Our Product Disclosure Statement (PDS)

Transcription

1 Our Product Disclosure Statement (PDS) Your HIF Hospital & Extras Cover in Detail. Visit hif.com.au to get a quote and join online Call Australia s first certified Carbon Neutral health fund.

2 What s inside? inside? Hospital Cover GoldVital Hospital GoldStarter Hospital GoldSaver Hospital Gold Hospital GoldStar Hospital Cover Extras Cover 24 Ways to claim 26 Feedback, disputes and privacy 50 Frequently asked questions 52 Glossary 53 A bit about us, this PDS and health insurance At HIF, we aim to make choosing smart health insurance simple and painless. With that in mind, we ll keep this Product Disclosure Statement (PDS) as short and sweet as possible. No unnecessary information. Just the must-know stuff. We want you to be able to make the right health insurance choice but we don t want you to fall asleep. So here we go About us and you HIF is a not-for-profit private health insurer. That means we don t have shareholders, so any income we earn after paying for our members benefits and covering our operating expenses is available to pay bigger and better benefits. And that s a good thing. About this PDS You ll find lots of useful info about our health insurance in this brochure: what s and what isn t; details of different cover options; explanations about our services and the terminology we use. All the stuff you need to know when comparing, choosing and reviewing your health cover. Important Tip When you join HIF or add a person to your policy, we will send you a Member Statement to confirm. To avoid confusion, it s a good idea to keep your statement with this brochure. Keep Updated HIF is always reviewing and improving its services and benefits so to ensure you are claiming all possible benefits remember to regularly visit hif.com.au/domesticpds for an updated version of this PDS. About Australian private health insurance All Australian private health insurers, and residents and non-residents who pay tax in Australia, have potential responsibilities, obligations and entitlements under Australian health insurance laws. These laws include directions about services that can or must be, entitlement to the private health insurance rebate and obligations to pay the Medicare Levy Surcharge (MLS) and the Lifetime Health Cover (LHC) loading. The legislation or rules that affect your premiums, cover and membership obligations include: The Private Health Insurance Act 2007 (the PHI Act) Fairer Private Health Insurance Incentives Act 2012 Fairer Private Health Insurance Incentives (Medicare Levy Surcharge) Act 2012 Fairer Private Health Insurance Incentives (Medicare Levy Surcharge Fringe Benefits) Act 2012 Under the PHI Act, we are required to document our operating guidelines, known as Fund Rules or Business Rules. All private health funds have to do this. These rules detail our obligations as a private health insurer, as well as the obligations of our members. As such, when you become a HIF member, you agree to be bound by these rules. If you would like a copy of the rules, simply hello@hif.com.au or call us on Want more information? Visit hif.com.au to find out more about our not-for-profit health fund. Alternatively, if you would like to know more about us or the rules and regulations around health insurance, please hello@hif.com.au or call us on

3 HIF Hospital Cover Options Restrictions and exclusions Choice of Excess Cover for in-hospital procedures GoldStarter GoldSaver Gold GoldStar Product Restricted Excluded GoldStar Surgery by podiatrists Cosmetic services* Private Room Private room (maternity) (3 days) (5 days) (uned) Shared room Intensive Care Theatre Care Same-day Accommodation Same-day Theatre Appliances Prostheses Pharmacy Drugs AccessGap Palliative Care Cardio (heart)** Psychiatric Care & Treatment Joint Replacement Assisted Reproductive Technology (e.g. IVF) Eye Surgery (non-cosmetic) Gastric banding & Obesity surgery Rehabilitation Restricted Restricted Restricted Restricted Restricted Restricted Restricted Restricted Some restrictions and exclusions may apply - please see next page. Services not by Medicare* Gold Surgery by podiatrists Cosmetic services* GoldSaver GoldStarter Assisted reproductive technology Cardiac (heart) conditions, procedures or monitoring** Eye surgery Joint replacement Psychiatric Surgery by podiatrists Palliative care Psychiatric Rehabilitation Surgery by podiatrists Services not by Medicare* Gastric banding and obesity surgery Cosmetic services* Services not by Medicare* Gastric banding and obesity surgery Cardiac (heart) conditions, procedures or monitoring** Eye surgery Joint replacement Assisted reproductive technology Obstetrics (maternity) Cosmetic services* Services not by Medicare* For restricted services HIF will pay a basic benefit known as the public hospital rate, toward accommodation charges. All other charges raised by the hospital during the stay will be paid by the member. An excluded service means all charges raised during the stay will be paid by the member. * Where a service is deemed by Medicare to be cosmetic and/or does not attract a Medicare rebate, all charges raised in association with the hospital stay will not be eligible for payment. ** Some examples of cardiac (heart) procedures including medical treatment or surgical procedures for cardiac conditions, are arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrilators, stent insertion. 4 5

4 Things you need to know about our Private Hospital Insurance cover When selecting Hospital cover, it s important to ensure that you understand how each level of cover will apply to you, as well as being aware of details such as ations, restrictions or exclusions that might also apply to your chosen cover. AccessGap Cover AccessGap Cover applies to medical accounts for members undergoing in-patient hospital procedures. It s designed to reduce or eliminate out-of-pocket expenses by allowing doctors to use the scheme on a patient-bypatient basis. If a doctor uses the scheme, he/ she agrees to charge you a set fee for each item and will then receive a payment from HIF and Medicare combined, which is more than the Medicare Schedule Fee. To be eligible for AccessGap Cover, doctors must be willing to participate for your particular surgery and the account must be lodged directly with HIF (not Medicare). To find out more about specific payment amounts for upcoming procedures, or for your doctor to register for the scheme, please call us on Healthcare providers HIF covers extras, medical and hospital providers throughout Australia. To confirm if a provider is approved by HIF, go to hif.com.au, us at hello@hif.com.au or call us on Benefits will not be paid for any hospital services provided outside Australia, or for services purchased or provided within Australia from a non-australian recognised provider. Ambulance services HIF is required under New South Wales and Australian Capital Territory legislation to financially contribute toward the cost of operating state or territory-provided emergency ambulance services on behalf of any person who is a permanent state or territory resident and holds any level of HIF Hospital cover. Under this arrangement, our members who are residents of NSW or ACT and hold HIF Hospital cover may submit their resident state or territory emergency ambulance invoice to HIF to claim a benefit toward the fees charged. Please note that ambulance benefits may not be claimable under a NSW or ACT HIF Hospital cover if the service was not provided by your local state-controlled ambulance service, or if the service was not deemed by the ambulance attendant to be an emergency (medically necessary). For more information about this, see page 24 or visit hif.com.au and visit the Ambulance Cover page within the Health section. Medical Gap Different medical providers may charge different prices for the same procedure. If you are planning a procedure, we recommend that you ask your medical provider and any associated health provider (e.g. anaesthetist or assistant) if they will participate in our AccessGap scheme to help you avoid or minimise your out-of-pocket expenses. If your health provider does not confirm your out-of-pocket expenses, we recommend you contact us with your provider s details, item numbers and charges and we will provide you with a benefit estimate. Waiting Periods and the Pre-existing Condition Rule In addition to specified waiting periods, every hospital policy has a 12-month waiting period for hospital treatment for preexisting conditions. A pre-existing condition is defined as Any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher level benefits under the new policy. The test applied under the law relies on the presence of signs or symptoms of the illness, ailment or condition, not on a diagnosis. It is not necessary for the member or their doctor to know what their condition is or for it to be diagnosed. In forming an opinion about whether or not an illness is a pre-existing condition, the HIF-appointed medical practitioner who makes the decision must take into account information provided by the member s treating doctor. This rule applies whether the ailment, illness or condition was known to the member or not. Restricted services Where services are noted as restricted in your Hospital cover, this means that if you receive them in a private hospital, you will only be at the basic public hospital benefit rate, which includes: The cost of a shared room in a public hospital A benefit towards the cost of surgically implanted prosthesis AccessGap for in-patient medical services No other benefits are payable for restricted services, unless specifically listed in the individual product description within this brochure. Excluded services Where services are noted as excluded in your Hospital cover, this means that you are not and you must pay all costs. Workers Compensation and Dual Insurance Benefits cannot be claimed and are not payable by HIF where you have or can claim benefits or compensation (in full or in part) for treatment, goods or services from a third party including Workers Compensation or Public Liability sources, your employer or any other Insurance policy. Transferring and upgrading your cover New members who transfer Hospital cover from another Australian health fund to an equivalent level of HIF Hospital cover will not have any waiting periods applied for the services for which you were previously, providing these were served with the previous fund. New members who transfer Hospital cover from another Australian health fund to a higher level of Hospital cover, or equivalent level of cover with a reduced or nil excess, will have qualifying periods applied for the higher level of cover and/ or benefits. During these periods benefits will be payable at the equivalent level of cover to that of your previous fund. Current HIF members who transfer Hospital cover to a higher level of Hospital cover, or equivalent level of cover with a reduced or nil excess, will have qualifying periods applied for the higher level of cover and/or benefits. During these periods benefits will be payable at the lower level of cover. Any benefits paid by your previous private health insurer will be considered when determining rebates for your future claims. 6 7

