Cover Summary PremierPlus

Transcription

1 Cover Summary PremierPlus This provides an important summary of your cover and we recommend that you read and retain it. You can find out more about your membership by referring to the Member Guide, which is a summary of our Fund Rules and terms and conditions, or by calling us on Hospital cover Hospital cover provides benefits when you are treated as a private patient admitted to hospital. This means any related services that are provided when you re not admitted (eg. GP or specialist visits) are not included under this cover. Here are the services that are Included under your hospital cover. Before booking treatment, you should call us to ask about the benefits you can expect to receive and any out-of-pocket expenses you might incur. Services and Treatments Ambulance services + Appendicitis treatment Removal of appendix Removal of tonsils and adenoids Knee reconstruction surgery and investigations Shoulder reconstruction surgery and investigations Surgical removal of wisdom teeth (hospital charges only) Palliative care Rehabilitation treatment Psychiatric treatment Colonoscopies Heart-related admissions Plastic and reconstructive surgery Hip and knee joint replacement surgery All other joint replacement surgery Major eye surgery (including cataract and other lens-related services) Renal dialysis Surgery for slipped disc and scoliosis Spinal fusion surgery Cancer treatment* Weight loss surgery All other MBS items (includes thousands of additional in-hospital services) Obstetrics-related services (eg. pregnancy) Fertility treatment (including IVF and GIFT programs) Included What does it mean? Included service: We pay benefits towards overnight and same day hospital accommodation, intensive care and medical services where a Medicare benefit is payable. It s important to know that if you are treated in a non-members Choice hospital, the benefits we pay are generally lower than for a Members Choice hospital and you may incur significant out-of-pocket expenses. Members Choice providers are not available in all areas. Where you are treated as a private patient in a public hospital, we ll pay benefits towards overnight and same day accommodation in a shared room. Please be aware that cosmetic treatment is Excluded on all Medibank covers. Private Room Guarantee a special feature on this cover If there isn t a private room available at a Members Choice hospital, you may be entitled to receive $50 a night, up to a maximum of five nights per stay. The following conditions apply to the Private Room Guarantee: You must request a private room at least 24 hours prior to admission & provide supporting documentation from the hospital; Does not apply for same day admissions or admissions for sleep studies or where your doctor considers that you should be located in a shared room for clinical reasons; You must be eligible to receive benefits for the treatment you received during your stay. + Waiting periods apply. For ambulance attendance or transportation to a hospital where immediate professional attention is required and your medical condition is such that you couldn't be transported any other way. Tasmania and Queensland have state schemes to cover ambulance services for residents of those states. *Your hospital cover does not include non-pbs drugs. Cover Summary PremierPlus 1

2 Waiting periods A waiting period is a period of time you need to wait after taking out your cover before you re entitled to 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 are serving a waiting period or before you joined Medibank. Accident Waiting Period Waiver The 2 month hospital treatment waiting period is waived for injuries sustained in an Accident after joining this cover. Waiting Periods 1 Psychiatric treatment, rehabilitation treatment, palliative care and ambulance services. Hospital treatment for conditions requiring hospitalisation that are not deemed pre-existing conditions. Pre-existing conditions A pre-existing condition is an ailment, illness or condition that in the opinion of a Medical Practitioner appointed by Medibank, the signs or symptoms of which existed at any time in the period of six months before you either took out your new cover, or transferred to a higher level of cover. Obstetrics-related services. CPAP-type devices. Other features and benefits Excess No excess is payable on this cover GapCover available for eligible medical services Medibank s GapCover is a way to eliminate or reduce your out-of-pocket expenses for in-hospital doctor s charges. Check with your doctor if they will participate in Medibank s GapCover. Find out more at medibank.com.au Choice of treating doctor or specialist You can choose your doctor or specialist when you re treated in hospital as a private patient Surgically implanted prostheses For an Included service, we ll pay the minimum benefit as listed in the Government s Prostheses List CPAP-type devices Up to $500 benefit per member every 5 years towards the hire or purchase of an approved device Cover Summary PremierPlus 2

