Health insurance 4 April 2018

Transcription

1 Health insurance 4 April 2018

2 Contents Welcome to CUA Health 4 CUA Member Discount 5 Hospital cover 5 Hospital - what s covered 6 Hospital - what s not covered 8 More on your hospital benefits 9 Hospital waiting periods 9 Access Gap Cover Scheme 11 Extras cover 11 Extras what s covered 13 Extras - limits and benefits 13 Extras - waiting periods 22 Extras - what s not covered 22 Ambulance Benefits 23 Healthy Start Package 25 Other things you should know 30 How to claim 31 Hospital claims 31 Extras claims 32 Online Services portal 33 Joining is easy 34 Additional information 35 Privacy notice 36 Complaints 39 We are here to help 40 2 CUA Health Insurance is provided by CUA Health Ltd ABN (CHL) which is not an authorised deposit-taking institution. While CUA Health Insurance may be distributed by Credit Union Australia Ltd ABN (CUA), CUA is not liable for this product and does not stand behind CHL. Please note that benefits received under the products referred to in this brochure are paid in accordance with CUA Health fund rules. Not every aspect can be covered in this policy document. If you d like additional information please contact CUA Health. This brochure outlines the services that are covered under the products referred to in this brochure, and any applicable limits. CUA and other intermediaries receive a commission in respect of any new health insurance business entered into by the consumer through, or as a result of, the service of the intermediary. 3

3 Hi, and welcome to CUA Health Thank you for trusting CUA Health to protect the ones you love. We ve been helping Australians care for their health since Here you ll find a summary of your CUA Health Insurance like what s included in your cover, and how to make a claim. You ll also find some information on how you can make the most of: your hospital and extras cover the freedom to choose your health provider member when direct debit from a CUA Everyday account additional benefits for families like - no excess for dependants and bonus dental checkups for adults and dependants Your cover is governed by our Fund Rules, which are available on our website. Also, please read our CUA Health Member Guide for important information about your cover. Our Hospital and Extras products are available to all residents of Australia who are eligible for Medicare benefits and hold a Green or a Blue Medicare card. It s important you fully understand your policy, so if you have any questions, are not eligible for Medicare or hold a reciprocal (Yellow) Medicare card, please get in touch with us: Phone: cuahealth@cua.com.au Fax: Web: cua.com.au/health-insurance Post: GPO Box 100, Brisbane QLD 4001 CUA Health is a registered private health insurer under the Private Health Insurance Act. We re committed to the Private Health Insurance Code of Conduct. For more information please visit CUA Health Limited ABN Registered Office: 145 Ann Street, Brisbane QLD 4000 CUA Member Discount To return more value to our members who use CUA for both their banking and their health insurance, we d like to offer you a 4% on your premium, simply by paying by direct debit from a CUA Everyday account* Find out more, visit cua.com.au/health-insurance/ health- *The 4% is applied to CUA Health premiums paid by direct debit from a CUA transaction account. CUA Health reserves the right to amend or remove the and any qualifying criteria at any time. We will always provide you with reasonable notice before exercising this right. Your needs and financial circumstances have not been taken into account. Terms and conditions are available on application. Other fees and charges may apply. A General Information, Terms & Conditions brochure and Schedule of Fees are available online or from your local CUA branch. You should read both these documents before deciding whether to purchase this product, issued by CUA. Hospital cover Cover options Our private hospital products allow you to choose the level of cover that best suits your needs and budget. You can choose from our value-for-money top hospital cover options, meaning you ll be covered for all clinically relevant treatment. Or check out our mid and basic level hospital covers that include a set number of services while meeting the eligibility requirements for the Medicare Levy Surcharge exemption, the Australian Government Private Health Insurance Rebate and the Lifetime Health Cover loading. Options to save on your premium You can save on your premium by choosing a policy with an excess payment. We offer a range of excess options which include annual caps so you know the most you ll have to pay per person each year. If you ve got kids, you ll pay no excess for their hospital admission. An excess is a fixed amount you pay once in exchange for lower premium costs. For example, if you have Premium Hospital cover with $500 excess and you require hospital treatment, then you ll pay $500 per person, per calendar year. This doesn t apply to dependants listed on the policy. 4 5

4 Hospital - what s covered PREMIUM HOSPITAL NIL / $250 / $500 EXCESS* PREMIUM HOSPITAL NON-OBSTETRICS STANDARD HOSPITAL HOSPITAL ACCIDENT ONLY HOSPITAL Pregnancy (incl. childbirth) IVF and assisted reproduction Gastric banding and 24 month benefit obesity related services limitation period^ Joint replacements (incl. revisions) Cataract and eye lens procedures Renal dialysis Cardiac and related services Cancer treatment Non cosmetic plastic and reconstructive surgery Sterilisation (incl. reversal) Spinal fusion Vascular surgery Nerve treatment (for movement disorders or chronic pain) Brain surgery Stroke treatment Grommets in ears Accidents after joining Psychiatric services Restricted benefits^^ Palliative care Rehabilitation services Minor gynaecological procedures Major gynaecological procedures Removal of appendix or Appendicitis treatment Surgical removal of tonsils Surgical removal of adenoids Surgical removal of wisdom teeth Joint reconstructions and investigations (incl. arthroscopy and meniscectomy) All other inpatient treatments receiving medicare benefits Ambulance Restricted benefits^^ Restricted benefits^^ Restricted benefits^^ Restricted benefits^^ Restricted benefits^^ Restricted benefits^^ Restricted benefits^^ Excess* Nil / $250 / $500 $500 $500 $500 $500 Available stand alone? Where a particular procedure or treatment is covered on your policy, benefits will be paid towards the following services Charges for overnight or same day accommodation in a private or shared room Intensive care Operation theatre or labour ward fees Surgically implanted prostheses (to the minimum benefit listed on the Federal Government s Prostheses List). Medical gap for doctors and surgeons in-hospital medical fees up to the Medicare Schedule fees. *The excess applies once per person per calendar year. This excess is not payable for dependant children up to 23 years old (or 25 if full-time student). ^Benefits are limited to public hospital rates for the first 24 months if treated in a private hospital (see page 9 for more details). If deemed a pre-existing condition, no benefits are payable during the waiting periods (see page 10 for more details). ^^Covered in a public hospital with choice of doctor only. If treated in a private hospital, benefits limited to public hospital rates as set by the federal government. We re here to help - please contact us prior to any treatment so you fully understand what you re covered for. 6 7