5 GoldVital Hospital This is our entry-level option for young singles and couples who want cover for vital medical services. It covers treatment after an accident, intensive care and theatre fees, plus other essential services, including surgery to remove tonsils, adenoids, appendix and wisdom teeth. GoldVital Hospital Cover for emergency treatment in hospital resulting from an accidental injury* Hospital accommodation and theatre fees for surgical removal of wisdom teeth Tonsils, appendix and adenoids Minor gynaecological procedures^ Joint reconstruction and investigation Same-day accommodation and theatre fees for approved services No maternity cover Full cover for the cost of a shared or private room, theatre fees and charges in an HIF contracted hospital anywhere in Australia for approved services Hospital waiting periods Treatment received as the result of an accident one day General hospitalisation two months All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 1 Services GoldVital Hospital will cover the services outlined in the table on the following page in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Preexisting Ailment Rule. Benefits for noncontracted private hospitals are available from HIF. Check with us prior to admission to ensure that the hospital is an HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The benefits listed in the table opposite are offered to members who are admitted to those hospitals. Exclusions As an entry-level option, GoldVital provides basic cover for a ed range of vital medical services and essential emergency treatment. As such, it only covers the services listed in the table on page 10 all other non-emergency and hospital care services are excluded. Assisted reproductive technology (eg IVF) Cardiac (Heart) procedures including medical treatment or surgical procedures for cardiac conditions such as, arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrillators, stent insertion. Eye Surgery (any procedure on the surface or within the structures of the eye) Dialysis Gastric banding and Obesity surgery including reversal and adjustment procedures Joint replacement Obstetrics related services Spinal fusion Sterility reversals Services deemed cosmetic by Medicare and service that do not attract a Medicare rebate Services not listed as include are excluded. Restricted services Benefits for the following services will include basic public hospital rate (only) for accommodation. However, full AccessGap coverage for inpatient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a copayment by the patient: Psychiatric care or attention Palliative care Rehabilitation No benefits will be payable for other charges related to these services (e.g. theatre or some pharmaceutical costs), so significant out-of-pocket expenses may apply for these procedures if you are admitted as a private patient. Applicable excess A mandatory excess is applied to GoldVital Hospital to reduce premium costs: GoldVital - $500 per person to a max of $1000. Excesses are paid once per person per admission under the policy in a calendar year up to the maximum. The excess applies to all hospital treatments. Full AccessGap Cover for inpatient medical procedures for approved services Includes an excess to reduce the premium Restrictions and exclusions apply Available for singles and couples only * An accident is an unforeseen event, occurring by chance and caused by an external force or object which results in an injury to the body requiring immediate medical treatment in hospital within 24 hours of the accident. If further hospital treatment (as an admitted patient) is required, the patient must be re-admitted to a hospital within 90 days of the initial hospital treatment. Please note you ll need to hold a suitable level of Extras Cover to attract a benefit towards the dentist fees. ^ Benefits will be paid for same-day procedures only for minor gynaecological procedures. Minor gynaecological procedures include items such as the Removal of cervical polyp or polypi - (MBS item number 35611) or Hysteroscopy with dilation - (MBS item number 35627). Important, please note: Major surgery items or procedures requiring overnight admission are excluded. To confirm the applicable benefits payable prior to hospital admission, please contact HIF on or hello@hif.com.au. 8 9

6 Description of charges and benefits Accommodation Charges Full cover in a shared or private room Full cover in a shared or private room Theatre Fees charges Charges are not raised for this service Full cover for theatre charges Pharmaceutical drugs (does not include discharge drugs) Charges are not raised for this service Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs, Prostheses and consumables Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Prostheses items used in relation to relevant exclusion services are not. Outpatient theatre fees (not emergency department fees) Medical Gap For more details please refer to the AccessGap Cover section in this brochure, or hello@hif.com.au or call us on Applicable Excess All hospitals and approved day care facilities Mandatory excess is applied to GoldVital hospital. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses items used in relation to relevant exclusion services are not. No charge raised Full cover for outpatient theatre fees Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. GoldVital - $500 per person in a calendar year to a max of $1000 per membership. Excess applies to overnight or same day admissions

7 GoldStarter Hospital This is our basic-level private Hospital insurance cover. Like GoldVital, it s great value and a smart choice if you re younger and less likely to require things like maternity and cardio procedures, but it also includes a broader range of nonemergency care. GoldStarter Hospital No maternity cover Restrictions and exclusions apply Full cover for the cost of a shared room, theatre fees and charges in a HIF contracted hospital anywhere in Australia for approved services Full AccessGap Cover for inpatient medical procedures for approved services Includes an excess to reduce the premium Hospital waiting periods General hospitalisation two months All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 1 Restricted services Benefits for the following services will include basic public hospital rate (only) for accommodation. However, full AccessGap coverage for inpatient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient: Rehabilitation Surgery by podiatrists No benefits will be payable for other charges related to these services (e.g. theatre or some pharmaceutical costs), so significant out-of-pocket expenses may apply for these procedures if you are admitted as a private patient. Exclusions Benefits are not payable for any charges raised for the following services: Assisted reproductive technology (e.g. IVF) Cardio (e.g. conditions of the heart requiring surgery, monitoring or other procedures) Eye surgery (any procedure on the surface or within the structures of the eye) Gastric banding and obesity surgery Joint replacement Obstetrics Services deemed cosmetic by Medicare and services that do not attract a Medicare rebate Services GoldStarter Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check with us prior to admission to ensure that the hospital is a HIF contracted facility. Accommodation charges including day patient, intensive care and neonatal care Full cover in a shared or private room. The full cost of a shared room. If you occupy a private room you will be up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge. Theatre fee Charges are not raised for this service. Full cover for theatre charges. Pharmaceutical drugs (does not include discharge drugs) Charges are not raised for this service. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Prostheses and consumables Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Prostheses items used in relation to relevant exclusion services are not. Outpatient theatre fees (not emergency department fees) Medical Gap For more details, please refer to the AccessGap Cover section in this brochure, or hello@hif.com.au or call us on Applicable excess All hospitals and approved day care facilities Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses items used in relation to relevant exclusion services are not. No charge raised. Full cover for outpatient theatre fees. Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. HIF has negotiated contractual A mandatory excess is applied to GoldStarter Hospital cover to reduce premium costs: arrangements with most hospitals and day GoldStarter $200 per person to a max of $400 hospital facilities throughout Australia. The Excesses are paid once per person per admission under the policy in a calendar year up to the listed benefits are offered to members who maximum.excesses apply to all hospital treatments. Psychiatric care or attention are admitted to those hospitals. Some examples of cardiac (heart) procedures including medical treatment or surgical procedures for cardiac 12 conditions, are arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart Palliative care transplants, pacemakers and defibrilators, stent insertion. 13 * Therapeutic Goods Administration

8 GoldSaver Hospital This is our intermediate Hospital cover and is a step up from GoldStarter. It s great for young couples and families who are likely to need things like maternity cover but not services such as cardio and joint replacement surgery. GoldSaver Hospital Intermediate Hospital cover Includes maternity services Full cover for the cost of a shared room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia for approved services Private room for up to 3 days for management of labour and delivery of child Full AccessGap cover for inpatient medical procedures Includes an excess to reduce the premium Some restricted services human tissue) may be subject to a co-payment by the patient: Joint replacement Cardio (e.g. conditions of the heart requiring surgery, monitoring or other procedures) Eye surgery (any procedure on the surface or within the structures of the eye) Psychiatric care or attention Assisted reproductive technology (e.g IVF) Surgery by a podiatrist No benefits will be payable for other charges related to these services (e.g. theatre or some pharmaceutical costs), so significant out-of-pocket expenses may apply for these procedures if you are admitted as a private patient. Exclusions Benefits are not payable for any charges raised for the following services: Gastric banding and obesity surgery Services deemed cosmetic by Medicare and services that do not attract a Medicare rebate Some examples of cardiac (heart) procedures including medical treatment or surgical procedures for cardiac conditions, are arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrilators, stent insertion. Accommodation charges including day patient, intensive care and neonatal care Theatre fee and labour ward charges Pharmaceutical drugs (does not include discharge drugs) Full cover in a shared or private room. Full cover in a shared room. A private room will be fully for up to 3 days for maternity stays relating to the management of labour and delivery. If you occupy a private room for maternity stays greater than 3 days, for the fourth and additional days you will be up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge. Charges are not raised for this service. Full cover for theatre and labour ward charges. Charges are not raised for this service. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Prostheses and consumables Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Prostheses items used in relation to relevant exclusion services are not. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses from excluded services not. Hospital waiting periods General hospitalisation All obstetric related services 1 Services Outpatient theatre fees Full cost of the charge raised. GoldSaver Hospital will cover the following (not emergency department All treatment related to a pre-existing Full cover for outpatient theatre fees. services in a public hospital or contracted fees) ailment or condition, but not including private hospital facility, subject to any Medical Gap All hospitals and Admitted patients are entitled to the difference pre-existing conditions for psychiatric care, waiting periods which may apply and the For more details, please refer approved day care between the Medicare rebate and the rehabilitation or palliative care 1 Pre-existing Ailment Rule. Benefits for noncontracted to the AccessGap Cover facilities Commonwealth Medical Benefits Schedule fee private hospitals are available section in this brochure, or for all medical services performed whilst the Restricted Services hello@hif.com.au or patient is admitted as an inpatient in hospital from HIF. Check prior to admission to ensure Benefits for the following services will call us on and may be entitled to a further refund of that the hospital is a HIF contracted facility. include basic public hospital rate (only) for the AccessGap cover amount. Funds are not accommodation. However, full AccessGap HIF has negotiated contractual permitted to pay gap cover if the patient is coverage for in-patient medical procedures arrangements with most hospitals and day treated as an outpatient or when the patient and benefits will be paid towards prostheses hospital facilities throughout Australia. The is not formally admitted to hospital. in accordance with the Commonwealth listed benefits are offered to members who Applicable excess Prostheses List. Items on the list (excluding are admitted to those hospitals. A mandatory excess is applied to reduce premium costs: GoldSaver $200 per person to a max of $ Excesses are paid once per person per admission under the policy in a calendar year up to the maximum.excesses apply to all hospital treatments. 15 * Therapeutic Goods Administration

