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Understanding private health insurance can be complicated.
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 commonly used terms you might not be familiar with.
It is important you read the Member Guide you'll receive after you join.. This contains a summary of the rules of your membership with us (known as our Fund Rules) – things like your responsibilities as a member. It's also important to read the Cover Summary you'll receive, which further details your cover and entitlements.
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 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.
How long is the waiting period?
It's important to note that not all services listed below are included on all covers. That depends on the types of services or items included on your cover. Refer to the relevant Cover Summary to see the waiting periods that apply for a specific cover.
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 your cover commencing, and no claims have been made against your cover there's no problem. We can either transfer you to a more suitable cover or refund your premium in full. If you close your membership after the cooling-off period we will refund any unused premium less an administration fee.
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 are granted permanent residency, 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.
What's 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 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
- Family membership, which covers you (the policy holder) and your partner and
- any of your child dependants and/or
- any of your student dependants
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 Australian private health insurer, am I covered immediately?
You'll be covered for services on your new cover from the date you join if: those services were also included on your cover with your former health insurer, you join us within two months of leaving your former health insurer and 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 with your former health insurer, you'll need to serve the balance before you're eligible for benefits. Additional waiting periods may 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. Find out more about waiting periods.
Any loyalty bonus or other similar entitlements built up with your former fund (eg. 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 waiting periods may apply to your partner. To add your partner to your membership, contact us
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 membership. If you do this within two months of the date of their birth or date of inclusion in your family unit (for example, 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 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. Depending on the cover you hold, you may have to pay additional premiums.
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 your baby is admitted to hospital, please call us on 134 190.
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 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.
Am I eligible for Overseas Workers Health Cover?
Medibank's Overseas Workers Health Covers are only available to people who are in Australia on certain visas approved by Medibank. We may require proof of eligibility such as a copy of your visa.
Medibank can transfer anyone who is not eligible for our Overseas Workers Health Covers to an alternative cover. We can backdate this change and require you to pay any additional premiums and/or repay any higher benefits you received on your Overseas Workers Health Covers. So it's important that you let us know if your visa status changes.
Am I eligible for Overseas Student Health Cover?
Medibank's Overseas Student Health Covers (OSHC) are only available to people who are in Australia as an overseas student and either hold, or are applying for, a student visa. We may require proof of eligibility such as a copy of your visa.
Medibank can transfer anyone who is not eligible for our Overseas Student Health Covers to an alternative cover. We can backdate this change and require you to pay any additional premiums and/or repay any higher benefits you received on your Overseas Student Health Covers. So it's important that you let us know if your visa status changes.
Is Overseas Visitors Health Cover right for you?
Medibank's Overseas Visitors Health Covers are designed for visitors, temporary residents and other residents in Australia who are not eligible for full Medicare entitlements, are not eligible for Medibank's Overseas Workers Health Cover or Overseas Student Health Cover, and do not hold a visa subject to condition 8501, but want health cover during their stay in Australia for maximum peace of mind.
Reciprocal Health Care Agreements (RHCA)
Australia has Reciprocal Health Care Agreements with the United Kingdom, New Zealand, Italy, Belgium, Malta, the Netherlands, Sweden, Finland, Norway, Slovenia and the Republic of Ireland. If you're a resident of a country which has a Reciprocal Health Care Agreement with Australia, you may be entitled to restricted access to Medicare, but only for medically necessary treatment. Post-arrival time limits and other restrictions may apply. So be sure to check what you're covered for before relying on a Reciprocal Health Care Agreement. For further information, please contact Medicare on 132 011.
What if I'm an international student?
If you're an overseas student in Australia with a valid student visa, our Overseas Visitors Health Covers and Overseas Workers Health Covers will not meet your student visa requirements. We recommend you purchase a Medibank Overseas Student Health Cover (OSHC) which is specifically designed with the needs and budgets of students in mind, and come with a health insurance certificate which can be used as part of your visa application.
What if I'm on a working or graduate visa?
