Important information - GMHBA Health Insurance

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Important information - GMHBA Health Insurance Powered By Docstoc
					                        Important information

                        Before you join or transfer your           Index                                                                             Application for membership with GMHBA                       Any other rights accrued to the member will be
                                                                   Application for membership with GMHBA ........ 57                                 You’ll be asked to complete a membership                    forfeited.
                        health insurance to GMHBA we                                                                                                 application when you join GMHBA or make
                                                                   Arrears .................................................................... 57                                                               Arrears
                        recommend you read the following                                                                                             changes to your membership. For example, when
                                                                                                                                                                                                                 GMHBA fund members are responsible for
                                                                   Audits ..................................................................... 57   you change your level of cover or add/remove a
                        important information.                                                                                                                                                                   ensuring their premiums are up to date.
                                                                   Benefit limitation periods ..................................... 57               person covered by your membership. You can
                                                                                                                                                                                                                 Membership will cease when premiums fall into
                        If you have any question give us a                                                                                           make changes to your membership anytime.
                                                                   Claiming ................................................................. 57                                                                 arrears of more than 2 months after the premium
                                                                                                                                                     When you complete a membership application it’s             due date. To claim benefits a fund member must
                        call on 1300 4 GMHBA (46422) or            Code of Conduct.................................................... 60
                                                                                                                                                     important that you provide us with all the                  be financial at the time of incurring the expense
                        visit a branch.                            Compensation or damages ................................. 60
                                                                                                                                                     information requested to allow us to maintain an            for the service or treatment.
                                                                   Community Rating ................................................ 60              accurate record of your membership. It is also
                        We remind you to contact us                                                                                                                                                              Audits
                                                                   Connect Rewards Plus .......................................... 60                important that the information you provide is true
                                                                                                                                                                                                                 GMHBA undertakes audit activities in order to
                        for a benefit estimate before              Customer Service Charter .................................... 61
                                                                                                                                                     and correct.
                                                                                                                                                                                                                 protect members’ assets and contain costs.
                        commencing any treatment to                Dependants ............................................................ 61        GMHBA will consider your membership void if                 From time to time, in the general interest of
                                                                                                                                                     you provide false or incorrect information on your          members, a GMHBA representative may contact
                        confirm the benefit payable and            Electronic claiming................................................ 62
                                                                                                                                                     membership application and premiums received                you with a request for assistance to monitor costs
                        that our premiums may vary for             Excess ..................................................................... 62   in advance for coverage beyond the termination              - whether relating to benefits paid or charges
                        each state/territory. Please retain        Exclusions .............................................................. 62      date will be refunded. Like most health funds,              raised by health care providers. Your co-operation
                                                                                                                                                     GMHBA uses the terms wfund member’, ‘spouse/                with such requests is critical to our cost
                        this member guide with any other           Healthy Start Benefit ............................................. 63
                                                                                                                                                     partner’ and ‘dependant’ to define the people               containment efforts, and will be treated in a
                        GMHBA documents.                           If things go wrong ................................................. 63           covered by a membership. Only the person                    completely confidential manner.
                                                                   Insure? Not sure? .................................................. 64           nominated as the ‘fund member’ can authorise
                                                                                                                                                                                                                 Benefit limitation periods
                                                                   Liabilities of fund members to GMHBA.............. 64                             changes to the membership unless the fund
                                                                                                                                                                                                                 During your first 24 months of cover (after the
                                                                                                                                                     member has previously authorised the spouse/
                                                                   Medicare levy surcharge ...................................... 64                                                                             standard hospital waiting periods have been
                                                                                                                                                     partner to make such changes.
                                                                                                                                                                                                                 served) Gold Hospital, Silver Hospital Single
                                                                   Membership card .................................................. 64
                                                                                                                                                     Similarly, correspondence issued by GMHBA                   Parents and Silver Hospital cover from GMHBA’s
                                                                   Membership for non-residents of Australia ....... 64                              will be addressed to the fund member and it is              Everyday range are subject to benefit limitations
                                                                   Migrants ................................................................. 65     the fund member’s responsibility to notify                  on selected services. This means that the benefits
                                                                   Overseas travel ...................................................... 65         GMHBA of any change of address. The signing of              payable on these services are limited to receive
                                                                                                                                                     the membership application and the payment of               the public hospital default benefits only, during
                                                                   Participating providers ......................................... 65
                                                                                                                                                     any premium constitutes an acceptance of any                the 24 month benefit limitation period. Once the
                                                                   Payment in advance.............................................. 66
IMPORTAnT InFORMATIOn