5 Hospital - what s not covered Hospital treatment for which Medicare pays no benefit, like cosmetic surgery. Any difference between the fee for your doctor and/or specialist (surgeon, anaesthetist, etc) and the Medicare benefit Schedule fee or Access Gap Cover agreed fee. Prostheses required for cosmetic surgery are not covered even if they are listed on the Federal Government s Prostheses List, (as the surgery itself is not covered). Other prostheses are covered to the minimum benefit listed on the Federal Government s Prostheses List. Gap payments may be applicable to certain prostheses if charged over the minimum price. Any items of a personal nature, including TV rental or phone calls that are not part of the agreed hospital charges. The patient s portion applied to any nursing home type patient admission into a public or private hospital. This amount is determined by the Federal Government. Experimental and some high-cost drugs not included in the TGA Schedule. Services not invoiced by the hospital. Treatment provided at an Emergency Department as an outpatient or in an emergency ward. Hospital cover only covers you when you are admitted for treatment in hospital. Any treatment considered an outpatient service e.g. Radiation Treatment. Benefits relating to sport, recreation or entertainment unless they re part of an approved chronic disease management or a health management program. Extras services for which a Medicare benefit is payable, except as allowable as hospital substitute treatment. Treatment, goods or services provided during a waiting period. See page 10 for more details of waiting periods. Any check-ups or treatment not requiring admission to a hospital. Services relating to IVF or other reproductive assistance that don t require hospital admission. The cost of residential aged care e.g. nursing homes, aged care facilities or for associated respite care. More on your hospital benefits Agreement hospitals CUA Health has agreements with the majority of private hospitals and day surgeries in Australia. If your chosen hospital or day surgery doesn t have an agreement with CUA Health, you may be subject to large out-of-pocket expenses, in addition to any excess payment. Please check with us or your hospital prior to admission. A complete list of agreement hospitals is available at Benefit limitation periods CUA Health has a 24 month benefit limitation period for Gastric banding and obesity related treatment. During the first 24 months, benefits paid for these treatments will be limited to the same amount you d receive in a public hospital. After 24 months you ll be eligible for the full benefits under your policy. Benefit limitation periods run concurrently with any waiting periods that may apply to your cover. They don t apply if you re transferring from another hospital policy (with CUA Health or another insurer). Hospital waiting periods There s a period of time you ll need to wait before you can claim certain services on your Hospital cover. This can relate to different situations: when you get health insurance for the first time in Australia if you switch insurers and haven t fully served your waiting periods if you increase your cover (with CUA Health or when switching from another insurer). In the first two situations above, you won t be able to claim until your waiting period is over. However, if you ve increased 8 9

6 your cover (with CUA Health or when switching from another insurer) you ll be covered under your previous level of cover (or a CUA Health cover deemed similar to your cover with the previous fund if you are transferring) until you ve served waiting periods for the new higher level of cover. This table shows the waiting periods that apply to different services. Accidents and Ambulance Rehabilitation, Palliative care and Psychiatric care (including when pre-existing); and all other hospital treatments Pregnancy and other Obstetrics related conditions All other pre-existing conditions 1 day 2 Months 12 Months 12 months Accident An unforeseen and sudden event occurring by chance and caused by an external force or object, resulting in Involuntary bodily injury requiring immediate treatment from a medical practitioner or presentation to an emergency department, which occurred after joining the fund. It does not include any condition that can be attributed to medical causes. Pre-existing condition (PEC) A condition where signs or symptoms of your ailment, illness or condition - in the opinion of a medical practitioner appointed by us - existed at any time during the six months before you purchased your hospital cover or upgraded to a higher level of hospital cover. It is not necessary that you or your doctor knew what your condition was or that the condition was diagnosed. Treatment of all PECs have a 12 month waiting period, with the exception of some psychiatric care, rehabilitation and palliative care (the 2 month waiting period applies to these services). A medical practitioner appointed by us decides whether an ailment, illness or condition is pre-existing, not you or your doctor. They will consider your treating doctor s opinions regarding signs and symptoms of your condition, but is not bound to agree with them. Australian Government s Mental Health Upgrade Guarantee allows eligible members to upgrade to a higher level of hospital cover without any waiting periods once in a lifetime. Contact us for more information. Access Gap Cover Scheme Getting better is the only thing you should have to worry about when you go into hospital. CUA Health offers you access to a scheme that helps to simplify your claims for medical expenses. The Access Gap Cover Scheme will reduce or in some instances remove your out-of-pocket expenses for specialist care you receive while in hospital. Doctors and specialists who choose to participate in the Access Gap Cover Scheme can bill CUA Health directly. So, not only does your hospital treatment cost you less, but the billing system is made easier for you too. Access to a list of doctors and specialists participating in the Access Gap Cover Scheme is available at com.au/health-insurance/search-providers. If your doctor or specialist chooses to use the Scheme, you will either: have no out-of-pocket expenses, or be provided with an estimate of out-of-pocket expenses before your treatment. Your doctor or specialist may choose to use the Scheme on a patient-by-patient basis. Of course, whether or not your doctor or specialist participates in the Access Gap Cover Scheme will not affect the treatment you receive. At your first consultation with your doctor or specialist you should ask if they will be providing your treatment in hospital with no gap for you to pay. If there is a gap for you to pay, then ask what the gap amount will be. Remember, you re entitled to know how much you ll have to pay. Then you can choose to accept the amount to be charged. If you re not happy with the amount they will charge, you can always consult another specialist. Please refer to Appendix A on page 36 for more details on how you ll be covered at different types of hospitals. Extras cover Regardless of how great your health is, the need for dental, optical, pharmaceutical or physiotherapy services could arise. CUA Health Extras cover provides benefits for a range of services

