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Important information
Important information about your hospital cover
For more detailed information about your level of cover, download a policy document, effective 1 May 2008.
Accidents
Accidents do happen, so if you recently joined ahm and are still serving your waiting period you should call us to discuss whether your benefits apply.
If you have Top Hospital with a co-payment and you’re admitted to hospital for an accident (as defined by the hospital and ahm – see ahm’s definition below), where possible we’ll waive the co-payment upfront. The co-payment will only be waived for the first admission in relation to a non-compensable accident.
An accident is defined as an unplanned or unforeseen event resulting in bodily injury that requires immediate medical treatment in a hospital. We don’t waive the co-payment where it’s a compensable claim.
Access Gap Cover Scheme
In most cases, your health insurance will cover the majority of your costs but you may face extra expense if your specialist or doctor charges above the Medicare Benefits Schedule (MBS) fee for their services.
The Access Gap Cover scheme helps remove or reduce these costs so that you pay less for your specialist treatment in hospital, or pay nothing at all. Learn more about Access Gap Cover.
Agreed charge
To help you know your costs and benefits up front, ahm has contracts with most private hospitals, which include an agreement on how much they can charge.Ambulance transportation
You’re covered for medically necessary ambulance transport and services including air ambulance such as CareFlight, to the nearest hospital that’s able to provide the level of care you need. Some state governments however, have their own schemes in place. Find out more about ambulance cover in your state.Broader health cover
The Federal Government introduced legislation in 2007 that allows health insurers to provide more benefits to policy holders for disease management and prevention as well as services that substitute or avoid a hospitalisation. ahm has led the industry in offering health and disease management programs.
Broader health management
ahm offers a range of programs to help you manage your health and get the right support and advice when you need it.
NOTE: Changing your cover or allowing your policy to fall into arrears may affect your eligibility or participation in an ahm broader health management program.
Changing your cover
When changing your level of cover, you may be required to serve waiting periods for any additional items, increased benefits or lower co-payments that were not on your previous cover. Where limits apply, any benefits already paid on your previous cover within the current benefit year will be taken into account.
Changing your cover may affect your eligibility or participation in an ahm broader health management program.
Chronic disease
A chronic disease means a disease that has been, or is likely to be, present for at least six months, including, but not limited to asthma, cancer, cardiovascular illness, diabetes, a mental health condition, arthritis and a musculoskeletal condition.
Cooling-off Period
If the principal policy holder terminates their policy within 30 days of joining and hasn’t claimed a benefit during this period, they’re entitled to a full refund.Co-payments
A co-payment is the daily amount that you pay towards the cost of treatment if you go to any hospital or day surgery. It applies to each person covered on your policy (excluding child, adult child and student dependents and admissions as a result of non-compensable accidents for policy holders with Top Hospital, Top Hospital Level 5 or Top Hospital level 8). There are set limits for each person per membership year. To find how much you may need to pay and when, read more about how the co-payment works.Day only admission
This is when you’re admitted to a hospital and discharged on the same day. If you’ve chosen a co-payment on your cover, you’ll need to pay it in this situation.Day only surgery
This is a facility where you’re admitted, treated and discharged on the same day. If you’ve chosen a co-payment on your cover, you’ll need to pay it in this situation.Default benefit
We’ll pay the default benefit for accommodation as set by the Commonwealth Government for restricted services. The default benefit covers the cost of:
- shared accommodation at a public hospital; or
- a reduced level of accommodation benefits and no theatre fee benefits in a private hospital; plus
- medical gap
- if your doctor participates in our Access Gap Cover scheme and charges the agreed fee, we’ll cover the difference to the agreed amount;
- the difference between Medicare benefits and the Schedule fee for inpatient services; and
- surgically implanted prostheses – we’ll cover the full cost of any No Gap prostheses and the minimum benefit for Gap Permitted prostheses.
For services not covered by Medicare, the default benefit for accommodation only is payable. Any co-payment applicable to your cover will be charged even where a default benefit only is paid.
Dependents
Child dependents
Your child can be covered by a family or single parent family policy until the age of 18 if they’re single.
