient (this is because the baby comes under the mother’s admission). Because the baby isn’t an inpatient, it’s important to be aware that any treatment, tests or doctor’s visits (e.g. a pre-release check-up by a paediatrician) are outpatient services, for which Medibank doesn’t pay any benefits (except under some Visitors Covers). This means you’ll only be eligible to claim a Medicare rebate for those services and may have out-of-pocket expenses. 

In some cases, a newborn may need to be admitted to hospital in their own right (for example, where they require treatment in a special care nursery or an intensive care unit). This type of admission can be very expensive. 

To ensure your newborn will be entitled to receive benefits in the event they need these services, we strongly advise you to add them to your membership from their date of birth. If a newborn isn’t added within Medibank’s required timeframes, you’ll be responsible for any costs associated with their admission. 

You should also be aware that if you’re expecting a multiple birth (e.g. twins) your second or subsequent babies will always be separately admitted to hospital as inpatients. This means that an accommodation charge will be raised by the hospital, so it’s important to make sure they’re added to your membership.

As your children grow older, they can still be included on your membership 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 dependant 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 on certain covers called families with adult children. Although you'll pay an additional premium for this, 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.

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 will have continuous cover which if you hold hospital cover, means you can avoid paying the Medicare Levy Surcharge and also avoid using up any of the 1,094 permitted days you can be without hospital cover during your lifetime. Also, if you already have an LHC loading, it will move with you.

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.

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.

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.

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.

The Mental Health Waiver allows members who have served their two month waiting period for Restricted (Limited) in-hospital psychiatric treatment to upgrade to a cover with Included in-hospital psychiatric treatment and elect to have the two month waiting period for those higher benefits waived

Members can elect to use their waiver at the point of upgrading or after upgrading, prior to serving the two month waiting period for Included psychiatric treatment. Members need to have held Hospital cover without a break of more than two months to be eligible to use the waiver.

The waiver only applies to the two month waiting period for the higher Included benefits for in-hospital psychiatric treatment. All other applicable waiting periods will continue to apply.

Members will only be able to use the Mental Health Waiver once in their lifetime.

That depends on the types of services or items included on your cover.

* If you have an accident after joining us or changing cover and require treatment, we'll waive the 2 month waiting period.

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.

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.

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.

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.

This varies from item to item and generally applies per member unless specified in the following table.

It's a period of time you need to wait after purchasing an item included under your cover 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 2021, you can only receive benefits for another one purchased on or after 1 July 2023.

Yes, here are some of the other important rules for you to be aware of – refer to the Fund Rules for a complete list of benefit exclusions.

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 e.g. nebulisers.

To claim for a CPAP machine or similar device approved by Medibank, firstly, you'll need to hold an appropriate level of hospital cover (refer to your cover summary) for at least 12 months. You'll also need to undergo an overnight investigation for sleep apnoea (sleep study) which is listed in the Medicare Benefits Schedule. Lastly, the device must be purchased or hired within the 12 months following 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) for each course of treatment.

Limited hospital benefits apply to podiatric surgery (performed by a registered podiatrist) and dental procedures and you can incur significant out of pocket expenses. 

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 for non-medical purposes).

To claim for private room priority under selected hospital covers, 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 (e.g. allied health services).

It's important you call us on 1300 531 726 for information on recognised providers and the benefits you're entitled to before commencing treatment. 

Call us first on 1300 531 726 so we can help you understand what's involved and the types of questions you need to ask your doctor or specialist.

Hospital charges

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

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

Any excess you have chosen to have on your cover

Any pharmaceuticals not included in 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 included, or not fully included, by our agreement with the hospital or under your cover

Costs for treatment in an emergency department in a private hospital. Note, some covers include benefits on the facility fee charged (subject to annual limits) – check your cover summary to see if this is included on your cover..

If you go to a non Members' Choice private hospital, we pay the minimum hospital benefit set by the government and 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.

Gold Ultra Health Cover

Gold 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 1300 531 726.

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 (e.g. 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 included 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'. 

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 prices and/or discounts and generally receive higher benefits than you would with a non Members' Choice provider.

It's any expense for a hospital or extras service or item for which you won't be reimbursed – by either us or Medicare. You are responsible for paying the out of pocket expense.

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.

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.

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

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. To download a factsheet about the charter, please visit health.gov.au

For general information about private health insurance, see www.privatehealth.gov.au or call the Commonwealth Ombudsman’s on 1300 737 299. For health insurance complaints, you can contact the Ombudsman on 1300 362 072.

We'll try to resolve any complaint you may have the first time you raise it with us – for details on how to contact us with your issue, please click on the link below.

medibank.com.au/contact-us/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 1300 531 726
• visit any of our Medibank stores
• write to us at Medibank Private GPO Box 9999 in your capital city.

Benefits are not payable:

For any ambulance services where immediate professional attention isn’t required (such as general patient transportation).

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 1300 531 726.

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.