9 Gold Hospital This is our award-winning top shared room hospital insurance cover, complete with maternity cover. It offers total peace of mind for you and your family, plus a choice of optional excesses to further reduce your premium. With Gold, you're for theatre fees, ward fees and all other services, including up to five days in a private room for maternity visits plus the management of labour and delivery. Gold Hospital Top Hospital cover Comprehensive cover for all Medicare approved items Includes maternity services Private room for up to 5 days for management of labour and delivery of child Full cover for the cost of a shared room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia Full AccessGap Cover for inpatient medical procedures Choice of excesses to reduce cost Restrictions Surgery performed in a hospital by registered podiatrists is not eligible for Medicare rebates. However, under this level of cover HIF will pay ed benefits toward the podiatrist s charges. Hospital accommodation and theatre charges will also be ed. Exclusions No benefit is payable for services deemed cosmetic by Medicare and services that do not attract a Medicare benefit. Services Gold Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for noncontracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The listed benefits are offered to members who are admitted to those hospitals. Accommodation charges including day patient, intensive care and neonatal care Full cover in a shared or private room. The full cost of a shared room. A private room will be fully for up to 5 days for maternity stays relating to the management of labour and delivery. If you occupy a private room for maternity stays greater than 5 days, for the sixth and additional days you will be up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge. Theatre fees Charges are not raised for this service. Full cover for theatre fees. Pharmaceutical drugs (does not include discharge drugs) Prostheses and consumables Outpatient theatre fees (not emergency department fees) Medical Gap For more details, please refer to the AccessGap Cover section in this brochure, or hello@hif.com.au or call us on All hospitals and approved day care facilities Charges are not raised for this service. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. No charge raised. Full cover for outpatient theatre fees. Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. Hospital waiting periods General hospitalisation All obstetric related services 1 All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 1 Excess options Optional excesses to reduce premium costs: Gold Excess 100/200 $100 per person to a max of $200 Gold Excess 200/400 $200 per person to a max of $400 Gold Excess 400/800 $400 per person to a max of $800 Excesses are paid once per person per admission under the policy in a calendar year up to the maximum. The excess is not applied to same-day surgery or to child dependants under the age of * Therapeutic Goods Administration 17

10 GoldStar Hospital GoldStar is HIF's premium hospital insurance option, with all the bells and whistles including a private room in a private hospital for all services, plus complimentary access to our HIF Second Opinion service. It's perfect for anyone wanting complete peace of mind, providing comprehensive cover for theatre fees, ward fees, cardiac procedures, maternity cover and more. Plus you can choose from a range of excess options to further reduce your premium. GoldStar Hospital Cover Top Hospital cover Comprehensive cover for all Medicare approved items Includes maternity services Full cover for the cost of a private room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia Full AccessGap Cover for inpatient medical procedures Choice of excesses to reduce cost Hospital waiting periods General hospitalisation All obstetric related services 1 All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care 1 Restrictions Surgery performed in a hospital by registered podiatrists is not eligible for Medicare rebates. However, under this level of cover HIF will pay ed benefits toward the podiatrist s charges. Hospital accommodation and theatre charges will also be ed. Exclusions No benefit is payable for services deemed cosmetic by Medicare and services that do not attract a Medicare benefit. Services GoldStar Hospital will cover the following services provided in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The listed benefits are offered to members who are admitted to those hospitals. HIF Second Opinion HIF Second Opinion is a free service for HIF members with GoldStar Hospital cover (and/ or Premium Options Extras). It gives you access to the Best Doctors' network of the world's leading medical specialists, enabling you to get a free second opinion on any diagnosis, condition or treatment. Visit hif.com.au/secondopinion to find out more. Accommodation charges including day patient, intensive care and neonatal care Theatre fee and labour ward charges Pharmaceutical drugs (does not include discharge drugs) Prostheses and consumables Outpatient theatre fees (not emergency department fees) Medical Gap For more details, please refer to the AccessGap Cover section in this brochure, or hello@hif.com.au or call us on All hospitals and approved day care facilities Full cover in a shared or private room. Full cover in a shared or private room. Charges are not raised for this service. Full cover for theatre and labour ward charges. Charges are not raised for this service. Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. No charge raised. Full cover for outpatient theatre fees. Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap Cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. Excess options Optional excesses are available to reduce premium costs: GoldStar Excess 200/400 $200 per person to a max of $400 GoldStar Excess 400/800 $400 per person to a max of $800 GoldStar Excess 500/1000 $500 per person to a max of $1000 Excesses are paid once per person per admission under the policy in a calendar year up to the maximum. The excess is not applied to same-day surgery or to child dependants under the age of 18. * Therapeutic Goods Administration 18 19

11 Cover: No Maternity Hospital with Mid Extras Combo Looking for intermediate Hospital and Extras cover with no maternity? Look no further. Our combined cover option provides great value private hospital insurance for singles and couples, plus a host of handy Extras services including dental, optical, ambulance, chiro, physio, healthy lifestyle services and more. Hospital services No Maternity Hospital with Mid Extras Combo will cover the services outlined in the table below, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check with us prior to admission to ensure that the hospital is an HIF contracted facility. HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The benefits listed in the table opposite are offered to members who are admitted to those hospitals. Accommodation Charges Full cover in a shared room Full cover in a shared What Hospital services are? Full cover for a shared room in a contracted private hospital. (If you d like a private room, you simply pay the difference between the cost of a shared and a private room.) Joint reconstruction and investigation Joint replacement Cardiac (heart) conditions, procedures or monitoring Cancer related treatment and services Colonoscopy, endoscopy and gastroscopy Back surgery Brain surgery Renal dialysis Non-cosmetic eye surgery Surgical removal of appendix Removal of tonsils and adenoids Hernia repair Intensive care Theatre care Palliative care AccessGap Cover Benefits for surgically implanted prostheses and other items on the Federal Government s Prostheses Schedule Inpatient pharmacy drugs (charges vary between private hospitals depending on the contracts in place please check with us or the hospital.) Applicable excess Excesses apply to all overnight hospital treatments and is not applicable for day procedures such as colonoscopies. A per person excess is only paid once per calendar year, up to the maximum of $500 for a single membership and $1,000 for couples. Restricted services Psychiatric care and treatment Benefits for restricted services include basic public hospital rate (only) for accommodation. However, full AccessGap coverage applies for inpatient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a patient co-payment Exclusions Benefits are not payable for any charges raised for the following services: Assisted reproductive technology (eg IVF) Pregnancy and birth related services Gastric banding and Obesity surgery including reversal and adjustment procedures Services deemed cosmetic by Medicare and service that do not attract a Medicare rebate Prostheses items used in relation to excluded services Services not listed as included are excluded. Hospital waiting periods General hospitalisation two months Psychiatric care, rehabilitation and palliative care - All treatment related to a pre-existing ailment or condition, but not including preexisting conditions for psychiatric care, rehabilitation or palliative care 1 What Extras services are? Please see over the page. Theatre Fees charges Charges are not raised for this service Pharmaceutical drugs (does not include discharge drugs) Full cover for theatre charges Charges are not raised for this service Charges vary between hospitals depending on the contract that s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-tga* approved, experimental or high cost drugs, Prostheses and consumables Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Prostheses items used in relation to relevant exclusion services are not. Outpatient theatre fees (not emergency department fees) Medical Gap For more details please refer to the AccessGap Cover section in this brochure, or hello@hif.com.au or call us on Applicable Excess All hospitals and approved day care facilities Mandatory excess is applied to No Maternity Hospital with Mid Extras Combo Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses items used in relation to relevant exclusion services are not. No charge raised Full cover for outpatient theatre fees Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital. No Maternity Hospital with Mid Extras Combo. - $500 per person in a calendar year to a max of $1000 per membership. Excess applies to overnight hospital person in a calendar year to a max of $1000 per treatments and is not applicable for day procedures

12 Cover: No Maternity Hospital with Mid Extras Combo What Extras services are? Ambulance Chiro, Physio & Podiatry (combined ) Complementary Therapies Dental Emergency : 100% Non-emergency callouts : A $50 co-payment applies Limit per person: No Waiting period: : Inter-hospital transportation except for inter-hospital transfers relating to an emergency or new illness where approved on a case by case basis by HIF. Transportation from a hospital to your home, nursing home or other hospital Transportation for ongoing medical treatment Off road or air ambulance. 60% of the charge $500/year The following services have a combined of $1000 per person, and you can claim 60% back until your has been reached: Dental Chiro, physio & podiatry Complementary therapies Healthy Lifestyle services If you would like a benefit estimate prior to having any treatment, please get in touch. This policy includes acupuncture, homeopathy, myotherapy, naturopathy, remedial massage, and traditional Chinese medicine. 60% of the charge $150/year The following services have a combined of $1,000 per person, and you can claim 60% back until your has been reached: Dental Chiro, physio & podiatry Complementary therapies Healthy Lifestyle services Treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. Benefits are not payable on medicines. This policy includes general dental, periodontic, endodontic, inlay/onlay, and dentures, crowns and bridges. 60% of the charge $600/year The following services have a combined of $1,000 per person, and you can claim 60% back until your has been reached: Dental Chiro, physio & podiatry Complementary therapies Healthy Lifestyle services : Most general dental, Periodontic & Endodontic. 1 - Inlay/onlay,dentures crowns and bridges, and General Dental item numbers and If you would like a benefit estimate prior to having any treatment, please get in touch. Healthy Lifestyle Optical Pharmacy How to make a claim Services include health assessments (including gym memberships), exercise physiology, pilates, yoga, weight management programs, quit smoking plans and skin cancer screenings. $150/year The following services have a combined of $1,000 per person, and you can claim 60% back until your has been reached: Did you know... HIF members get bonus discounts of up to 25% from a range of optical stores. Visit: hif.com.au/optical for full details. Benefit: 100% up to Limit per person: $150/year Waiting period: PBS = Pharmaceutical Benefit Scheme Benefit: Member pays PBS contribution. Benefit is 100% of the balance up to $60 per script item. Limit per person: $200/year Waiting period: Please note: Benefits are not payable on contraceptives or NHS (PBS) prescriptions or over the counter items purchased with or without a prescription. With HIF, making an Extras claim is easy! In fact, the toughest bit is choosing from our host of convenient ways to make your claim. You can claim online, through our mobile app, by , fax or post. In any case, it s quick and easy. Please note: items carried out by a registered You ll have your rebate in no time, Dental Chiro, physio & podiatry optometrist or optical provider, and we offer some of the most Complementary therapies approved by HIF. Benefits are not competitive benefits in Australia. Healthy Lifestyle services paid on non-prescription safety Benefits are payable for HIF approved glasses, tinting, sunglasses, cosmetic programs delivered by registered To find out more and download a providers only. Please contact us prior to glasses or cosmetic contact lenses, or commencing the program to check your frames not purchased via a registered claim form, visit hif.com.au/claim eligibility. Australian optical provider