Adult child dependents
Your child aged 18 and over and under 21 years can be covered on a family or a single parent family policy if they’re single, not working full time and living at home.
Student dependents
Your child aged 21 and over and under 25 can be covered on a family or single parent family policy if they’re single, studying full-time and not working full-time.
NOTE: If your dependents have stopped or suspended their study, have a partner, live away from home or have entered the workforce, they should have their own health insurance policy.
Disease management appliances
Proof of the diagnosis of your condition and the recommendation for a relevant appliance by a medical practitioner must accompany a claim to receive benefits. The following forms of proof are accepted:- a doctor’s or specialist’s letter relating to management of the condition;
- a doctor’s referral to a specialist for the management of the condition;
- prescription for an appliance relevant to the condition;
- if you’re currently enrolled in an ahm disease prevention or chronic disease management program relevant to the condition
Exclusions
Some health insurers exclude certain hospital services, but you’ll be pleased to know that all our hospital covers are exclusion free!Health insurance policy
Acceptance of a policy application and continued eligibility for health insurance is conditional on the requirement that no person on the policy also has an active hospital cover with another private health insurer.
Single policy
A policy that includes only one person (the principal policy holder).
Single parent policy
A policy that includes two or more persons, of whom only one is an insured adult (the principal policy holder) and the other insured persons are dependents of the insured adult.
Family policy
A policy that includes an adult who is the principal policy holder, their partner and any dependents of the principal policy holder or their partner.
Hospital claims
Claims are only payable if:- the service is performed by an ahm recognised provider
- the service date on the receipt is less than two years old
- an original receipt or invoice is submitted to and kept by ahm
- your claim is not payable or subsidised by a third party such as workers compensation unless an authority has been completed
- your policy is financial on the date of service.
Inpatient
An inpatient is someone who is:- admitted to a hospital; and
- allocated a bed; and
- treated or uses the hospital's facilities and is then discharged following treatment.
Medicare Benefits Schedule (MBS)
The Medicare Benefits Schedule is a list of medical services provided by doctors. The Commonwealth Government established the national Medicare scheme to pay benefits for these services. Medicare pays 75% of the MBS fee for hospital related medical services and health insurers pay the remaining 25%. A doctor can charge more than the MBS fee.Medical gap
The medical gap is the difference between what Medicare pays, the MBS fee and the fee your doctor charges. Health insurers pay the gap up to the MBS fee for inpatient hospital related medical services. Charges above the MBS fee are usually paid by the patient. The Access Gap Cover scheme is designed to help remove or reduce the medical gap between the MBS fee and what the doctor charges so you pay less for your treatment or pay nothing at all.Medicare eligibility
If you have a blue interim, yellow reciprocal or no Medicare card, some of the benefits outlined in this policy document may not be available to you.
In particular, because you may not be eligible for benefits paid under the Commonwealth Medicare Benefits scheme you may incur significant out of pocket expenses if you’re admitted to any hospital as a private patient.
If you have limited access to Medicare, we strongly recommend that you only purchase this cover in conjunction with an Overseas Visitors Health Cover policy, which is more suitable to your needs.
Many private health insurers offer Overseas Visitors Cover. We recommend you visit IMAN/Australian Health Insurance. For more information or to apply for a policy:
- Visit www.aushealth.com
- Freecall 1800 22 11 33 or
- Phone +61 2 8437 2888 if outside Australia
Medicare Levy Surcharge (MLS)
The Medicare Levy Surcharge was introduced on 1 July 1997 as a way of encouraging high income earners to take out private hospital cover, use the private hospital system and thereby reduce demand on the public system.
The surcharge is an additional 1% surcharge of taxable income imposed on high income earners who do not have an appropriate hospital cover with a Private Health Insurer. The Medicare Levy Surcharge is in addition to the normal 1.5% Medicare Levy.
To find out more about the Medicare Levy Surcharge, go to What you should know - Medicare Levy Surcharge
Find out how much you can save by having ahm health insurance using the Medicare Levy Surcharge Calculator.