3 Extras cover This table shows the services you can claim benefits for along with the annual limits, sub-limits and waiting periods that apply to your extras cover. An annual limit is the maximum amount of benefits payable for particular groups of extras services or items within a calendar year (ie. 1 January 31 December). Where the annual limit increases, it will increase on 1 January, up to the maximum limit. The first increase will be applied only after you have serviced one full calendar year of membership.' A sub-limit is a maximum amount you can receive on an annual basis (or within other defined periods of time) for a particular item or service within an overall annual limit. Service Waiting period Annual limits & sub-limits General dental eg. dental examinations, scale & clean Every member gets 100% back on two yearly check-ups at a Members' Choice dentist (excludes x-rays). And this doesn't count towards annual limits (1 for surgical procedures & extractions) No annual limit $300 sub-limit during the first 6 months of membership Endodontic services eg. root canal treatment 1 increasing to $800 Optical items eg. frames, prescription lenses & contact lenses 6 months $250 A sub-limit of $115 for frames & $200 for contact lenses Physiotherapy eg. consultations (includes group pilates & hydrotherapy sessions) Pharmaceutical prescriptions Includes most prescription-only items not subsidised by the government. Benefits will be paid after a set charge has been deducted. It's important to note that we don't pay benefits for oral contraceptives or for pharmaceuticals prescribed for cosmetic purposes. Major dental $700 $600 $2,000 Inlay/onlay restorative, eg. restorative fillings $300 increasing to $700 1 Dentures, crowns & bridges increasing to $800 Orthodontic (eg. braces) increasing to $800 (lifetime limit of $2,400 per member) Periodontic (eg. treatment for gum disease) $300 increasing to $700 Alternative therapies Consultations for: $500 Chiropractic & osteopathy Acupuncture Naturopathy Natural therapies: Remedial massage & myotherapy, reflexology, shiatsu, homeopathy, western & Chinese herbalism, Alexander technique, Bowen therapy, exercise physiology, aromatherapy & kinesiology Other therapies Consultations for: Podiatry Consultations Approved orthotics Dietetics (Includes Jenny Craig weight loss benefit) $200 $1,000 Sub-limits apply Occupational therapy Speech therapy Orthoptics (eye therapy) Cover Summary PremierPlus 3

4 Service Waiting period Annual limits & sub-limits Health appliances Hearing aids $1,000 $800 Sub-limits & other restrictions apply Breathing appliances (eg. peak flow meters, nebulisers & spacing devices) 1 $180 per membership every 3 years Blood glucose monitors Other health appliances (including external prostheses) 24 months $240 per membership every 3 years & $180 per person every 3 years $500 Sub-limits & other restrictions apply Clinical psychology Consultations only School Accident For preschool, primary & secondary school students $800 Benefit Replacement Periods apply. Referral Letter required. PackageBonus The PackageBonus is an amount of money that accumulates each year to help pay for a range of approved membership and health-related expenses. Any member may claim PackageBonus benefits up to the maximum membership limit. There is a 6 month waiting period and entitlements apply from 1 January each year. Single membership Couple/family membership First calendar year of membership $50 $100 Second calendar year of membership & each calendar year thereafter $100 $200 Maximum membership limit $500 $1,000 Any unused PackageBonus will be added to the following year s entitlement up to the maximum membership limit shown above, provided you stay on the same membership & on a cover with a PackageBonus. Benefit Replacement Periods (BRPs) This is the period of time you need to wait from the date of purchase for an item before you can receive another benefit to replace it. This is separate to the waiting period. Below are the benefit replacement periods that apply to your cover. These apply per member, unless otherwise stated. Additional restrictions may apply to some individual dental item numbers and services. Please contact us prior to your treatment. Service category Health appliances and external prostheses Blood glucose monitors Breathing appliances General dental Major dental Items External mammary prostheses and repairs of external prostheses Wigs, hip protectors and insulin delivery pens Other health appliances and external prostheses Blood glucose monitors Peak flow meters (per membership) Spacing devices and nebulisers Mouth guards* Dentures, crowns and bridges Benefit replacement period 1 24 months Hearing aids Hearing aids 60 months *Members under the age of 18 are entitled to a benefit for a replacement mouth guard once every 1. Cover Summary PremierPlus 4

5 Referral letter A referral letter is required to claim benefits for some items under your cover. Refer to the Member Guide for more information. Things to note Benefits are only payable for extras services provided by recognised providers. The benefit we pay for a particular claim is likely to be less than the annual limit and less than your provider s charge. This means you ll usually have out-of-pocket expenses for each service or item. You might need to wait for a period of time from the date of purchase of some items before you are entitled to another benefit to replace the item (benefit replacement period). Additional restrictions may apply to the payment of benefits for some services. Refer to your Member Guide for more information including the meaning of terms used in this document. To check whether a provider is a Members Choice provider go to medibank.com.au How to find out more If you d like to find out more about your cover please refer to our Member Guide, which is a summary of our Fund Rules. Where possible before booking treatment, you should always call us on to ask about the benefits you can expect to receive and any out-of-pocket expenses you might incur. If you have PremierPlus, call us on It s also a good idea to confirm any out-of-pocket expenses before admission with all doctors (including the surgeon, assistant surgeon and anaesthetist) and the hospital. medibank.com.au This information is current as at 18 October 2018 and subject to change from time to time. If you d like to change your cover, please contact us on (or for Priority corporate cover). Membership of Medibank Private is subject to our Fund Rules and policies which are summarised in our Member Guide. Medibank Private Limited ABN CS0063 Cover Summary PremierPlus 5