13 Things you should know about our Extras cover Here at HIF, we pride ourselves on enabling member choice. So, unlike some health fund insurers who pay lower benefits if you don t go to their preferred providers, with HIF you re free to visit any Extras provider in Australia. Our only requirement is that members must visit healthcare providers who are legally qualified to practise in Australia and are therefore approved by HIF. So as long as your preferred doctor, dental provider, optical provider, physiotherapist, chiropractor or other type of healthcare provider is approved by HIF, you re free to use whichever one you want. Our Member Loyalty Program HIF recognises and rewards members who retain their Extras cover (excluding Vital Options) each year by providing increasing benefits or s. Our dental s increase every year from commencement until the maximum is available in your sixth year of membership. Benefits or s for services like optical, physiotherapy, occupational and speech therapy increase after 5 years and benefits or s increase for chiropractic, osteopathic and pharmacy after 3 years. Where a policy is upgraded to a higher level of Extras cover (excluding Vital Options), s and benefits will automatically move to the next highest loyalty benefit on the new level of cover and progress each year until all maximum benefits and s are reached. Annual s HIF Extras covers have an for most services, which means there is a on how much HIF will pay toward your claims. Most s are for the calendar year (January to December) but each January your benefit s will be refreshed, allowing you to claim benefits again for Extras services provided in the new year. Claiming timeframe ation Claims must be made within two years of the service being provided. Approved consultations Unless stated, to be eligible for HIF benefits all services must be provided by a HIF approved health provider at that provider s registered practice address in a face-toface setting, or as otherwise approved by HIF. Video, telephone or online facilitated services, with the exception of HIF approved Hospital Substitute treatment or Chronic Health Disease Management programs, are not approved consultations. Workers Compensation and Dual Insurance Benefits cannot be claimed and are not payable by HIF where you have or can claim benefits or compensation (in full or in part) for treatment, goods or services from a third party including Workers Compensation or Public Liability sources, your employer or any other Insurance policy. Transferring and upgrading your cover New members who transfer Extras cover from another Australian health fund to an equivalent level of HIF Extras cover will not have any waiting periods applied, providing these were served with the previous fund. New members who transfer Extras cover from another Australian health fund to a higher level of Extras cover, or equivalent level of cover with additional or higher benefits will have qualifying periods applied for the higher level of cover and/ or benefits. During these periods benefits will be payable at the equivalent level of cover to that of your previous fund. Vital Options Vital Options offers great value, entry-level Extras cover for singles and couples only (not available for families). What services are included? Chiropractic Dental (General) Emergency Ambulance Endodontic Periodontal Osteopathy Physiotherapy Important, please note: Benefits are only payable on the following dental items. If you are planning dental treatment in the future, please call HIF prior to treatment on to confirm that you will be. Dental - General (2 month waiting period) Item numbers: , , 121, , , , , , , 926, Endodontic (2 month waiting period) Periodontal (2 month waiting period) Dental - General (12 month waiting period) , Current HIF members who transfer Extras cover to a higher level of Extras cover, or equivalent level of cover with a reduced or nil excess, will have qualifying periods applied for the higher level of cover and/or benefits. During these periods benefits will be payable at the lower level of cover. Any benefits paid by your previous private health insurer will be considered when determining rebates for your future claims. How much can I claim on Vital Options? With a combined of $800 per person per year, Vital Options gives complete choice as to how the is used. This could be used for a quick check-up at the dentist or visits to a chiropractor, for example. Each member can choose the services they d like to use and Vital Options will pay back 50% on each service claimed until the maximum annual of $800 is reached. For example, one member could claim up to $800 on dental services each year, while another member chooses to split the across more of the services by Vital Options. For instance, they could choose to use $250 on dental, $400 on osteopathy and $150 on chiropractic treatment. Emergency ambulance services are included. If urgent ambulance transport is needed, Vital Options cover will pay 50% of the bill up to the maximum of $800 per person. This can be a valuable benefit as Medicare doesn t cover urgent ambulance transport, which can cost over $

14 Ways to claim Instant eclaiming Providers with electronic claiming technology (HICAPS or IBA) can settle your account with you on the spot. Simply swipe your HIF membership card and pay any difference. Claim Online Members can now submit paid Extras accounts of $1,000 or less via our Online Member Service Centre. Jump online now and visit hif.com.au/members to find out more and lodge an online claim. SmartClaim Mobile App Members who own an Apple or Android mobile device can now submit paid Extras accounts of $1000 or less by using their mobile s in-built camera to photograph receipts and invoices. To find out more, visit hif.com.au/claim or download HIF SmartClaim now from Apple's App Store or the Android Marketplace. Fast-Track e-claiming ( /fax) For paid Extras accounts of $1000 or less, try our quick and easy Fast-Track option. Simply scan your completed HIF claim form and associated receipts and invoices, and a copy to claims@hif.com.au or fax a copy to (08) To find out more, visit hif.com.au Hospital and AccessGap Accounts Your doctor may send the accounts to HIF direct. If not, you can send the unpaid account to us for processing the HIF and Medicare benefits payable. We will then send the payment direct to your doctor or hospital on your behalf. Please call us before you go into hospital so we can assist you with your claims. By post Complete a claim form and post it to: HIF GPO Box X2221 Perth WA 6847 Claim forms can be downloaded from hif.com.au or mailed to you on request. For more information on the different ways to make a claim, check out the How to Claim page here: hif.com.au/claim Extras waiting periods Type of service Vital Saver Special Super Premium Ambulance* Auxiliary Home Nursing Asthmatic Spacers Chiropractic Complementary Therapies Waiting Period Dental - General Uned Limited Diabetes Education Dietetics Healthy Lifestyle Services Occupational Therapy Optical Orthoptics (Eye Therapy) Osteopathy Peak-flow Meter Pharmacy Drugs Physiotherapy Podiatry Consultations Speech Therapy Dental - General Limited** Up to 12 months Blood Glucose/Pressure Monitor Dental - Major External Prosthesis/ Medical Appliances Nebuliser / Humidifier Orthotic Appliances Psychological Consultations Assisted Reproduction Drugs Hearing Aids CPAP Machine months 36 months 36 months From time to time we promote special offers for new members. Visit hif.com.au for more information and to view our current offers. * Does not include inter-hospital transfers or transport to home. ** Limited item numbers are, please contact HIF for more details 26 27

15 Ambulance benefits Benefit is paid on charges raised for approved ambulance services. On all our Extras cover except Vital Options, HIF fully covers the cost of emergency ambulance transport for cases classified by approved ambulance service providers as requiring urgent attention and where the patient is admitted to the emergency department of a hospital. A patient co-payment of $50 per service applies to non-emergency call-outs and transportation. Benefits are not payable for transportation from a hospital to your home, nursing home or other hospital, or for transportation for ongoing medical treatment. Benefits are not payable for off road or air ambulance. Vital Options cover will pay 50% of an emergency ambulance bill up to a maximum of $800 per person per calendar year. Where a member is eligible for a state or Federal government subsidy, HIF will pay a benefit, less this entitlement. e: Ambulance services, charges and levies vary significantly across Australian states and territories: QLD & TAS Residents are for uned emergency services provided by their respective state governments. Interstate ambulance service charges for these residents may not apply if reciprocal agreements are in place with the other states where the ambulance service was required. NSW and ACT Residents who hold HIF Hospital cover are for uned emergency ambulance services provided in their home state by their state government or territory ambulance service. Interstate emergency services may also be if under a reciprocal state agreement. All other emergency services In all other locations and circumstances, emergency ambulance services may be claimable from HIF Options covers, subject to the services being provided by the recognised St John or state government controlled ambulance organisation and the service being deemed as medically necessary by the attending ambulance officer. Premium Options Super Options Special Options Saver Options Type of service Additional information Benefit Person Ambulance As above Emergency: 100% Benefit N/A N/A Emergency: 100% Person Benefit Person N/A N/A Emergency: 100% Benefit Person N/A N/A Emergency: 100% N/A N/A Nonemergency call-outs and transportation: 100% with a $50 co-payment Nonemergency call-outs and transportation: 100% with a $50 co-payment Nonemergency call-outs and transportation: 100% with a $50 co-payment Nonemergency call-outs and transportation: 100% with a $50 co-payment Interhospital transfers: No benefit Interhospital transfers: No benefit Interhospital transfers: No benefit Interhospital transfers: No benefit 28 29