7 For only a few dollars each week, CUA Health Extras cover can help reduce your costs for many of those services not covered by Medicare up to the limits shown on the following pages. With CUA Health Extras covers, you re not restricted by a network of preferred providers so you can choose when and where you re treated, and which healthcare provider you see. However, it s important to know that we only pay a benefit for services performed by practitioners in a private practice, provided their governing body or professional associations and services are recognised by us. If you re unsure if the provider you have selected, or service you require is covered under our policy, please contact CUA Health for confirmation. The following items, limits and benefits are provided as a general guide only. Please call us if any further information is required or login to CUA Health Online Services to obtain a detailed benefit quote. All limits are calculated for a calendar year i.e. 1 January to 31 December each year. Extras what s covered General dental Major dental Orthodontics Optical Non-PBS pharmaceuticals Physiotherapy Chiropractic Podiatry Alternative therapies Psychology Speech therapy Eye/Orthoptic therapy Occupational therapy Dietetics & nutrition Exercise physiology Health aids & appliances Bonus Dental Check-ups On Total & Classic extras covers, you will receive additional general dental benefits to help reduce or eliminate the cost of dental care. For routine dental services (comprehensive examination item 011, periodic oral examination - item 012, scaling/cleaning item 114, and fluoride item 121) there will be no out of pocket expenses up to a total value of $250 per visit, for the first visit every year for adults and for two visits every year for dependants under 23. Dependants under 23 can also claim one mouth guard item 151 every year. Ambulance transport Wellness benefits Available stand alone? Extras - limits and benefits On Essential extras only dependants under 23 receive no out of pocket expenses up to a total value of $250 per visit for the first two visits every year for routine dental services (comprehensive examination item 011, periodic oral examination - item 012, scaling/cleaning item 114, and fluoride item 121). On all the above covers, this benefit is paid out of the general dental annual limits. Dental General dental Major dental Includes endodontics, periodontics (e.g. treatment of gum disease), root canal, crowns, dentures and bridges; & major restorative fillings (e.g. veneers) No annual limit $1300 Year 1 - $700 Year 2 - $800 Year 3 - $900 Year 1 - $650 Year 2 - $700 Year 3 - $750 $400 Orthodontics $900 (Lifetime limit $2,500 ) $500 (Lifetime limit $1,500 ) 12 13

8 Examples of benefits Periodic oral examination (Item # 012) $35 $26 $23 Specsavers Frames and lenses Only available from the $149 and above range purchased at retail stores. No on two pair deals or complete glasses with less than $149 value. 25% X-rays (Item # 022) $28 $21 $18 Scale & clean (Item # 114) $70 $53 $46 Fluoride treatment (Item #121) $22 $17 $14 Simple extraction (Item # 311) $100 $75 $65 Surgical extraction (Item # 322) $176 $132 Root canal obturation (Item #417) $184 $138 One surface filling (Item # 511) $84 $63 $55 Three surface fillings (Item #513) $120 $90 $78 Crown (Item 615) $974 $600 Bridge (Item 643) $755 $566 Full dentures (item 719) $1,100 $600 Optional lens extra Includes Suntint & UV filter, polaroid lenses, transition lenses, driving tints, Drivewear lenses, Thin & Light lenses Contact lens assessment, fitting and trial Eye test Bulk billed to Medicare plus free Digital Retinal Photography Eyebenefit Lenses Spectacle lenses only Frames and lenses For one pair of complete spectacles Contact lenses VSP Global Lenses and lens add-ons All in store contact lenses 20% Free Free 15% 20% 10% 15% Optical All lens add-ons Choice of frames and lens packages available at ed prices in store 20% Calendar year limit per person $250 $200 $150 Frames, lenses, tinting, repairs, contact lenses - items available by prescription only 100% up to limit 100% up to limit 100% up to limit Physiotherapy No benefits are paid for frames only purchases All CUA Health policy holders get additional s from the following optical retail stores: Calendar year limit per person Year 1 - $700 Year 2 - $800 Year 3 - $900 Year 1 - $550 Year 2 - $600 Year 3 - $650 $250 Luxottica (OPSM, Laubman & Pank) Lenses and Lens add-ons Off the normal retail price for all lenses purchased at retail stores. 20% Examples of benefits Initial consultation (max. 3 per calendar year) $50 $38 $34 Non-prescription sunglasses Off the normal retail price for all non-prescription sunglasses purchased at retail stores. 15% Subsequent consultation $33 $26 $22 Extended home treatment $41 $33 $27 Contact lenses Off the normal retail price for all contact lenses purchased at retail stores. OPSM Direct 10% Group session (hydrotherapy or pilates group session run by a physiotherapist) $9 $7 $6 Additional 5% off the online price, plus free delivery within Australia, for contact lenses purchased from OPSM online (