                                                                                                                                                     conditions laid down in the regulations of the              waiting period and benefit limitation period has
                                                                   Pre-existing conditions (PEC)............................... 66                   fund in force at that time or as they may be                been served, you will have access to the benefits
                                                                                                                                                     amended from time to time.                                  applicable on your level of cover. Applicable
                                                                   Privacy .................................................................... 66
                                                                                                                                                     GMHBA reserves the right to refuse admission                benefit limitation periods can be found in product
                                                                   Proof of age ........................................................... 67
                                                                                                                                                     to membership of any level of health insurance              descriptions under the hospital tab of this member
                                                                   Recommendation or endorsement ..................... 67                                                                                        guide.
                                                                                                                                                     except Bronze Hospital cover.
                                                                   Refunds .................................................................. 67                                                                 Claiming
                                                                                                                                                     In the event of any member or person named on
                                                                   Replacement rule .................................................. 67            the members’ membership is convicted in a court             Claims may be made personally at any GMHBA
                                                                                                                                                     of law of assault or similar offence against a staff        branch, by post or by the assignment of your
                                                                   Restrictions ............................................................ 67
                                                                                                                                                     member related to that staff member’s                       benefit entitlement to a hospital or health care
                                                                   Single room guarantee......................................... 67                                                                             provider. In order to assess your claim and
                                                                                                                                                     performance of their duties, has obtained or
                                                                   Standard Information Statement ........................ 67                                                                                    calculate your benefit, GMHBA needs the
                                                                                                                                                     attempted to obtain an improper advantage, for




                                                                                                                                                                                                                                                                       IMPORTAnT InFORMATIOn
                                                                   State of the health funds report........................... 68                    themselves or for any other member or is                    following information:
                                                                                                                                                     convicted in a court of law of fraud against the               A
                                                                                                                                                                                                                 •	 	 	completed	claim	form	when	remitted	by	post	
                                                                   Suspension ............................................................ 68
                                                                                                                                                     fund, the Board may in its discretion, declare the             or via a provider, and
                                                                   Transferring from another health fund ............... 68                                                                                         T
                                                                                                                                                                                                                 •	 	 he	fully	itemised	health	care	account/s,	and,	
                                                                                                                                                     members’ membership void.
                                                                   Waiting periods ..................................................... 68                                                                         if you have paid the account/s, the original
                                                                                                                                                     The status of the members’ membership will be                  receipt/s. Photocopies/facsimiles of accounts
                                                                                                                                                     assessed with any outstanding claims being                     and/or receipts cannot be accepted.
                                                                                                                                                     honoured and any premiums shall be refunded.


                                                              56                                                                                                                                            57
                        Important information