Membership year
Means the annual period commencing on the date that the policy holder or dependent joins a policy with ahm or changes to a new policy covering hospital treatment and renews every year on that date.Midwife assisted home births
As some policy holders choose to have a home birth, Top Hospital, Top Hospital Level 5 and Top Hospital Level 8, Family Hospital and Family Hospital Level 5 will pay a benefit towards midwife assisted deliveries with a registered midwife. This benefit is $600 for each home birth. The benefit doesn’t apply if there’s a hospitalisation related to the birth.Newly born infants
To be eligible for benefits towards the hospitalisation of your newborn child you must have a family or single parent family policy.
So if you’re having a baby and you have a single policy, you’ll need to change to a single parent family or family policy at least two months before the baby’s birth. This rule also applies to premature births.
If you wait until after the birth of your baby to change your cover then your baby will have to serve all waiting periods.
A newborn won’t be charged accommodation for the first 10 days of life unless they’re admitted to a special care nursery.
If there are multiple births, the first baby isn’t charged for accommodation unless admitted as an inpatient. All other babies will be charged for accommodation so you need to ensure they are covered.
Please note, if you have:
Basic Hospital - Your co-payment will apply to the mother and admitted babies up to the per person limit.
Essential Hospital level 5 or Family Hospital Level 5 – Your co-payment will apply for the mother and admitted babies up to the per person limit.
Top Hospital level 5 or Level 8 - Your co-payment will apply for the mother only up to the per person limit (subject to any waiver that may apply).
Non-agreement hospitals
Agreements with hospitals are based on agreed charges and quality of care. In some instances, we haven’t been able to reach an agreement with a private hospital, or the hospital has defaulted on their existing agreement. These hospitals are referred to as non-agreement hospitals and will only be paid the default benefit. The default benefit for accommodation is prescribed in the Private Health Insurance Act.
If you elect to use the services of a non-agreement hospital, you may be significantly out of pocket. We recommend you call us before being treated to clarify your exact benefit entitlements. We can’t guarantee what you might have to pay.
Nursing home patients
We don’t pay benefits for patients of nursing homes, aged care facilities or for associated respite care.Obstetrics
Obstetrics is the term used for services or treatment relating to pregnancy, pre or post conception and delivery of a baby (including assisted reproductive services).
A twelve month waiting period has to be served before benefits appropriate to your level of hospital cover apply. This also applies to premature birth and whether you’re pregnant or not at the time of joining the policy or changing your cover.
NOTE: Basic Hospital, Essential Hospital and Essential Hospital Level 5 only pays the default benefit for obstetrics.
Outpatient services
Medicare will only cover 85% of the MBS fee when you receive medical services outside hospital, such as visits in a specialist’s room, or in an accident and emergency room, or as a non-admitted patient in a hospital.
Health insurance benefits don’t apply to outpatient medical services when Medicare pays 85% of the benefit and where the service provider doesn’t have an agreement with ahm.
Overseas claims
Your hospital policy doesn’t cover you for any medical, hospital or ambulance services received overseas or goods purchased outside of Australia, including online purchases from overseas companies.
If you’re travelling overseas, call us so that we can help you arrange travel insurance at discounted rates. Without adequate travel insurance you could find yourself paying a lot of money if you’re hospitalised overseas.
NOTE: If you’re out of the country for more than 30 days, you can suspend your policy for the time you’re away (see Policy suspension below). However, by doing this, you could be subject to the Medicare Levy Surcharge (MLS).
Palliative care
Palliative care is a type of health care that provides support to people with a life-limiting illness. Palliative care aims to comfort, not to cure; to relieve pain and distress for people who are dying, and to support parents, families and friends in approaching death and dealing with grief.Partner
A partner of a person is the person’s husband or wife or a person who, although not married to the person, lives with that person on a bona fide domestic basis and includes a same-sex partner.Private Hospitals and day surgeries
ahm has agreements in place with the majority of private hospitals and day surgeries throughout Australia. These agreements guarantee your cover for agreed theatre and accommodation charges as outlines in your policy.