9 Chiropractic & osteopathic Pharmaceutical Calendar year limit per person Examples of benefits Initial consultation (max. 3 per calendar year) Subsequent consultation Year 1 - $400 Year 2 - $450 Year 3 - $500 $250 $200 $45 $34 $30 $27 $22 $18 Chiropractic x-rays $70 $53 $35 Calendar year limit per person $570 $250 $100 Cover for items prescribed or provided by a medical practitioner. An official pharmaceutical receipt is required. Some services not covered include: Pharmaceutical Benefit Scheme (PBS) scripts items normally available without a doctor s prescription contraceptives unless prescribed specifically for the treatment of an illness (a letter from your medical practitioner is required each calendar year) Purchases from a pharmacy will require an official pharmaceutical receipt or invoice with the policy holder s name. Examples of benefits Alternative Therapies Acupuncture Naturopathy & homeopathy Remedial massage & other therapies including Reflexology, Kinesiology, Bowen therapy, Aromatherapy and Remedial Therapy. Examples of benefits Acupuncture, Homeopathy, Naturopathic services Initial consultation (max. 3 per calendar year combined for all alternative therapies) $400 Up to $800 per family Sublimit $250 per service group $250 Up to $500 per family Sublimit $150 per service group $100 Up to $200 per family $45 $36 $30 You pay an amount equivalent to PBS contribution (e.g. $39.50 as of 1 January 2018) and we cover the balance of the script up to Ambulance transport Podiatry and orthotics $50 $35 $25 100% 100% 100% For residents of all states, except Queensland and Tasmania, benefits are payable for emergency ambulance transport costs occurring anywhere within Australia (including aerial ambulance), where the service is provided by a fund recognised Ambulance service provider and the use of an ambulance is directed by a hospital or medical practitioner due to the seriousness of a policy holder s medical condition. State government ambulance transport schemes operate in Queensland and Tasmania. Calendar year limit per person $400 $ Subsequent consultation $27 $22 $18 Bowen Therapy, Remedial Therapy, Kinesiology, Reflexology and Aromatherapy Per consultation $27 $20 $18 Note: Benefits for multiple consultations with the same provider, for different treatments are payable only when services are provided with at least a 2 hour time difference between consultations. No benefits are paid for any medicines or herbs. The provider must be registered with ARHG (or relevant governing body recognised by us) for any alternative therapy claim to be paid. Examples of benefits Initial consultation (max. 3 per calendar year) $36 $29 Subsequent consultation $29 $23 Foot surgery performed by Australian Government accredited podiatrists 80% 60% Podiatry-related aids* (including custom-made orthotics) 80% 60% * No benefit is payable on pre-made, off-the-shelf and/or customised items. Benefits only paid for custom-made orthotics. A 12 month waiting period applies for orthotics. 17

10 Health aids and appliances Other services Calendar year limit per person $800 $600 Calendar year limit per person $500 $250 Examples of benefits Examples of benefits All aids & appliances 80% of cost up to sub-limit for that aid/ appliance 60% of cost up to sub-limit for that aid/ appliance Psychology Initial consultation $85 $68 Repair of health aids & appliances 80% of cost up to sub-limit of $150 within the limit for that aid or appliance 60% of cost up to sub-limit of $100 within the limit for that aid or appliance Subsequent consultation $62 $50 Group consultation $40 $32 Orthoptic eye therapy Health aids and appliance sub-limits and business rules Hearing aids: One set of hearing aids per person every 3 years Blood glucose monitors: Sub-limit of $500 per person, per year on Total Extras, $350 on Classic Extras Nebulisers: Sub-limit of $300 per year on Total Extras, $200 on Classic Extras. One device per person every 2 years CPAP devices: Sub-limit of $500 per year on Total Extras, $350 on Classic Extras. One device per person every 2 years. A recognised sleep study program must have been undertaken for a CPAP pump. Replacements for full CPAP masks are payable every 2 years from the date of previous supply. Benefits are not payable towards any hire of CPAP masks and CPAP pump components TENS machine/circulation boosters: Sub-limit of $175 per year on Total Extras, $125 on Classic Extras. One device per policy every year Peak flow meters/spacers: Sub-limit of $50 per year on Total Extras, $35 on Classic Extras. One device per person every year Blood pressure monitor: Sub-limit of $175 per year on Total Extras, $125 on Classic Extras. One device per policy every year Mammary prosthesis: Sub-limit of $175 per year on Total Extras, $125 on Classic Extras Repair of Health Aids and Appliances: Benefits only payable if the appliance is not under warranty. Repair benefits will not be paid within the warranty period. Benefits for repairs count towards the limit of that Health Aid/Appliance. No sub-limit for other prostheses including pressure garments, custom-built braces, splints and other approved orthoses. Benefits are only payable for custom-made braces. Otherwise, no benefits are payable on pre-made and/or customised items. Benefits for compression stockings or circulation boosters are payable for chemotherapy or lymphedema, venous stasis or major surgery. We may require a letter from a medical provider before payment of wigs, compression stockings or circulation boosters. Benefits for wigs are payable from approved providers for chemotherapy or alopecia only. The list above is not comprehensive and may include other Health Aids and Appliances apart from the ones listed above. Benefits are only paid on purchases from companies with registered Australian Business Numbers (ABNs) We may ask for additional supporting documentation in order to pay a benefit for some other health aids and appliances e.g sleep study report for a CPAP device, proof of custom made orthotics, etc. Each visit $86 $69 Occupational therapy Initial consultation $59 $47 Subsequent consultation $38 $30 Speech therapy Initial consultation $80 $64 Subsequent consultation $38 $30 Dietitian and Nutritionist* Initial consultation $51 $41 Subsequent consultation $29 $23 Exercise physiology Consultation $45 $36 Group session $9 $7 * Nutritionists must be registered with The Nutritionists Society of Australia to be eligible to receive any benefits. Wellness Benefits Calendar year limit per person Year 1 - $250 Year 2- $325 Year 3- $400 Year 1 - $100 Year 2- $150 Year 3- $

