GAP PAYMENTS FOR EXTRAS SERVICES
payments can also occur if the fee charged by your service provider
such as dentist, physiotherapist or optician, is greater than the
benefit paid by your fund for that service. The level of benefit health
funds pay for extras services is at the discretion of health funds and
is not regulated by the Government.
health funds impose annual limits on the benefits payable for some
ancillary services. Some health funds also have agreements with extras
service providers to reduce or eliminate out of pocket expenses.
agreements with hospitals, doctors and extras service providers may
change over time. CDH Health Benefits members can check their benefits
or limits associated with their level of cover by referring to the
THINGS TO CHECK BEFORE
agreeing to either in-hospital treatment or receiving treatment for
ancillary services you should:
. Check to
confirm the level
of benefits payable and whether any waiting periods apply – in
particular whether or not the pre-existing ailment waiting period will
apply. You should also check whether there is an agreement between the your health fund and the hospital.
. Speak to
your doctor or ancillary service provider to find out if they have
arrangements with your health fund that minimise the out-of-pocket
expenses you have to pay. This will help to ensure that you don’t
receive any unexpected bills after your treatment. You should also
check this detail with your health fund. In cases such as an emergency
admission, it may not be possible to discuss fees prior to treatment.
Where this occurs the hospital, health fund
and doctors should provide you with this information as soon as
possible after treatment.
TRANSFERRING BETWEEN FUNDS
cover, you can transfer between funds at the same or a lower level of
cover, without serving additional waiting periods. This is sometimes
between health funds. The fund you transfer to must give
you credit for any waiting periods already served. You may have to
serve additional waiting periods if you upgrade
your level of cover even if it is with your current fund.
also be aware that the fund to which you transfer may not provide
exactly the same hospital benefit entitlements as the one from which
you have transferred. Check the details with the funds involved before
funds are not required by law to recognise waiting periods served for
ancillary services, but many funds do including CDH Health Benefits
Fund. Any claims made with your previous fund for ancillary services
may be taken into account by your new fund. Check the details with the
funds involved before
transferring. For more information on what you can expect if you do
change health funds, collect the brochure titled “The Right to Change”
produced by the Private Health Insurance Ombudsman, and available from
either your health fund or the Ombudsman’s office. Contact the
Ombudsman’s Office on free call 1800 640 695 or (02) 9261 5855 or email
FEATURES OF HOSPITAL COVER
THAT MAY REDUCE YOUR INSURANCE PREMIUM
reduce the cost of health insurance by choosing a product that has some
or all of the following features:
- An Excess;
Co-payment; (CDH do not have Co-payments)
exclusions for certain treatments;
these features is explained below. It should be noted that, in general,
choosing a product where the premium has been reduced through an
excess, co-payment, etc, would lead to a lowering of benefit levels or
an increase in what you pay for treatment. CDH Health Benefits does not
charge co-payments or an excess so the levels of benefits you receive
will be the highest we offer. Make sure you read and understand what is
covered and what is not. If you are unsure of any of the terms or exact
treatments that are excluded or pay limited benefits, ask your fund.
is an amount of money you pay towards the cost of hospital treatment,
regardless of the number of days of hospitalisation. For example, Mary
and Tom and their children, Mark and Samantha have a family membership
with an excess of $500. This means that they are charged a lower
premium for their hospital insurance because they have agreed to pay
the first $500 of hospital charges if they require hospital care.
policies, this excess is only charged once a year, regardless of the
number of hospital admissions required throughout the year by the
people covered by the product. Under other excess policies, the excess
may apply on each
hospital admission in the year. When choosing a health insurance
product make sure you understand how these excess payments apply.
Co-payments No Excess
are transferring to CDH Health Benefits from a cover at another Fund
which had an excess/co-payment, and it is deemed to be a pre-existing
condition, that excess or co-payment will apply for that
hospitalisation for the indicated waiting periods. If it is not deemed
a pre-existing then an excess or co-payment may not be payable.
lower cost health insurance products specify that certain hospital
treatments are not covered and no benefits are payable. These are
called exclusion products. If you choose an exclusion product, you need to be careful that
you do not exclude treatments that you may need in the future.
The need for some treatments that are excluded, e.g., for coronary
disease, is not always easy to predict.
health insurance products allow you to choose to be covered for only a
minimum level of benefits for certain treatments in return for a lower
premium. Some restricted benefits products sometimes referred to as
‘basic benefits’, only entitle you to basic benefits for accommodation
but do not cover any theatre fees, intensive care unit, coronary care
unit, labour ward or same day theatre fees.
restricted benefits products, pay minimum accommodation benefits and
also pay some
but not all, of the costs for theatre fees, intensive
care unit, coronary care unit, labour ward or same day theatre fees. You should check with your
health fund to ensure that you fully understand your benefit
entitlements if you choose a restricted benefits product.
You should also be aware that there is generally a significant price
difference for hospital accommodation in a public hospital compared
with a private hospital.
limitation period means you face restricted benefits, as described
above, for a particular condition or treatment for a set period of
time. For example, you may decide to take out a product that restricts
benefits for knee replacement surgery for the first 2 years. You would
have to wait for 2 years after joining that fund before you would be
entitled to that fund’s full benefits for knee replacement surgery.
if a waiting period also applies under that product, the fund may
commence the benefit limitation period from the end of this initial
waiting period. For example if the waiting period is 12 months because
the condition is pre-existing, and you elect a 2 year benefit
limitation period for this treatment, you would not be entitled to
receive full benefits for 3 years from the time you purchase that
cover. Again check these details with your fund.