This doesn't include restricted services. If you have a co-payment with your policy, you need to pay this first.
Pharmaceutical Benefits Scheme (PBS)
The PBS is the national pharmaceutical benefits scheme funded by the Commonwealth Government where patients pay a set amount towards the cost of a subsidised drug. We’ll pay the PBS amount if you’re an inpatient and the drug is relevant to your treatment.The PBS is only available to persons with Medicare eligibility.
Policy suspension
If you’re travelling overseas for more than 30 days, you can suspend your policy.
To suspend your policy just send us a written or email request including the dates of travel. We’ll get back to you before you leave to confirm the suspended period.
To reactivate your policy you need to provide proof of the date of entry back into Australia within 30 days of your return.
NOTE: You’ll still need to serve any waiting periods you may have had before leaving the country and no benefits will be paid for services provided during the suspension period.
Suspending your policy may result in you being charged the Medicare Levy Surcharge. Consult your accountant, tax agent or the Australian Taxation Office for further advice.
Policy termination
Only the principal policy holder and ahm have the right to terminate a policy. Notice of termination must be given in writing, effective from the date specified in the notice (being a date no earlier than the date of the notice). You’re entitled to a refund of any premiums paid in advance of the date of termination.
Any policy holder or dependant over the age of 16 covered by a policy can terminate their own individual cover by giving notice in writing to ahm, effective from the date specified in the notice (being a date no earlier than the date of the notice) but cannot terminate the policy.
Pre-existing condition
Is an ailment, illness or condition that in the opinion of a Medical Practitioner appointed by ahm, the signs or symptoms of that ailment, illness 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 or changed their cover. The appointed Medical Practitioner must have regard to any information in relation to the ailment, illness or condition that the Medical Practitioner who treated the ailment, illness or condition provides or that ahm provides.
Principal policy holder
Is the first named policy holder of a policy. This person is responsible for the payment of premiums under a policy issued by ahm. This person has the authority to terminate the policy and add or delete persons from the policy.
Private cover in a public hospital
If you choose to be treated as a private patient in a public hospital we’ll cover the cost of accommodation in a private or shared room for all procedures except restricted services and those not paid by Medicare (in which case the benefit would be the equivalent of a shared room). If you have a co-payment with your cover, you have to pay it in this situation.Private Patients' Hospital Charter
The Commonwealth Government has produced a Private Patients' Hospital Charter to inform health insurance policy holders of their rights. You can view the charter on their web site or download a copy here.Prostheses
This term refers to surgically implanted items such as stents (for coronary arteries), grommets, artificial hips and knees, or titanium plates and screws (used in reconstructions or bone breaks).
The majority of prostheses listed on the Government’s Prostheses List are No Gap prostheses. These are fully covered by ahm (less any applicable co-payment) and there’s at least one clinically appropriate No Gap prosthesis for any procedure you may require.
Commonwealth legislation allows for a Prostheses Gap payment for a small number of prostheses. These prostheses are referred to as Gap Permitted prostheses and aren’t fully covered. This means if there is a gap, you’ll have to pay it.
If you need a prosthesis, please discuss the choices with your doctor prior to giving your doctor consent. This will allow you to make a fully informed decision about the cost of your treatment. If you choose a Gap Permitted prosthesis that costs more than the minimum benefit, you’ll have to pay the difference between the minimum benefit and the prosthesis charge. Find out more »
Recognised providers
It’s important for ahm to register service providers so that you receive quality health care from the providers you choose.
Recognising a provider means we get specific details and credentials from them to make sure they meet legislative and ahm criteria for benefit payment. All service providers must be registered with ahm before we can pay benefits. Recognition of a provider means that ahm may check with the provider on the goods or services supplied to any person on a policy to ensure that appropriate claims are being paid.
Benefits won’t be paid for services performed or goods supplied by unrecognised practitioners or by a provider on themselves, their partner or dependants, business partners or business partners’ partner or dependants.
Call 134 246 to find out if your service provider is recognised by ahm or use ahm’s online provider search tool.