11 Wellness Benefits include the following services: Quit smoking You can claim benefits towards hypnotherapy and nicotine replacement therapy (patches, gum, lozenges and inhalers) to assist in quitting and reducing smoking to help improve or prevent an associated health condition, when such services aren t claimable under the PBS. The benefits are limited to 50% of the cost, to a maximum of $100 (Total Extras) or $75 (Classic Extras) per year. Health association fees & subscriptions You can claim benefits equivalent to 50% of association fees for the Arthritis Foundation, Asthma Foundation, Coeliac Society, Diabetes Australia, Heart Foundation, Crohn s and Colitis Association, Parkinson Australia, Australian Breastfeeding Association and Ostomy Associations to help manage and receive support for these diagnosed chronic conditions or life stages. The benefits are limited to 50% of the cost to a maximum of $100 (Total Extras) or $75 (Classic Extras) per year. Health management programs You can claim benefits towards approved health management programs intended to prevent or manage a diagnosed health condition. Benefits are payable for services where they re part of a health management program or are provided on the advice of a health professional approved by us, and where the treatment is intended to improve a specific health condition/s. A health management program benefit approval form renewal is required every year. Goods or services that are primarily for the purpose of sport, recreation or entertainment are not eligible for benefits. For example, you can t claim for any sports club membership, gym membership or sporting equipment, footwear or clothing. You ll need to provide us with a health management program benefit approval form, along with: a tax invoice from the program provider benefits are limited to 50% of the cost to a maximum of $125 (Total Extras) or $100 (Classic Extras) per year. Health checks, scans & screenings Benefits can be claimed for doctor s health checks and Healthy Heart checks to assist with early diagnosis and/or prevention of an illness or condition. You can also claim benefits towards some services that assist with early diagnosis and/or to prevent an illness or condition e.g. Health screenings at a pharmacy. Benefits are limited to 50% of the cost to a maximum of $75 (Total Extras) or $50 (Classic Extras) per year. pre-employment or pre-visa health checks) or when it can be claimed through a third party insurer. Kids swimming lessons You can claim benefits towards swimming lessons for dependants covered on your policy, provided by an Austswim or Swim Australia accredited swim school or instructor. A medical practitioner or doctor s recommendation to undertake swimming classes due to a specific health condition needs to be provided to us. The benefits are limited to 50% of the cost to a maximum of $150 (Total Extras) or $100 (Classic Extras) per year. Weight control You can claim benefits towards approved weight management programs only when they are intended to prevent or manage a diagnosed health condition. Benefits are payable for services when they re part of a health management program and where the treatment is intended to improve a specific health condition or condition/s. A letter from a medical practitioner referring the program may be needed clearly stating that the referred program is to manage the condition that has been diagnosed and its expected outcomes. The benefits are limited to 50% of the cost to a maximum of $200 (Total Extras) or $100 (Classic Extras) per year. Travel vaccinations Benefits can be claimed for travel vaccinations when not claimable under a Medicare rebate. The benefits are limited to a maximum of $50 (Total Extras) or $35 (Classic Extras) per person per year. Mammograms Benefits can be claimed for mammograms when not covered by the Medicare rebate. Benefits are limited to a maximum of $100 (Total Extras) or $80 (Classic Extras) per person per year. Travel expenses You can claim benefits for travel expenses if a hospital admission is required for a policy holder, or a dependant covered on the policy, outside their usual place of residence and the return distance trip is greater than 400 km. You ll need to give us a tax invoice that includes the date of service and service provider s ABN. The benefits are limited to 50% of the cost to a maximum of $200 (Total Extras) or $100 (Classic Extras) per year. Benefits are not paid for any accommodation required for family members during hospital admission or when no hospital admission is needed e.g. visits to specialists etc. However, you can t claim a benefit if the test is claimable through Medicare. Also, the benefit isn t payable when the health check is related to employment or immigration requirements (such as 20 21