                        You’ll also be required to provide additional              on members achieving their goal weight where           Medical benefits                                        Agent’s authority
                        documentation with claims for the services/items           achieved within 24 months and up to the total          Claims for medical benefits can only be paid after      You may authorise another person to collect
                        including:                                                 of programs fees not already reimbursed.               your claim for medical services has been assessed       benefits on your behalf by completing the
                           A
                        •	 	 	doctor’s	letter	of	recommendation	is	required	       Where program fees are less than $100 at each          by Medicare (except in the case of claims made          Agent’s Authority section of the claim form.
                           to be lodged with claims for the following items/       of these milestones, GMHBA will pay the total          through GMHBA’s medical gap cover - see page            The fund member and the agent (the person
                           services: blood glucose monitor, extremity              of the program fees only and not $100. A 2             26-27 for details) and your claim for hospital          who is being authorised to collect the benefits)
                           pump, nebuliser pump, appliances, sleep                 month waiting period for commencement of               benefits has been assessed and paid. GMHBA              must sign the authority. The agent will be
                           apnoea monitor, pressure garments, GMHBA                weight loss program applies                            benefits are not payable for services rendered          requested to sign the claim form again when
                           approved orthopaedic appliances, non-surgical            G
                                                                                 •	 	 MHBA	reserves	the	right	to	take	the	following	      when the patient is not a hospital inpatient.           benefits are paid.
                           prostheses, oxygen, tens monitor, medical aids,          actions against any policy holder or persons
                           home and domestic nursing aids, respite care,            where improper, fraudulent or indiscretion            Item numbers included under Preventative Dental limit:
                           nicotine replacement therapy patches, learn to           occurs whilst making claims against the fund.
                           swim lessons, blood pressure monitors and joint          Actions that may be taken are:                          Item
                                                                                                                                                                ADA Schedule                                   Simplified definition
                           supports.                                             	 •	 		 uspension	of	electronic	claiming	with	the	
                                                                                     	S                                                    number
                           A
                        •	 	 n	orthodontic	treatment	plan	certificate,	                period of time determined by the fund
                                                                                                                                             011     Comprehensive oral examination               Evaluation of all teeth, also includes recording
                           completed by the treating orthodontist/dentist              depending on the severity of the incident                                                                  medical history
                           is required before orthodontic benefits can                 R
                                                                                 	 •			 estitution	(voluntary	or	negotiated)
                           commence. You can obtain an orthodontic                     P
                                                                                 	 •			 rosecution                                                   Periodic oral examination                    Follow up consult, records all changes to
                                                                                                                                             012
                           treatment plan certificate by calling our             •	 	 o	extras	benefit	will	be	payable	unless	a	
                                                                                    N                                                                                                             patients teeth since previous consult
                           customer service centre on 1300 4 GMHBA                  medical reason/condition is present.
                           (46422) or from any GMHBA branch. For the                                                                         013     Oral examination - limited                   A "problem focused" consult done
                                                                                    S
                                                                                 •	 	 ervices	for	both	ancillary	and	hospital	                                                                    immediately prior to required treatment
                           purpose of benefit payments, orthodontic                 benefits must be validated by clinical notes.
                           treatment is regarded as commencing on the               No benefit is payable where there are no                         Consultation                                 A consult to seek advice/discuss treatment
                           date the appliance is originally fitted. Limits                                                                   014
                                                                                    clinical notes outlining the service provided.                                                                regarding a specific condition
                           apply every calendar year.                               The clinical notes must be legible, written in
                                                                                                                                                     Consultation - extended (30 minutes          A consult to seek advice/discuss treatment
                           W
                        •	 	 eight	loss	program	is	only	payable	when	               English and be understandable by a peer.                 015     or more)                                     regarding a specific condition which goes for
                           recommended in writing by a doctor for the            Physiotherapy consultation must be for a                                                                         30 minutes or more
                           purpose of preventing or improving a specific         minimum of 15-20 minutes to qualify for
                           health condition/s. The Weight Loss provider          one-on-one physiotherapy benefits.                                  Consultation by referral                     A consult with a patient referred by a dental
                           must be a member of the Weight Management                                                                         016                                                  or medical practioner for the management/
                           Council of Australia and agree to abide by the        unpaid accounts (other than hospital accounts)                                                                   opinion of a specific dental condition
                           Weight Management Code of Practice,                   Claims for unpaid accounts will be paid by direct
                                                                                 credit (where available) or cheque. The benefit                     Consultation by referral - extended          A consult with a patient referred by a dental
                           including:- Weight Watchers Australia - Jenny
                                                                                 cheque will be made payable to the health care              017     (30 minutes or more)                         or medical practitioner for the management/
                           Craig Weight Loss Centres Pty Ltd - Fernwood                                                                                                                           opinion of a specific dental condition which
                           – Simplicity Weight Loss. Benefits are only           provider. The cheque should be immediately
                                                                                                                                                                                                  goes for 30 minutes or more
                           payable for weight loss program fees and not          forwarded to the health care provider, together
                           meals or exercise components.                         with your payment for any account balance.                          Written report (not elsewhere                A written report of the patients care
                                                                                                                                             018
                                                                                 Paid accounts                                                       included)
                          Upon claiming GMHBA members are required
                          to provide the following in support of their claim     Benefits for paid accounts will be paid:
                                                                                                                                             111     Removal of plaque and/or stain               Removal of plaque/stain from all surfaces
                          for weight loss program benefits:                         i
                                                                                 •	 	n	cash	at	any	GMHBA	branch	for	claims	of	                                                                    of the teeth
                        	 •	 		 	report	from	the	weight	loss	provider	or	
                           	A                                                       less than $500, when claimed in person,
                              photocopy of your membership record of fees        •	 	 y	cheque,	made	payable	to	the	fund	member	
                                                                                    b                                                        113     Recontouring of pre-existing                 Reshaping/repolishing of existing fillings
                              paid at the time that the milestone is reached.       for larger claims, and mail claims,                              restoration(s)
                        	 •	 		 	report	from	the	weight	loss	provider	or	
                           	A                                                       d
                                                                                 •	 	 irectly	into	the	members’	financial	institution	
                                                                                                                                                     Removal of calculus - first visit            Removal of tartar from the surfaces of the
IMPORTAnT InFORMATIOn