FEDERAL GOVERNMENT REBATE
Federal Government rebate makes private health insurance more
affordable for eligible Members by reducing your private health cover
premiums. The scheme commenced 1 January 1999 and was revised 1 April
2005 and introduced the Seniors Rebate scheme now giving three levels
Government rebate off your premium for members aged 64 or under
additional percentage rebate off your premium for members aged 65 - 69
- and a further
additional percentage above 65 - 69 rebate off your premium for members
aged 70 or over.
membership is entitled to the Federal Government rebate as soon as one
person covered by the membership turns 65 and then again when they turn
three ways to claim the Federal Government rebate
- As a
premium discount thus reducing your upfront cost by completing the
‘Application to receive Federal Government Rebate Form’;
- Claim the
rebate from a Medicare Office using the receipts we will provide.
- Claim the
rebate in your tax return using the statement we will provide.
PAYMENTS FOR HOSPITAL COVER
payment is the difference between the fee charged by the hospital or
doctor who treats you in hospital and the benefit paid by your health
payments for hospital treatment can occur for the following 3 reasons:
payments will arise if you have chosen a hospital product with an
excess, a co-payment, or an exclusion or
restricted benefits for certain procedures.
payments – hospital accommodation
hospitals have an agreement with individual health funds to charge an
agreed amount for treatment so that you will have either no
out-of-pocket expenses for hospital or medical related services or you
will know before-hand what costs you will bear.
payments for hospital accommodation can also arise if you choose to be
treated in a hospital that does not have an agreement with your health
possible, you should always contact your fund before hospitalisation to
confirm the level of benefits that will be paid.
payments – doctor’s fees for in-hospital services
payments may also arise for medical services received in hospital. When
you receive medical treatment in hospital as a private patient,
Medicare pays 75 per cent of the Commonwealth Medicare Benefits
Schedule (MBS) fee for the doctor’s service and your health fund pays
the remaining 25 per cent of the MBS fee. If your doctor charges above
the MBS fee, you may have to pay the difference between the MBS
schedule fee and the doctor’s fee.
health fund may be able to cover the gap, in full or in part, that is
above the MBS if:
- there is
an agreement between your fund, hospital and/or doctor; or
- the fund has
a gap cover scheme.
there is an agreement or scheme you will have either no out-of-pocket
expenses or you are entitled to be given an estimate of the costs you
will have to pay in advance. You should ask your doctor
for an estimate of any costs you will have to pay, even when there is
no scheme or agreement.
now offer gap benefits as part of most hospital insurance products. In
most cases these benefits have been added to existing hospital products
– so you may already be covered for all or part of the medical fee gap.
CDH Health benefits has gap
cover on all its hospital component products. This is aimed at
eliminating any out of pocket expenses to our members. However, this is
not always the case and it is important that members
obtain a quote from their practitioners, including other practitioners
involved such as anaesthetists or assisting surgeons to
determine prior to any procedure if there will be an out of pocket
LIFETIME HEALTH COVER (LHC)
Lifetime Health Cover, health funds are required to charge people who
were not members of a hospital table prior to 1 July 2000, 2% extra on
top of normal premiums for every year they are aged over 30 when they
first take out hospital
that a person who does not take out health insurance until they are 35
will pay 10% more for their health insurance than they would have had
they joined before they turned 31. This
will always apply for 10 continuous years when the LHC will
to no penalty. Contact us for more details.
born before 1 July 1934 are exempt from Lifetime Health Cover and can
take out hospital cover at any time and not pay a premium loading.
hospital policies, except overseas visitor’s cover, offered by
registered health funds meet the Lifetime Health Cover requirements.
More information on Lifetime Health Cover is available from the
Department of Health and Aged Care website at http:/www.health.gov.au.
MEDICARE LEVY SURCHARGE
high-income earners do not take out private health insurance, they are
charged an additional 1% on top of the Medicare Levy. If you are a
high-income earner and seek to avoid the additional 1% Surcharge you
need to make sure you have purchased hospital cover with an excess less
than or equal to $500 per annum for single contributors or $1,000 per
annum for couples and families.
information on the Medicare Levy Surcharge is available from the
Department of Health and Aged Care website at http://www.health.gov.au
or the Australian Taxation Office at www.ato.gov.au or ATO special
HEALTH INSURANCE – SUMMARY
OF THE KEY FACTORS TO CONSIDER
of cover you choose determines the BENEFITS you receive. The higher the
cover, the higher the COST of the premium within each fund. WAITING
PERIODS will have to be served BEFORE you are entitled to benefits.
can be INCREASED by having treatment with a service provider, doctor or
hospital that has an AGREEMENT with your fund. BENEFITS can be LIMITED
by choosing a product which has:
BENEFITS FOR CERTAIN TREATMENTS;
COVER FOR CERTAIN CONDITIONS;
LIMITATION PERIODS; and
LIMITS ON THE TOTAL BENEFITS PAYABLE FOR SOME
have a problem with your private health insurance you should:
the fund directly.
- If you are
unable to reach a satisfactory agreement with your fund after written
communication, contact the office of the Private Health Insurance
Ombudsman. The Ombudsman is independent of the health funds and the
Government and is able to provide free information and assistance to
resolve complaints. The Ombudsman’s office can be reached on the free
call number 1800 640 695 or directly on (02) 8235 8777. Alternatively
you can write to the Ombudsman at Suite 2, Level 22, 580 George Street, Sydney NSW 2000 or fax (02)
2835 8778 or email firstname.lastname@example.org.
Website: www.phio.org.au and www.privatehealth.gov.au
detailed information is available from CDH Health Benefits Fund
– Just call us on (02) 4990 1385 to talk to one of our helpful staff.
We can also post a more detailed brochure out to you with full details
of all of our products including premiums. Or visit our website at