12 Extras - waiting periods When you take out health insurance for the first time, switch insurers and haven t fully served your waiting periods, or increase your level of cover, CUA Health asks that you wait a period of time before you can claim for certain services. To find out what waiting periods apply, take a look at this table. 1 day Ambulance 2 months General dental Physiotherapy Chiropractic & Osteopathic Alternative therapies Pharmaceutical Podiatry Orthoptic (eye) therapy Clinical psychology Occupational therapy Speech therapy Dietitian and Nutritionist Exercise physiology 6 months Optical Wellness Benefits 12 months Major dental (e.g. veneers, crowns and bridges, dentures, wisdom teeth, periodontics, endodontics) Orthodontics All health aids and appliances (including hearing aids) Podiatry-related aids/ Orthotics Extras - what s not covered Any ancillary treatment for which Medicare pays a benefit, like Psychology or Physiotherapy services referred by a GP and paid by Medicare Any difference between the fee for your provider and benefit paid by us Benefits relating to sport, recreation or entertainment unless they re part of an approved health management program Services where there is no itemised invoice, date of service, provider details and patients details, or other information that we may ask for to assess that claim Any treatment considered an inpatient service Any other treatment that is outside the definition of ancillary services we provide a benefit for. Ambulance Benefits We will only provide ambulance benefits, when you do not hold a subscription with an ambulance provider, and are not eligible for concession or a free ambulance transport, and the state ambulance scheme does not provide cover. State Ambulance schemes Most State schemes cover their respective residents within their state of residence only. However, some states have entered into reciprocal agreements that allow you to be covered for ambulance services when you travel outside your state of residence. You should check with your state ambulance provider for when these reciprocal arrangements apply and the level of cover offered. NSW and ACT: If you reside in New South Wales or the Australian Capital Territory and you have Hospital cover, you pay an ambulance levy as part of your premium. This entitles you to free emergency ambulance transport under the State Government ambulance transport schemes. When you receive an account for ambulance transport, simply send it to us and we ll endorse it for you to send back to the appropriate ambulance transport scheme. QLD and Tas: If you reside in Queensland or Tasmania, you are covered under your state service scheme. Vic, SA, WA and NT: If you reside in Victoria, South Australia, Western Australia or the Northern Territory you will receive cover for recognised emergency ambulance transport and on-the-spot treatment from us. This is as long as you don t have an ambulance subscription with your State ambulance service or cover through a state-based arrangement Government Concession Card holders Health Care Concession Card and Pensioner Concession Card holders are entitled to free ambulance transport services. Additionally, in NSW, Commonwealth Seniors Health Card holders are also entitled to free ambulance transport services. Certain types of concession cards issued by Centrelink or the Department of Veterans Affairs (DVA) entitle the cardholders to free ambulance services. These arrangements also vary per state so should be checked directly with Centrelink or the DVA. When will CUA Health cover me? If you fall outside your state-based arrangement (including any reciprocal agreement) and are not covered for emergency ambulance services, you ll be covered by CUA Health as long as the services are provided by a recognised provider

13 Emergency Ambulance If you have a CUA Health cover, you re covered for Emergency Ambulance services provided by a CUA Health approved ambulance provider. This means a sudden or unexpected need for hospitalisation where the only practical way of getting to a hospital is by ambulance. We don t pay benefits for ambulance subscriptions and we don t cover you for other ambulance services such as: Transfer between a public and private hospital. Changing hospitals to be closer to home. Travelling from home to hospital for tests or consultations. Any transport on discharge from hospital (e.g. hospital to home). any other patient transport services. Recognised Ambulance Providers We will only pay benefits towards ambulance services when they are provided by recognised providers including: ACT Ambulance Service Ambulance Service of NSW/NEPT - PTS Ambulance Victoria Queensland Ambulance Service South Australia Ambulance Service St John Ambulance Service Tasmanian Ambulance Service Healthy Start Package Packaged cover If you are looking for health cover to get you started, our Healthy Start Package offers you basic level hospital cover if the unexpected happens and that little bit extra to keep you fit and healthy, like physiotherapy and remedial massage. Where a particular procedure or treatment is covered on your hospital policy, benefits will be paid towards the following services: charges for overnight or same day accommodation in a private or shared room intensive care operation theatre fees surgically implanted prostheses (to the minimum benefit listed on the Federal Government s Prostheses List). medical gap for doctors and surgeons in-hospital medical fees up to the Medicare Schedule fees. Benefit conditions and waiting periods related to Hospital apply as stated in pages 10 and 11. Our Healthy Start Package also pays benefits towards common Extras services, as listed below. Waiting periods may apply, see page 21. CUA Health also pays benefits for Ambulance Services provided by another provider where the service is provided on behalf of and invoiced by one of the above State Ambulance Services. Healthy Start Package cover is available only for singles and couples. Minor gynaecological procedures Grommets in ears Accidents after joining Removal of appendix or Appendicitis treatment Surgical removal of tonsils Surgical removal of adenoids Joint reconstructions and investigations (incl. arthroscopy and menicectomy) Wisdom teeth removal Ambulance Psychiatric services Palliative Care Rehabilitation services Pregnancy (incl. childbirth) IVF and assisted reproduction Gastric banding and obesity related services Joint replacements (incl. revisions) HOSPITAL COVER Restricted benefits^^ Restricted benefits^^ Restricted benefits^^ 24 25