16 30 31 Premium Options Type of service Additional information Benefit Person Asthmatic spacers Auxiliary Home Nursing Blood glucose or blood pressure monitor Chiropractic N/A $18 2 per person per year Benefits must be ordered by a medical practitioner. Contact us for conditions. A letter of recommendation from the patient s treating practitioner is required. Benefits are paid for spinal manipulation or spinal adjustments carried out by a registered chiropractor approved by HIF. $120 $1,800 per year 75% of cost 1 of either monitor every 3 years Spinal adjustment manipulation First visit: $30 Visits 2-10: $29 Visits 10+: $18 X-ray: $110 Max: $200 (chiropractic and osteopathic) Up to 3 years: $650 Over 3 years: $750 1 x-ray per year Special Options Type of service Additional information Benefit Person Asthmatic spacers Auxiliary Home Nursing Blood glucose or blood pressure monitor Chiropractic Super Options Benefit Person No $18 2 per person per year No $75 $1,800 per year No 75% of cost 1 of either monitor every 3 years (chiropractic and osteopathic) Up to 3 years: $1300 Over 3 years: $1500 Spinal adjustment manipulation First visit: $28 Visits 2-10: $23 Visits 10+: $14 X-ray: $85 Max: $200 (chiropractic and osteopathic) Up to 3 years: $550 Over 3 years: $650 1 x-ray per year No No No (chiropractic and osteopathic) Up to 3 years: $1100 Over 3 years: $1300 Saver Options Benefit Person N/A N/A N/A No N/A N/A No Benefits must be ordered by a medical practitioner. Contact us for conditions. A letter of recommendation from the patient s treating practitioner is required. Benefits are paid for spinal manipulation or spinal adjustments carried out by a registered chiropractor approved by HIF. N/A N/A No N/A N/A No N/A N/A No N/A N/A No Spinal adjustment manipulation First visit: $26 Visits 2-10: $21 Visits 10+: $10 X-ray: $70 osteopathic, physiotherapy, podiatry and therapies) $450 1 x-ray per year osteopathic, physiotherapy, podiatry and therapies) $900 Spinal adjustment - manipulation: First visit: $26 Visits 2-10: $21 Visits 10+: $10 X-ray: $65 dietetics, healthy lifestyle, pharmacy, osteopathic, physiotherapy and podiatry) $350 1 x-ray per year dietetics, healthy lifestyle, pharmacy, osteopathic, physiotherapy and podiatry) $700 Extras benefits

17 32 33 Premium Options Type of service Additional information Benefit Person Complementary therapies - Naturopathy - Homeopathy - Acupuncture - Traditional Chinese Medicine - Remedial massage therapy - Myotherapy Dental Diabetics education Dietetics Benefits are not payable on medicines provided by the practitioner. The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. For consultations or information sessions held by Diabetes Association in relation to diabetes. consultations carried out by a registered dietician approved by HIF. Visits 1-6: $25 Visits 7+: $17 First visit: $36 $18 First visit: $40 $20 Group: $12 Special Options Up to 3 years: $500 Over 3 years: $600 Super Options Benefit Person No * Visits 1-6: $20 See page 44 for more details 6 visits per year Type of service Additional information Benefit Person Complementary therapies - Naturopathy - Homeopathy - Acupuncture - Traditional Chinese Medicine - Remedial massage therapy - Myotherapy Dental Diabetics education Dietetics Benefits are not payable on medicines provided by the practitioner. The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised. For consultations or information sessions held by Diabetes Association in relation to diabetes. consultations carried out by a registered dietician approved by HIF. Visits 1-6: $16 Visits 7+: $11 Visits 7+: $13 No First visit: $36 $18 $324 per year No First visit: $36 Up to 3 years: $100* Over 3 years: $200* $18 Group: $10 Saver Options Up to 3 years: $250 Over 3 years: $350 6 visits per year $324 per year Benefit Person $400* Visit 1-6: $15 Visits 7+: $10 See page 44 for more details $700 Up to 3 years: $50 # Over 3 years: $100 # No * Subject to combined overall person of $450 and membership of $900 for chiropractic, osteopathic, physiotherapy and podiatry. # Subject to combined overall person of $350 and membership of $700 for therapies and chiropractic. per year per person, dietetics, healthy lifestyle, pharmacy, osteopathic, physiotherapy, and podiatry. $200 # N/A N/A No N/A N/A No First visit: $36 $18 Group: $10 $252 per year No First visit: $36 $18 Group: $10 annual dietetics, healthy lifestyle, osteopathy, pharmacy, physiotherapy and podiatry) $350 annual dietetics, healthy lifestyle, osteopathy, pharmacy, physiotherapy and podiatry) $700 Extras benefits

18 34 35 Premium Options Type of service Additional information Benefit Person External Prosthesis/ Medical Appliances Healthy Lifestyle Healthy Lifestyle services include Gym, Yoga, Pilates, Exercise Physiology, Weight Loss Programs, Health Assessments, Health Management Programs, Quit Smoking Plans, and Skin Cancer Screenings. HIF approved prosthetics items such as artificial limbs, wigs and external mammary prostheses and approved medical devices such as a Tens machine, Circulation Booster and Cam Walker. Conditions apply so please contact us for details prior to purchasing item. Benefits are payable for HIF approved programs delivered by registered providers only. Please contact us prior to commencing the program or paying subscriptions to ascertain if the program is eligible for a rebate. 75% of fee $1,500 per year. Single: $125 Family: $250 e: sub s apply depending upon item. Super Options Benefit Person No 75% of fee $1,500 per year. $125 Single: $100 Special Options Type of service Additional information Benefit Person External Prosthesis/ Medical Appliances Healthy Lifestyle Healthy Lifestyle services include Gym, Yoga, Pilates, Exercise Physiology, Weight Loss Programs, Health Assessments, Health Management Programs, Quit Smoking Plans, and Skin Cancer Screenings. HIF approved prosthetics items such as artificial limbs, wigs and external mammary prostheses and approved medical devices such as a Tens machine, Circulation Booster and Cam Walker. Conditions apply so please contact us for details prior to purchasing item. Benefits are payable for HIF approved programs delivered by registered providers only. Please contact us prior to commencing the program or paying subscriptions to ascertain if the program is eligible for a rebate. Family: $200 e: sub s apply depending upon item. $100 Saver Options Benefit Person No N/A N/A No N/A N/A No Single: $75 Family: $150 $75 Single: $50 Family: $100 $50 dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy and podiatry) $700 Extras benefits

19 36 37 Premium Options Type of service Additional information Benefit Person Hearing aids Humidifier or nebuliser Occupational therapy Optical Orthotics replacement hearing aids after 5 years from date of supply. A letter of recommendation from the patient s treating practitioner is required. consultations carried out by a registered occupational therapist, approved by HIF. items carried out by a registered podiatrist or orthotic supplier, approved by HIF #. Up to 5 years: $550 5 to 10 years: $600 per ear 10+ years: $700 per ear Up to 5 years: 1 Over 5 years: 1 per ear 75% of cost 1 of either monitor every 3 years. Maximum $180. First Visit $60 Subsequent $27 Group $10 (orthoptics, physiotherapy and speech therapy) Up to 5 years: $1200 Over 5 years: $ % of cost $240 1 every 2 years from date of supply ^ Super Options Benefit Person No Up to 5 years: $ years: $550 per ear Up to 5 years: 1 Over 5 years: 1 per ear No 75% of cost 1 of either monitor every 3 years. Maximum $140. No First visit: $45 See page 40 for more details $25 Group: $10 (orthoptics, physiotherapy and speech therapy) Up to 5 years: $900 Over 5 years: $1100 No 75% of cost $200 1 every 2 years from date of supply ^ No No No No # e: benefits are not available for orthotics which are not specifically modified and fitted for the individual member s condition. ^ Orthotic includes associated services such as muscle testing, ROM testing and gait analysis. Special Options Type of service Additional information Benefit Person Hearing aids Humidifier or nebuliser Occupational therapy Optical Orthotics replacement hearing aids after 5 years from date of supply. A letter of recommendation from the patient s treating practitioner is required. consultations carried out by a registered occupational therapist, approved by HIF. items carried out by a registered podiatrist or orthotic supplier, approved by HIF #. Saver Options Benefit Person N/A N/A No N/A N/A No N/A N/A No N/A N/A No N/A N/A No N/A N/A No See page 40 for more details N/A N/A No N/A N/A No # e: benefits are not available for orthotics which are not specifically modified and fitted for the individual member s condition. Extras benefits