If you're in Australia on a working visa, our Overseas Visitors Health Covers and Overseas Students Heath Covers may not meet any visa requirements you might have. We recommend you consider purchasing one of our Overseas Workers Health Cover which meet the Australian government's health insurance requirements for working and graduate visas, and come with a health insurance certificate which can be used as part of your visa application. You can purchase Overseas Workers Health Cover online.
What happens if I become a permanent resident?
If you are granted permanent residency our Overseas Health Covers may not be the most suitable cover for your needs. When your residency status changes remember to call us on 134 190 to discuss your options.
- Medibank encourages providers to offer high quality products and services at competitive prices to its members.
- However, where Medibank recognises a provider, advertises on behalf of a provider, or appears by reference of 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:
a. an endorsement by Medibank;
b. an acknowledgement or representation by Medibank as to fitness for purose; or
c. a recommendation or warranty by Medibank of, for, or in relation to, the product and/or service of the provider. Accordingly, Medibank neither takes nor assumes any responsibility for the product and/or service provided.
- Members should rely on their own enquiries and seek any assurance or warranties direct from the provider of the service or product.
- Medibank can change the health care providers who participate in our Members’ Choice network or the providers whose services we pay benefits for.
- Members’ Choice providers may not be available in all areas. Benefits and other arrangements with these providers may vary depending on their location.
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.
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. 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, GPO Box 9999, Melbourne, VIC 3000.
If you're unhappy with the result, you can contact the Private Health Insurance Ombudsman (PHIO) Hotline on 1800 640 695 for free independent advice (free call anywhere in Australia; mobile charges may apply).
How we manage your information?
Our Visitors Health Insurance and Working Visa Health Insurance are subject to a Goods and Services Tax (GST), which is included in the premium you pay. Under Medibank's Fund Rules, if you're on any of our Visitors Health Insurance or Working Visa Health Insurance covers it is assumed you have no entitlement to claim any part of the GST as an input tax credit. If you're eligible and intend to claim back part or all of the GST you must notify us in writing.
If you're an Australian resident for taxation purposes you may be required to pay the Medicare Levy and the Medicare Levy Surcharge (MLS).
Neither Visitors Health Insurance or our Working Visa Health Insurance covers will exempt you from the Medicare Levy Surcharge.
For more information on the MLS, please contact the Australian Taxation Office on 132 861, or visit ato.gov.au.
If I cancel my membership, will I get a refund?
If you need to cancel your membership you may apply to claim a refund of premiums paid in advance and we may apply an administration fee.
Are pre-paid premiums protected from rate increases?
Where premiums have been paid in advance of the rate increase, the new rates will apply from your next payment. However, if you change the level of your cover or membership category, the new rates will apply from the date of the change.
What is covered?
Where you need an ambulance and your medical condition is such that you can’t be transported any other way, you’ll be covered for services provided by a Medibank approved ambulance provider:
- ambulance transportation to a hospital or other approved facility is required to receive immediate professional attention
- when an ambulance is called to provide immediate professional attention but transport by ambulance is not needed
- when, as an admitted patient, the hospital requires you to be transferred from one hospital to another (excluding transfers between public hospitals)
- for transport by air ambulance, where pre-approval has been obtained from Medibank by the air ambulance provider.
What is not covered?
Medibank does not pay benefits for any ambulance service that has not been defined under ‘What is covered?’. This includes:
- ambulance services where immediate professional attention is not required (e.g. general patient transportation)
- any ambulance transport required after discharge from hospital (e.g. transport from hospital to home)
- inter-hospital transfers when, as an admitted patient, you’re transferred from one public hospital to another public hospital
- any ambulance costs that are fully covered by a third party arrangement, such as an ambulance subscription or federal/state/territory ambulance transportation scheme, WorkCover or the Transport Accident Commission.
For more information call us on 134 190.
What's an out-of-pocket expense?
It's any expense for a hospital, medical or extras service or item for which you won't be reimbursed by us.
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 charges and/or discounts and generally receive higher benefits than you would with a non Members' Choice provider.
What kinds of out-of-pocket expenses can I expect if I go to a hospital?