14 Cataract and eye lens procedures Renal dialysis Cardiac and related services Cancer treatment Non cosmetic plastic and reconstructive surgery Sterilisation (incl. reversal) Spinal fusion Vascular surgery Nerve treatment (for movement disorders or chronic pain) Brain Surgery Stroke treatment Major gynaecological procedures All other inpatient treatments receiving medicare benefits HOSPITAL COVER Excess* $500 ^^Covered in a public hospital with choice of doctor only. If treated in a private hospital, benefits limited to public hospital rates as set by the federal government. *The excess applies once per person per calendar year. Limits and benefits General & Major Dental Annual Limits (per person, per calendar year) Year 1 - $350 Year 2 - $350 Year 3 - $450 Examples of benefits Periodic Oral examination (Item # 012) $23 X-rays (Item # 022) $18 Scale & clean (Item # 114) $46 Fluoride treatment (Item #121) $14 Simple extraction (Item # 311) $65 Surgical extraction (Item # 322) $118 Root canal obturation (Item #417) $123 One surface filling (Item # 511) $55 Three surface filling (Item #513) $78 Crown (Item # 615) $350 Bridge (Item # 643) $350 Full dentures (item # 719) $350 General dental Major dental Optical Physiotherapy Chiropractic Ambulance transport Alternative therapies Orthodontics Non-PBS pharmaceuticals Podiatry Psychology Speech therapy Eye/Orthoptic therapy Occupational therapy Dietetics & nutrition Exercise physiology Health aids & appliances Wellness Benefits COVER Remedial massage only Optical Annual Limits (per person, per calendar year) Year 1 - $150 Year 2 - $150 Year 3 - $200 Examples of benefits Frames, lenses, tinting, repairs, contact lenses - items available by prescription only No benefits are paid for frames only purchases 100% up to Limit All CUA Health policy holders get additional s from the following optical retail stores: Luxottica (OPSM, Laubman & Pank) Lenses and Lens add-ons Off the normal retail price for all lenses purchased at retail stores. Non-prescription sunglasses Off the normal retail price for all non-prescription sunglasses purchased at retail stores. 20% 15% Contact lenses Off the normal retail price for all contact lenses purchased at retail stores. 10% 26 27

15 OPSM Direct Additional 5% off the online price, plus free delivery within Australia, for contact lenses purchased from OPSM Direct ( Specsavers Frames and lenses Only available from the $149 and above range purchased at retail stores. No on two pair deals or complete glasses with less than $149 value. Optional lens extra Includes Suntint & UV filter, polaroid lenses, transition lenses, driving tints, Drivewear lenses, Thin & Light lenses Contact lens assessment, fitting and trial Eye test Bulk billed to Medicare plus free Digital Retinal Photography Eyebenefit Lenses Spectacle lenses only Frames and lenses For one pair of complete spectacles Contact lenses 25% 20% Free Free 15% 20% 10% VSP Global Lenses and lens add-ons All in store contact lenses All lens add-ons Choice of frames and lens packages available at ed prices in store 15% 20% Physiotherapy, Chiropractic, Osteopathy, Psychology & Remedial Massage Annual Limits (per person, per calendar year) Year 1 - $300 Year 2 - $300 Year 3 - $350 Examples of benefits Physiotherapy Initial consultation (max. 3 per calendar year) $34 Subsequent consultation $22 Extended home treatment $27 Group session (hydrotherapy or pilates group session run by a physiotherapist) $6 Chiropractic & Osteopathy Initial consultation (max. 3 per calendar year) $30 Subsequent consultation $18 Chiropractic X rays $35 Remedial Massage Per Consultation The provider must be registered with ARHG $18 (or relevant governing body) for any alternative therapy claim to be paid. Psychology Initial consultation (max. 3 per calendar year) $57 Subsequent consultation $42 Extended home treatment $27 Healthy Start Bonus Each person covered on this policy upon joining and, each calendar year thereafter will receive a $100 bonus that can be used to offset any gaps on your extras services. Any unused portion of the Healthy Start Bonus does not roll into the next calendar year

16 Other things you should know You can pay your premiums up to 12 months in advance You may not contribute to similar insurance policies with more than one private health insurer Family policies provide cover for the policy holder, their spouse and any dependant children until their 23rd birthday. Full-time student dependants are covered up until they turn 25, as long as they confirm to us each year (after they turn 23) that they are still students We ll waive the waiting periods for a baby, provided they re added to a Single Parent or Family policy from their date of birth No benefits are paid for services able to be claimed by way of compensation or damage. CUA Health reserves the right to a full and immediate reimbursement of any claims covered by way of compensation or damages from another party. Your health cover does not pay benefits for products, services or treatments purchased from or provided by practitioners overseas, whether you buy them in person, by mail order or online No benefits are paid for treatment, goods or services if false or misleading information is provided. Benefits are not payable for services provided by a family member. Suspending your cover You must have held a CUA Health policy for 12 months before becoming eligible for suspension Policy holders may apply to suspend their policy for periods of 2 months to 36 months while overseas Documents such as, but not limited to, your boarding pass or overseas itinerary may need to be sighted by us before cover is reinstated CUA Health does not pay benefits for any services received while overseas. Remember, if suspending your cover while overseas, you might be liable for the Medicare Levy Surcharge if your income exceeds the relevant threshold. Payment in arrears If you get too far behind in your payments (two months or more) your policy will automatically be cancelled. If this happens, full waiting periods will apply if you decide to re-join. Benefits won t be paid while premiums are in arrears. How to claim Before you claim, please remember: All Extras claims under $500 need to be paid in full prior to claiming You ll need to serve the relevant waiting periods (as outlined in this brochure) Premium payments must be up to date The service must have already been provided and paid for (you can t claim for a service before it s been provided) Claims need to be lodged within two years from the date the service was provided. The healthcare provider must be recognised by CUA Health Hospital claims Claims for treatment you receive in hospital after being admitted will be sent to CUA Health for assessment. Please read the claim form carefully and sign the form. If your policy requires you to pay an excess then you ll need to pay this directly to the hospital. Medical claims The federal government has a schedule of fees for medical services (i.e. doctor s and specialist s services) known as the Medicare Benefits Schedule (MBS). For privately insured patients, Medicare pays 75% of the fee for a medical service provided in hospital, and CUA Health pays the remaining 25%. If the doctor charges in excess of the MBS, a gap payment is required. This is in addition to any contributions that are applicable to the cover you have selected. For example, Julie s doctor has charged $1500 for an item for which the MBS allows $1000. Medicare covers $750 (75%) and CUA Health $250 (25%). Julie s gap payment is $500. If your doctor participates in the Access Gap Cover 30 31