20 38 39 Premium Options Type of service Additional information Benefit Person Orthoptics (eye therapy) Osteopathic Peak Flow Meter items carried out by a registered orthoptics supplier, approved by HIF. items carried out by a registered osteopath, approved by HIF. Initial: $50 $25 First visit: $30 Visits 2-10: $29 Visits 10+: $18 with occupational physiotherapy and speech therapy Up to 5 years: $1200 Over 5 years: $1500 (chiropractic and osteopathic) Up to 3 years: $650 Over 3 years: $750 Super Options Benefit Person No Initial $50 (chiropractic and osteopathic) Up to 3 years: $1300 Over 3 years: $1500 Subsequent $25 First visit: $28 Visits 2-10: $23 Visits 10+: $17 with occupational physiotherapy and speech therapy Up to 5 years: $900 Over 5 years: $1100 (chiropractic and osteopathic) Up to 3 years: $550 Over 3 years: $650 No (chiropractic and osteopathic) Up to 3 years: $1100 Over 3 years: $1300 N/A $30 1 per year No $30 1 per year No Special Options Type of service Additional information Benefit Person Orthoptics (eye therapy) Osteopathic Peak Flow Meter items carried out by a registered orthoptics supplier, approved by HIF. items carried out by a registered osteopath, approved by HIF. Saver Options Benefit Person N/A N/A No N/A N/A No First visit: $26 Visits 2-10: $21 Visits 10+: $16 physiotherapy, osteopathic and podiatry) $450 physiotherapy, osteopathic and podiatry) $900 First visit: $26 Visits 2-10: $21 Visits 10+: $16 dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy & podiatry) $350 N/A N/A N/A No N/A N/A No annual dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy and podiatry) $700 Extras benefits

21 40 41 Premium Options Type of service Additional information Benefit Person Pharmacy Physiotherapy payable on contraceptives or NHS (PBS) prescriptions or over the counter items purchased with or without a prescription. Benefits are paid on items carried out by a registered physiotherapist, approved by HIF. Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item. First visit: $45 Visits 2-10: $40 Visits 10+: $30 Hydrotherapy: $15 Antenatal: $15 Group: $15 Up to 3 years: $200 Over 3 years: $400 (occupational, orthoptics and speech therapy) Up to 5 years: $1200 Over 5 years: $1500 $600 sub for hydrotherapy, antenatal and group. Special Options Type of service Additional information Benefit Person Pharmacy Physiotherapy payable on contraceptives or NHS (PBS) prescriptions or over the counter items purchased with or without a prescription. Benefits are paid on items carried out by a registered physiotherapist, approved by HIF. Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item. First visit: $32 Visits 2-10: $24 Visits 10+: $19 Hydrotherapy: $13 Antenatal: $13 Group: $13 Super Options Benefit Person No Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item. No First visit: $35 Visits 2-10: $29 Visits 10+: $20 Hydrotherapy: $13 Antenatal: $13 Group: $13 Up to 3 years: $200 Over 3 years: $400 (occupational, orthoptics and speech therapy) Up to 5 years: $900 Over 5 years: $1100 $500 sub for hydrotherapy, antenatal and group. Saver Options Benefit Person $200 No Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item. ( chiropractic, physiotherapy, osteopathic and podiatry) $450 $400 sub for hydrotherapy, antenatal and group. ( chiropractic, physiotherapy, osteopathic and podiatry) $900 First visit: $32 Visits 2-10: $24 Visits 10+: $19 Hydrotherapy: $13 Antenatal: $13 Group: $13 dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy & podiatry) $350 dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy and podiatry) $350 $300 sub for hydrotherapy, antenatal and group. No No dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy and podiatry) $700 dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy and podiatry) $700 Extras benefits

22 42 43 Premium Options Type of service Additional information Benefit Person Podiatry* Psychology Speech therapy consultations carried out by a registered podiatrist, approved by HIF. Maximum of 2 sessions will be paid on the same date if there is a minimum of 2 hours between sessions. consultations carried out by a registered psychologist, approved by HIF. items carried out by a registered speech therapist, approved by HIF. First visit: $32 $25 Consultations that are not performed in the podiatrist s registered practice: $12 First visit: $100 $55 Group: $30 per person to a max of $75 per session First visit: $75 $45 $382 includes podiatry surgery performed in the podiatrist s registered rooms only. $1,000 per year (occupational, orthoptics and physiotherapy) Up to 5 years: $1200 Over 5 years: $1500 Super Options Benefit Person No First visit: $32 $23 Consultations that are not performed in the podiatrist s registered practice: $12 No First visit: $75 $55 Group: $25 per person to a max of $75 per session No First visit: $75 $45 $354 includes podiatry surgery performed in the podiatrist s registered rooms only No $740 per year No (occupational, orthoptics and physiotherapy) Up to 5 years: $900 Over 5 years: $1100 * Benefits not payable when provided as part of treatment provided in, or arranged by a hospital (including surgery). Special Options Type of service Additional information Benefit Person Podiatry* Psychology Speech therapy consultations carried out by a registered podiatrist, approved by HIF. Maximum of 2 sessions will be paid on the same date if there is a minimum of 2 hours between sessions. consultations carried out by a registered psychologist, approved by HIF. items carried out by a registered speech therapist, approved by HIF. First visit: $32 $23 Consultations that are not performed in the podiatrist s registered practice: $12 physiotherapy, osteopathic and podiatry) $450 Saver Options Benefit Person physiotherapy, osteopathic and podiatry) $900 First visit: $32 $23 Consultations that are not performed in the podiatrist s registered practice: $12 dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy & podiatry) $350 No : dietetics, healthy lifestyle, osteopathic, pharmacy, physiotherapy and podiatry) $700 N/A N/A No N/A N/A No N/A N/A No N/A N/A No * Benefits not payable when provided as part of treatment provided in or arranged by, a hospital (including surgery). Extras benefits

23 Extras benefits: Optical - claim 100% of your! Type of service Additional information Premium Options Super Options Special Options Saver Options Optical Limit per person Annual, all services s up to 5 years s over 5 years s up to 5 years s over 5 years s up to 5 years s over 5 years s up to 5 years s over 5 years $280 $350 $260 $325 $140 $155 $110 $121 items carried out by a registered optometrist or optical provider, approved by HIF. Benefits are not paid on non-prescription safety glasses, protective glasses, tinting, sunglasses, cosmetic glasses or cosmetic contact lenses, or frames not purchased via a registered Australian optical provider. In-store savings Optical discounts on the high street Online savings Online stores and special offers If you currently hold Saver, Special, Super or Premium Extras cover with HIF, you can visit one of these high street retailers today and access the following exclusive member discounts with a simple flash of your HIF member card. Even better, you'll still receive the maximum benefit available on the remaining amount payable after your discount has been deducted. OPSM and Laubman and Pank - 20% off lenses - 20% off lens extras (such as anti-reactive UV coating and tinting) - 15% off non-prescription sunglasses - 10% off contact lenses purchased in-store - Eye test bulk billed to Medicare EyeBenefit - 20% discount on complete glasses (e.g. frames and lenses) - 15% discount on lenses only - 10% discount on contact lenses VSP - 15% discount on contact lenses - Free second pair of glasses to the value of $149, where the value of the primary pair is $300 or over and not part of a no-gap deal. Specsavers - 25% discount on complete glasses (e.g. frame and lenses) from the $149 range or above. - 20% discounts on optical extras (including Suntint and UV Filter, Polaroid lenses, Transitions lenses, Driving tints, Drivewear lenses, Thin and Light lenses) - Free Digital Retinal Photography - Free contact lens assessment, fitting and trial (no discount on contact lens purchases) - Eye test bulk billed to Medicare We love making life easier for our members. That's why HIF members with Saver, Special, Super or Premium Extras cover can now buy prescription lenses, frames and contact lenses at potentially lower prices through the following online retail outlets. Rest assured that you'll still receive the maximum benefit available on your current level of cover too. 4 Eyes Optical: 4eyesoptical.com.au AusSpecs: ausspecs.com.au BeSpecd: bespecd.com.au Buy Contacts Online: buycontactsonline.com.au Clearly Contacts: clearlycontacts.com.au - spend $99 & enter code HIF to save 20% + free shipping Glasses Online: glassesonline.com.au Glasses Point: glassespoint.com.au My Lens: mylens.com.au Net Optical: netoptical.com.au Now Contacts: nowcontacts.com.au Optical Direct: opticaldirect.com.au Optics Online: optics-online.com.au Oscar Wylee: oscarwylee.com.au OzContacts: ozcontacts.com.au - save 15% with promo-code HIFOZ15 Specsavers: specavers.com.au Sneaking Duck: sneakingduck.com VisionDirect: visiondirect.com.au WebContacts: webcontacts.com.au WebGlasses: webglasses.com.au Please note: The online discounts listed above do not indicate any preference or priority of provider or traditional store based versus internet based providers. Unlike some other funds, HIF fully supports the principle that members receive the same benefit no matter which provider or service delivery method is chosen. Only HIF members who hold an Extras product are eligible for these discounts. This list is current as at 1 June Please note: The above discounts only apply to items purchased in brick-and-mortar optical 44 stores. They do not apply to items purchased online. 45

24 Extras benefits: SmartTeeth Our top 24 SmartTeeth dental services Item Number Description First Visit Subsequent Visits 011 or 012 Oral examination 100% 80% 111 or 114 or 115 Removal of plaque, stain or calculus 100% 80% 121 Topical application of remineralising agent 100% 80% 151 or 153 Provision of a mouthguard 100% 80% Please note: These benefits are payable on all our Saver, Special, Super and Premium Options products. The actual benefit amount cannot exceed our set maximum beneft for each dental item, service sub s or annual dental. See the example on page 43 for more information. Item Number Description Premium Options Super Options Special Options Saver Options 013 Oral examination - ed 80% 70% 65% 65% 014 Consultation 80% 70% 65% 65% 022 Intraoral periapical or bitewing radiograph 80% 70% 65% 65% 118 Bleaching, external per tooth 80% 70% 65% 65% 161 Fissure sealing per tooth 80% 70% 65% 65% 311 Removal of permanent tooth 80% 70% 65% 65% Metallic restoration two surfaces direct Metallic restoration three surfaces direct Adhesive restoration one surface anterior Adhesive restoration two surfaces anterior Adhesive restoration three surfaces anterior Adhesive restoration one surface posterior Adhesive restoration two surfaces posterior Adhesive restoration three surfaces posterior 80% 70% 65% 65% 80% 70% 65% 65% 80% 70% 65% 65% 80% 70% 65% 65% 80% 70% 65% 65% 80% 70% 65% 65% 80% 70% 65% 65% 80% 70% 65% 65% 575 Pin retention per pin 80% 70% 65% 65% How will my SmartTeeth dental rebate be calculated? We will pay a percentage of the dentist s fee, up to a set maximum benefit for each item of service^. For example, with our Premium Options Extras cover you get: 1 Top 8 general dental services: 80% to 100% of the fee, up to a set maximum benefit per item. 2 All other general dental services: 70% of the fee, up to a set maximum benefit per item*. 3 All other (i.e. major) dental services: 60% of the fee, up to a set maximum benefit per item*. ^ Benefits may be ed where potential rebates exceed dental service sub s or. * Contact us on for details of these services. This does not apply to Vital Options please see page 21 for more details. 577 Cusp capping per cusp 80% 70% 65% 65% Please note: The actual benefit amount cannot exceed our set maximum benefit for each dental item, service sub s or overall

