Other rules for paying benefits
Are there any other rules I need to know about?
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.