Restricted services
We pay the default benefit only for accommodation for restricted services and services not covered or paid by Medicare.
Refer to the 'What You're Covered For' section of your policy document for more information about restricted services.
Services not covered by Medicare
If you go into hospital to have a procedure that isn’t covered by Medicare then you’ll be paying a lot more. We’ll only pay benefits if Medicare considers the procedure to be medically necessary and pays a benefit for the doctor, unless specified otherwise. To make a claim, we need a Medicare statement that informs us of their payment.
If Medicare doesn’t pay a benefit we’ll pay the default benefit for your accommodation only and no benefit for theatre or medical fees.
Here are some examples of procedures that Medicare don’t pay benefits for and where we only pay the default benefit for your accommodation:
- breast enlargement (except following a mastectomy, as this is covered by Medicare);
- laser eye surgery to remove the need for glasses;
- blepharoplasty (eyelid reduction);
- liposuction (in some cases); and
- dermabrasion (abrasive therapy, chemical face peels).
Where a Medicare benefit is not paid due to the patient having restricted or no Medicare cover, the default benefit only will be paid.
Sterility reversal procedures
We’ll pay a theatre and accommodation fee for male and female sterility reversals (if you are charged). We’ll also pay a benefit to assist towards paying your doctor’s fee, but you may still be significantly out-of-pocket depending on what your doctor charges you.
Please call us before your procedure to confirm how much you may be out-of-pocket.
Please note: Only available with Top Hospital cover and Family Hospital cover.
Total Health Programs
ahm’s Total Health programs and services form part of your hospital cover so you can access them at any time when you need them. Some of the programs are subject to eligibility, hospital participation and your doctor’s approval. There are no waiting periods for the disease prevention and chronic disease management programs, normal waiting periods apply to other programs. ahm pays 100% of the cost for all eligible programs and services. You must be 18 years or older to participate in these programs.
If you’re eligible to participate in a program just call 134 246 and ask to speak with a health consultant.
NOTE: Falling into arrears (having a policy that is unfinancial) may affect your eligibility or participation in any of these programs.
Find out more about our Total Health Programs.
Transferring from another private health insurer
If you’ve transferred from another private health insurer, we’ll acknowledge the waiting periods you’ve already served for comparable benefits.
In accepting a transfer of policy from another private health insurer, we reserve the right to treat any benefits paid by the previous insurer in the current benefit year as already being used under the limits of your new cover.
Travel & accommodation
We’ll pay a travel and accommodation benefit related to a hospitalisation where either:
- the patient has to travel more than 200 kilometres return in relation to a hospitalisation; or
- in life or death situations for a partner or next of kin to accompany the patient; or
- for a parent to accompany a child dependant under the age of 18.
This benefit is only payable where both the patient and the supporter are covered under an ahm hospital policy and for travel or accommodation relating to a hospitalisation. We won’t pay benefits for both the patient and supporter for the same dates.
Accommodation for a patient who travels greater than 200km return in relation to a hospitalisation is only payable for one night before and one night after the admission, unless supported by medical certification of a genuine need for an extended stay.
We’ll pay for accommodation for the supporter during the patient’s hospital admission only.
NOTE: Proof of travel and accommodation costs will be required eg. petrol dockets, bus or train tickets, hotel receipts.
Unfinancial policy (arrears)
Benefits are not payable for services provided during the period in which a policy is in arrears until the premium is fully paid and accepted by ahm.
ahm has the right to refuse to accept premiums if more than two months have elapsed since the financial date of the policy.
Note: If a policy holder is more than two months in arrears then the policy will be terminated by notice in writing from ahm to the principal policy holder, effective from the last financial date of the policy.
Waiting periods
When you take out private hospital cover or change your level of cover, you’ll have to wait a set time before you can claim for services and benefits you weren’t previously covered for.
Where benefits are greater on your new level of cover, we’ll pay the benefit at the amount on your previous level of cover until the waiting period is served.
| Waiting Periods | |
| 1 day |
|
| 2 months |
|
| 12 months |
|