25 Extras benefits: Dental s Premium Options Item Number Year 1 Year 2 Year 3 Year 4 Year 5 After 5 Years General - 022, , Uned , No Limit No Limit No Limit No Limit No Limit No Limit General - Limited , $1,500 $1,800 $2,100 $2,400 $2,700 $3,000 Inlay/Onlay $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 Special Options Item Number Year 1 Year 2 Year 3 Year 4 Year 5 After 5 Years General - 022, , Uned , No Limit No Limit No Limit No Limit No Limit No Limit General - Limited $800 $950 $1,150 $1,350 $1,550 $1,750 Inlay/Onlay $500 $600 $700 $800 $900 $1,000 Denture, Crown, Bridge * , $600 $700 $800 $900 $1,000 $1,100 Denture, Crown, Bridge * $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 Periodontic & Endodontic $300 $400 $500 $600 $700 $800 Periodontic & Endodontic Orthodontic (Lifetime Limit* ) Total annual s per person Super Options General - Uned General - Limited $700 $800 $900 $1,000 $1,100 $1, $1,500 $1,800 $2,100 $2,400 $2,700 $3,000 $1,500 $1,800 $2,100 $2,400 $2,700 $3,000 Item Number Year 1 Year 2 Year 3 Year 4 Year 5 022, , , , After 5 Years No Limit No Limit No Limit No Limit No Limit No Limit $1,150 $1,350 $1,550 $1,750 $2,050 $2,350 Inlay/Onlay $700 $800 $900 $1,000 $1,100 $1,200 Denture, Crown, Bridge * Periodontic & Endodontic Orthodontic (Lifetime Limit *) Total annual s per person $900 $1,000 $1,100 $1,200 $1,300 $1,400 $500 $600 $700 $800 $900 $1, $1,300 $1,500 $1,700 $1,900 $2,200 $2,500 $1,300 $1,500 $1,700 $1,900 $2,200 $2,500 Orthodontic (Lifetime Limit *) Total annual s per person Saver Options $1,000 $1,200 $1,400 $1,600 $1,800 $2,000 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000 Item Number Year 1 Year 2 Year 3 Year 4 Year 5 After 5 Years General - 022, , Uned , No Limit No Limit No Limit No Limit No Limit No Limit General - Limited Inlay/Onlay Denture, Crown, Bridge * Periodontic & Endodontic Orthodontic (Lifetime Limit*) Total annual s per person , $750 $850 $950 $1,050 $1,150 $1,250 $750 $850 $950 $1,050 $1,150 $1,250 * For more information about replacement periods and lifetime s refer to "Important information about your dental cover" on page

26 Important information about your dental cover Benefits are only paid on accounts rendered by a registered dentist or dental prosthetist. The dentist or dental prosthetist must be in private practice. Dental prosthetists are allowed to perform a ed range of services for benefit purposes. There are some items within item code ranges for which HIF does not pay a benefit, or if they are performed with another item in the same course of treatment. Limits apply to the number of times some items, such as bleaching, attract a benefit. Benefits for replacement dentures and partial dentures are not paid within three years of previous supply. Orthodontic s are lifetime s per person. Benefits are not payable in excess of the shown and include benefits paid under another health insurance policy. The applicable benefit is payable on the date the service is rendered e.g. the date braces are fitted. Feedback, disputes and privacy Our Code of Conduct The Private Health Insurance Code of Conduct is a self-regulatory code with the primary goal of enhancing regulatory compliance. We support and apply these industry standards in four fundamental ways: 1. Our employees are trained in private health insurance; 2. The information we provide to you is communicated in a way that is easy to understand and allows you to make an informed decision; Orthodontic benefits (including payment plans) are not payable by HIF if the treatment or service has commenced prior to joining HIF. We welcome all customers transferring from other insurers however if you're engaged in an instalment payment plan with a health provider it is critical (to avoid potential out of pocket expenses) that you clarify the specifics of your arrangement with HIF prior to transferring cover. If you are unsure of your entitlements, please contact us before commencing a course of treatment with full details of the necessary dental items as provided by your dental provider and we will provide you with a benefit estimate. Annual s are refreshed on 1 January each year, so if you re planning a course of treatment it may be financially advantageous to stagger services over two calendar years. 3. We openly communicate our procedures for resolving any concerns you may have about your HIF membership and private health cover; and 4. We ensure that any information you provide to us is maintained in accordance with our privacy policy. To download a full copy of the Code of Conduct, please visit hif.com.au Cooling Off Period When you have applied for a HIF membership, you have 30 days to read your policy. If you decide during this time that you do not wish to take up the cover, you may cancel the policy and HIF will give you a full refund, provided you have not made a claim. Compliments and complaints Your feedback is valuable to us, so don t be afraid to get in touch. You may wish to comment on your personal experiences with HIF, or you may wish to lodge a compliment (or complaint) about the service you ve received from our team. Whatever your feedback relates to, we address each and every compliment/ complaint and will always respond accordingly. Your input is a vital part of ensuring our organisation meets or ideally exceeds your expectations at all times. To submit feedback, simply visit hif.com.au and complete the online feedback form. Alternatively, you can hello@hif.com.au or call us on Providing feedback or making a complaint HIF is committed to providing our members with access to the highest possible level of service and we value the feedback that our members provide. As part of HIF s commitment to continuous improvement if you have a concern regarding your HIF membership, our products, benefits or our service we would be happy to hear from you. If you have a complaint or concerns, you can discuss this with one of our Customer Service Representatives on or your complaint to hello@hif.com.au and we will: Treat you with respect and deal with your concerns promptly Resolve any complaints at the first point of contact, wherever possible Escalate complaints (if necessary) and resolve them swiftly, within two business days Invite you to further escalate complaints which could not be resolved to your satisfaction to HIF s formal Ex-gratia Committee (you should address your complaint in writing to Executive Manager Operations, Health Insurance Fund of Australia, GPO Box X2221, Perth WA, 6847) Openly share our complaints with you, including external resolutions options, like involving the Private Health Insurance Ombudsman (you can contact the Ombudsman on or write to: Office of the Commonwealth Ombudsman, GPO Box 442, Canberra, ACT, 2601) or Privacy Commissioner Resolve complaints in an equitable manner, with the best interests of all members in mind Use feedback to improve our products and services by passing it on to our Product Development Committee. Your privacy The personal information you provide to us will be primarily used by HIF to deliver health insurance products and services as requested by you. The information supplied by you will remain confidential. This information may be disclosed to third parties and authorised government agencies in order to facilitate the delivery of services associated with your health insurance. Failure to provide personal information may result in the failure to process or deliver the service requested. For a complete HIF Privacy Policy brochure, please contact us on or download a copy at hif.com.au 50 51