17 Scheme your account will be automatically forwarded to us for processing. Any medical account you receive should be submitted to Medicare on a Two-Way claim form. Extras claims On-the-spot claiming After visiting your healthcare provider, simply swipe your CUA Health card for on-the-spot claiming. All you pay is the difference between your account and the benefit paid for the service. Mobile claiming With the CUA Health Mobile Claiming app, you can use your smartphone to claim on Extras. To claim, all you need to do is take a photo of your invoice and then submit it with just the click of a button. You don t need to fill out any paperwork. Our app is free to download and works on iphones, Android phones and most tablets. To download the app, just head to the App store or Google Play and search for CUA Health. Claim by mail or in-branch Claim forms are available by visiting our website cua.com.au/health-insurance, through your CUA branch or by contacting us on Once you ve completed a paper claim form, attach the account and invoice and post it to us, fax it or drop it off at your local CUA branch. Benefits payable will be credited to your nominated bank account, or a cheque will be posted to you. Online Services portal You can use our Online Services portal to: submit most Extras claims check your Extras benefits balance check specific details about your cover manage your policy and personal details. Log in to to access these services. Submit most of your Extras claims Online You can claim benefits online for the following services: General dental Optical Physiotherapy Chiropractic & Osteopathic Occupational therapy Dietitian Podiatry Speech therapy Exercise physiology. Extras claims of up to $300 are assessed online immediately, so you ll know straight away how much you ll get back from your claim. Check your Extras benefits balance You can check how much you ve claimed, how much you have left on your annual benefit limit, and then plan additional treatments before your claim limits are refreshed each year (1 January). Check specific details about your cover Find out about any waiting periods or exclusions that might apply to your policy. Manage your policy and personal details You can manage your policy information anytime: change your contact details download your annual tax statement view your payment history set up/update direct debit or direct credit payment details make an immediate credit card payment 32 33

18 Joining is easy Additional information To join CUA Health visit cua.com.au/health-insurance and apply online, drop into your local branch or call us on If you join CUA Health, confirmation of your cover and policy information will be sent to you. If you re switching from another health provider If you re transferring from another health insurer, you won t lose your continuity of cover as long as you join us within two months of the date that you were paid up to with your previous health insurer. If you re without cover for more than 2 months then full waiting periods will apply. We ll record your official date of joining CUA Health as at the day immediately after the date you were paid to with your previous insurer, so there s no period of time for which you re not covered. Your premiums will also be deducted from that date. When you switch to CUA Health, we ll pick up where your other insurer left off. If you re switching to a higher level of cover or you haven t fully served your waiting periods, you ll be asked to serve these before you can start making claims. Where limits apply, any benefits already paid by your previous health fund will be treated as if CUA Health had paid them. To keep it simple, CUA Health will contact your previous health insurer to get a clearance certificate on your behalf. Please note that if you have an arrangement with another financial institution or your employer to make regular payments covering your premiums to your present insurer, you ll need to cancel this arrangement yourself. Australian Government Rebate (AGR) To encourage people to look after their health the Australian Government provides a rebate on private health insurance. The rebate changes depending on how much you earn every year. You can claim the rebate as a reduction to your regular premiums or as a tax rebate when you do your yearly tax return. For more information visit Medicare Levy Surcharge The Medicare Levy Surcharge (MLS) is levied on Australian taxpayers who do not have an appropriate level of private hospital insurance and who earn above a certain income. The MLS is in addition to the Medicare Levy and is income-tested, which means the more you earn the higher MLS you ll pay. All CUA Health hospital policies exempt you from the Medicare Levy Surcharge. For more information visit: Lifetime Health Cover The Lifetime Health Cover (LHC) is a government initiative designed to encourage people to take out private hospital insurance earlier in life and to maintain their cover. People who delay taking out private hospital cover will pay a 2% loading for 10 years on top of their premium for every year they re aged over 30 when they first take out private hospital cover. For more information visit: Cooling-off period If you change your mind, CUA Health provides a cooling-off period of 30 days from the start date of your policy. If you wish to cancel, you ll need to advise us in writing during the first 30 days after joining and any premiums paid will be refunded in full, providing you haven t made a claim. cuahealth@cua.com.au Phone: Fax: Post: GPO Box 100, Brisbane QLD 4001 More information on Australian Government Rebate, Medicare Levy Surcharge, Lifetime Health Cover and everything else that you may want to know about your cover is available in our CUA Health Member Guide available on our website under brochures and forms section. Please visit