Although hospital cover helps reduce the cost of your 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 us. To explain it further, the benefits you're entitled to for the medical services you receive while you're in an overnight hospital 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.
If you visit a doctor and they charge you more than the MBS fee, you may have out-of-pocket expenses. These can vary and may be significant, especially for doctors' visits when you're in hospital.
You should confirm all likely out-of-pocket expenses with your doctor and/or hospital admission.
How can I reduce my private hospital out-of-pockets?
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 difference between your doctors' charges (including pathology and radiology fees) and the benefits we pay you
- Any difference between the amounts you are charged for pharmaceuticals (including drugs issued on discharge from hospital) that are not covered by our agreement with the hospital and the benefits available to you under the extras component of your cover for pharmaceutical prescriptions (if your cover includes extras except for Young Visitors)
- Any Out-Of-Pocket Expenses 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.
If you go to a non Members' Choice private hospital, you're likely to have significant out-of-pocket expenses.
Going 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.
Yes, there 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 CPAP-type device firstly, you'll need Top 85 Working Visa Health Insurance. 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 (if any) per person, per provider, per calendar year (if any) only once in a course of treatment
- Limited hospital benefits apply to hospital charges for podiatric surgery (performed by an accredited podiatrist) and dental procedures that are performed in a private non Members' Choice hospital
- The benefits we pay toward hospital treatment for included services will be no less than the minimum benefit as set by the Federal Government.
- The benefits we pay towards surgically implanted prostheses, and other items included on the Federal Government Prostheses Schedule, will be no more than the minimum benefits as set by the Federal Government.
- If you no longer need acute care and stay in hospital for more than 35 days, then after 35 days you'll be classified as a nursing home type patient. If this happens, we'll only pay a small portion of the 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 requirement 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 generally don't pay benefits for hospital procedures not recognised for Medicare benefit purposes such as cosmetic treatment. However where eligible, we do pay benefits towards hospital charges for dental surgery or podiatric surgery (performed by an accredited podiatrist)
- Benefits are not payable for treatment not considered medically necessary (eg. health screening services as required for employment or visa renewal purposes)
- Benefits are not payable for treatment arranged prior to arrival in Australia
- Benefits are not payable for services provided outside Australia.
It's important you call us on 134 190 for information on recognised providers and the benefits you're entitled to before commencing treatment.
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.
Extras benefits and limits are only relevant to Top 85 Working Visa Health Insurance.
Your orthodontic entitlement starts with an opening balance, which you can access once your 12 months waiting period is served. Your balance is then topped up with an additional amount for each 1 January following the completion of your waiting period up to a maximum lifetime limit.
Opening balance + Any top ups – Any benefits ever claimed = The benefit you can claim (after waiting periods)
Orthodontic entitlements available on Top 85 Working Visa Health Insurance:
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 6 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, in their opinion, 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 provided in-hospital 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.
Visitors Health Insurance
Visitors to Australia are generally ineligible for benefits under the Pharmaceutical Benefits Scheme (PBS), so you may have significant out-of-pocket expenses.
Benefits are not payable for oral contraceptives or for pharmaceuticals prescribed for cosmetic purposes.
Working Visa Health Insurance
International visitors to Australia are generally not eligible for subsidised pharmaceuticals under the Pharmaceutical Benefits Scheme (PBS).
With our Working Visa Health Insurance, Medibank will pay some benefits towards PBS listed drugs, prescribed according to PBS-approved indications, that are administered during and form part of your admitted episode of care (including drugs prescribed upon discharge). Your benefit is equal to the PBS government subsidy in excess of your patient contribution.
Pharmaceuticals used in oncology (cancer) and other treatments can be very expensive for people who do not have access to subsidised pharmaceuticals under the PBS. If high cost pharmaceuticals are required for your treatment when in hospital, you may incur significant out-of-pocket expenses.
No benefits are payable for oral contraceptives, or for pharmaceuticals prescribed for cosmetic purposes.
For more information on the PBS, visit health.gov.au.
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