27 Frequently asked questions How long can children remain on family policies? With HIF, dependants are up until the age of 21, or up to 25 years of age for those registered as full-time students at a recognised educational institution. If I have health insurance can I still be admitted to hospital as a public patient? Yes. Every public hospital is required to ask if you wish to be treated as a public or private patient. It s your choice if you use your insurance or not. Which bills should I claim from HIF and which ones should I claim from Medicare? If you don t have health insurance, Medicare pays benefits for all medical accounts. For example, accounts for doctors, specialists, eye examinations, X-rays and pathology. However, if you have HIF Hospital cover, we ll process your hospital accounts. We also pay up to one quarter of the Medicare schedule fee for any medical accounts resulting from your time as a private inpatient in a hospital. If you have HIF Extras cover, we also process all your bills for extras services, such dental, physiotherapy or optical treatments. What is the Medicare Levy Surcharge? The Medicare Levy Surcharge (MLS) is levied on Australian taxpayers who earn above a certain income and don t have private Hospital cover. The MLS is a Federal Government initiative designed to encourage individuals to take out private Hospital cover and, where possible, to use the private hospital system to reduce demand on the public system. Is the Federal Government Rebate on Private Health Insurance means tested? Yes, since 1 July 2012, the Federal Government Rebate on Private Health Insurance is means tested, as is the Medicare Levy Surcharge (MLS). There are effectively four annual income tiers for single people and couples/families. The rebate you receive for holding private health insurance and the size of the MLS you pay are dictated by your age and annual income. For instance, if you re a single person under the age of 65 and you re earning less than $90,000 a year, you will receive a % rebate on the cost of your health insurance. Furthermore, while you have to pay the Medicare Levy (everyone does), you don t have to pay the MLS. On the other hand, if you re classified as a high income Tier 3 earner, you will be taxed 3.5% of your income if you don t have private Hospital cover (1.5% MLS plus the standard 2% Medicare Levy that everyone pays). See table on page 50. What is the Lifetime Health Cover loading (LHC)? The Federal Government introduced the Lifetime Health Cover loading to encourage Australians to take out private Hospital cover at a younger age. Basically, it recognises the length of time you ve had private health insurance and rewards that loyalty by offering lower premiums so the earlier you take out health cover, the cheaper your premiums. Does everyone have to pay LHC loading? No, you won t incur the loading if you: Had Hospital cover on 1 July 2000 and have maintained it since then; or Were born on or before 1 July How is the loading applied? For every year over the age of 30 that you don t have private Hospital cover, a 2% loading is applied to the cost of your insurance (and increases each year until it reaches 70%). For example, a single 37 year old would pay 14% LHC loading so it really pays to take out private Hospital cover sooner rather than later. For couples and families, however, the loading is initially calculated based on your respective dates of birth and then halved. For example, a couple aged 33 and 36 years would generate a combined loading of 18% initially (6% + 12%), so the final loading that is applied to their joint policy is 9%. If you find that you will incur a loading, you will be required to pay this on top of the base premium that you re initially quoted for your Hospital cover. If you decide to join HIF, your loading will automatically be applied to the quoted amount once you provide your date of birth. What if I m already over 31? If you re over 31, it still makes sense to take out Hospital cover. Remember, the sooner you join, the smaller the loading you will pay. And once you ve held continuous private Hospital cover for 10 years, your loading will be removed (as per the Private Health Insurance Act 2007). What isn t by private health insurance? Private health insurance doesn t cover you for outpatient services. These services include visits to your GP and consultations with specialists, as well as X-rays and blood tests (unless they re taken once you re admitted to hospital). What are waiting periods? Waiting periods are the time you need to be a member of a health fund before you can claim a benefit. They re there to protect the fund and its existing members from people who simply join a fund to make a big claim, only to cancel their membership afterwards. But there s good news. If you join us from another Australian health fund and take out an equivalent level of cover with us, you don t have to re-serve any waiting periods that you ve already served. Even better, it s really easy to switch we ll take care of all the paperwork for you. The waiting periods for Hospital and Extras cover can be found in our health insurance brochure or at hif.com.au Got more questions? Check out our handy online knowledge base. To read hundreds more handy FAQs, jump online and head to hif.com.au/help 52 53

28 Federal Government Rebate Federal Government Rebate (Refers to FAQ on page 42) Annual Income Thresholds Policy Type Unchanged Tier 1 Tier 2 Tier 3 Single <$90,000 $90, ,000 $105, ,000 >$140,001 Families <$180,000 $180, ,000 $204, ,000 >$280,001 Age Applicable Private Health Insurance Rebate Under % % 8.644% 0% years % % % 0% 70 and over % % % 0% Medicare Levy Surcharge (applicable if Hospital cover is not held) All ages 0% 1.0% 1.25% 1.5% Medicare Levy 2% for everyone e: The thresholds increase annually, based on growth in Average Weekly Ordinary Time Earnings. Single parents and couples (Including de facto couples) are subject to the family tiers. For families with children, the thresholds are increased by $1,500 for each child after the first. Glossary AccessGap Cover AccessGap Cover is our Medical gap cover arrangement, designed to minimise or eliminate out-of-pocket expenses for medical services when you re an inpatient in a registered overnight hospital or day facility. Accident An accident is an unforeseen event, occurring by chance and caused by an external force or object which results in an injury to the body. Accident - GoldVital Hospital An accident as defined above and requiring immediate medical treatment in hospital within 24 hours of the accident. If further hospital treatment (as an admitted patient) is required, the patient must be re-admitted to a hospital within 90 days of the initial hospital treatment. Admission The period of time during which a person is admitted as an inpatient for a condition or illness into an approved hospital/day facility for the purpose of receiving hospital treatment until the time they are discharged from the hospital/ day facility. Annual The maximum of benefits payable to a member in a calendar year, commencing 1 st January and ending 31 st December. Approved service provider A provider or service that s approved by HIF. If you re unsure about the status of a hospital, medical or extras provider, contact us on Unless stated, extras services are not approved unless the health provider and HIF member (patient) are both physically present in the health provider s registered practice at the time of a consultation. Basic benefit When the benefit payable is equivalent to the benefits available if the service was provided in a shared room in a public hospital. Benefit The payment due to the primary member for services received by an approved provider. Couples A couples membership includes one Adult member and Partner only. It does not include dependants. Dependant When you hear us refer to a "dependant", we mean a person who is dependant upon the primary member. This includes children, stepchildren, legally adopted children, or children to whom the primary member is the legal guardian. Dependants can stay on your family membership until their 21st birthday or, for full-time students at a recognised educational institution, until their 25th birthday. Dependants are not means-tested and do not have to live at home; however, dependants cannot be married or in a de-facto relationship and remain on the family membership. To register a dependant as a student, please download a Student Declaration Form from hif.com.au/forms and return a signed copy to hello@hif.com.au. Dependants without a student declaration will be automatically removed from a family membership on their 21st birthday. Excess The amount selected on a Hospital cover which the primary member agrees to pay before a benefit will be payable. Excluded service Services that are not by a benefit, so all costs will be paid by you. Extras At HIF, we call ancillary cover Extras it s our name for all those day-to-day health care services, such as dental, optical and physio, plus a whole host more, including emergency ambulance cover. Federal Government Rebate The proportion of private health cover premiums that the Government contributes for permanent Australian residents. HICAPS/ISOFT Providers with HICAPS or ISOFT technology can electronically claim your benefit directly from HIF

29 Inpatient A person who has been admitted into an approved hospital or day facility, allocated a bed and then discharged following treatment. Lifetime Health Cover Age The age that each member of a health fund is assigned when they first purchase Hospital cover from a registered health fund. The certified age at entry is based on a person s actual age at the time of joining a hospital fund table. Medicare Benefit Schedule (MBS) The schedule of benefits produced by the Department of Health and Aged Care, listing eligible services, fees and benefits for Medical Services, including inpatient services. The MBS is used to calculate the 75% Medicare benefit payable in respect to inpatient services. Non-contracted hospital A private hospital not contracted by the Australian Health Services Alliance or HIF to provide services to HIF members. Out-of-pocket costs cannot be guaranteed in these hospitals (basic default benefit applies). Out-of-pocket The amount remaining to be paid by the member after the HIF and/or Medicare benefits have been paid. Outpatient An outpatient is someone who has received medical treatment in a doctor s surgery or casualty department and has not been admitted into hospital. Benefits for outpatient services are only payable by Medicare Australia. Partner Means a person who lives with a Fund Member of the same or different gender in a marital or de facto relationship and who is under the same Fund notwithstanding the Primary Fund Member and a Partner may live apart temporarily. Policy holder A holder of an insurance policy who is referable to HIF. A holder of a HIF insurance policy is referred to as the primary member. Practitioners in private practice A practitioner who does not: a) Use any publicly funded hospital, clinic, health centre or other such facility, including a facility provided by a municipal authority for, or in connection with, the provision of an extras service for which a benefit is claimed under the extras table b) Receive publicly funded assistance or support, whether by way of remuneration, subsidy or otherwise, in connection with the provision of the extras service, except where the extras service is provided at the clinics of strategic alliance partners, joint ventures or HIF s clinics Pre-existing condition A pre-existing condition is defined as Any ailment, illness, or condition where, in the opinion of a medical adviser appointed by the health insurer, the signs or symptoms of that illness, ailment or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. Every hospital policy has a 12-month waiting period for hospital treatment for preexisting conditions. The pre-existing condition waiting period applies to new members and members upgrading their policy to any higher level benefits under the new policy. The test applied under the law relies on the presence of signs or symptoms of the illness, ailment or condition, not on a diagnosis. It is not necessary for the member or their doctor to know what their condition is or for it to be diagnosed. In forming an opinion about whether or not an illness is a pre-existing condition, the HIFappointed medical practitioner who makes the decision must take into account information provided by the member s treating doctor. This rule applies whether the ailment, illness or condition was known to the member or not. Primary member The first named member, irrespective of who pays contributions to HIF for the provision of health cover. The primary member also holds the legal responsibility to ensure the membership is kept financial at all times, and holds the right to add or remove dependants from the membership. In the instance that the primary member wishes to provide authority for another person to act on their behalf, a spousal/agents authority is required. Qualifying periods Any period occurring immediately after joining the fund or joining a higher benefiting table, during which either some or all fund benefit is not payable. Recognised educational institution An Australian educational institution such as a school, college or university, recognised by the Commonwealth, State or Territory Governments. Restricted service Hospital services which are only for payments at the basic benefit level. Transfer certificate The document transferred between registered health funds, detailing the member s fund history (including Certified Age at Entry), confirmation of the financial status of the member and claims history. Waiting periods The standard period which applies before a member becomes eligible for benefit. For more glossary terms, visit hif.com.au 56 57

30 Ready to join? Visit hif.com.au Call

31 Follow us on At HIF we re all about choice. Call, or contact us online. hif.com.au GPO Box X2221 Perth WA 6847 Australia s first certified Carbon Neutral health fund. The information in this brochure is correct as at 1 June Minor changes may occur after that date. If major changes occur, a separate insertion will be included in the brochure or the brochure will be reprinted. HIF members are encouraged to regularly download the latest copy of this brochure from hif.com.au, or contact us and we will send one to you. Health Insurance Fund of Australia Ltd (HIF) ACN An Australian public company ed by guarantee. A registered private health insurer.