                                                                                                                                                                                                                                                     IMPORTAnT InFORMATIOn
                              photocopy of your membership record of                account where these arrangements are in                  114
                                                                                                                                                                                                  teeth
                              weight loss achieved from commencement on             place,
                              the program.                                          t
                                                                                 •	 	 o	GMHBA,	where	the	member	requests	that	                       Removal of calculus - subsequent             Is the follow up consult to remove all tartar
                                                                                                                                             115
                                                                                    the benefit refund is, either in part or full, used              visit                                        from the surfaces of the teeth
                          An initial benefit of $100 is payable upon                to pay GMHBA premiums.
                          members achieving a 10% loss of their start                                                                                Topical application of remineralizing        An application of an agent to the surfaces
                          weight. Another benefit of up to $100 is payable                                                                   121     and/or cariostatic agents, one               of the teeth eg: calcium salts, fluoride
                                                                                                                                                     treatment


                                                                            58                                                                                                               59
                        Important information

                        Code of Conduct                                            Community Rating                                          C
                                                                                                                                          •	 	 onnect	rewards	plus	is	a	membership	                    Student dependants: are covered up until they
                        GMHBA is a fully compliant                                                                                           reward. Connect rewards plus entitlements                 turn 25 years of age. They have 2 months to
                                                                                   GMHBA is a strong supporter of the principles of
                        member of the private health                                                                                         cannot be transferred from one membership to              organise health insurance from this date
                                                                                   community rating. As such, GMHBA will not
                        insurance code of conduct.                                                                                           another.                                                  however, their new membership will commence
                                                                                   discriminate between members on the basis of
                        The Australian Health Insurance Association                                                                          W
                                                                                                                                          •	 	 hen	you	have	a	hospital	admission	which	                from the date they turned 25. They will not be
                                                                                   their health or any other reason described below.
                        (AHIA) in conjunction with the Health Insurance                                                                      results in out-of-pocket expenses, we’ll write to         required to serve waiting periods when
                        Restricted Membership Association of Australia             When making decisions in relation to members,             you within 60 - 90 days of your hospital                  transferring to an equivalent or lower level of
                        (HIRMAA) has developed codes of practice called            GMHBA will disregard the following:                       discharge to ask if you would like to use your            health insurance.
                        the Private Health Insurance Practice Codes to             1. The suffering by the member of a chronic               connect rewards plus dollars towards the cost
                                                                                                                                                                                                       Student dependants - mid year school/
                        reinforce existing regulatory obligations and to              disease, illness or any other medical condition.       of the inpatient medical gap. In the letter, we’ll
                                                                                                                                                                                                       apprenticeship & traineeship leavers: who
                        establish a minimum standard of business                                                                             include your current connect rewards plus
                                                                                   2. The gender, race, sexual orientation or                                                                          transfer from their parent’s GMHBA membership
                        practice applicable to all participants in such                                                                      balance. You must have a connect rewards
                                                                                      religious belief of a person.                                                                                    within 2 months of leaving school or finishing an
                        codes. The first code to be established is the                                                                       balance and an out-of-pocket medical expense
                                                                                                                                                                                                       eligible apprenticeship or traineeship through a
                        Private Health Insurance Code of Conduct.                  3. The age of a member, except in relation to             of at least $50 at the time of discharge to
                                                                                                                                                                                                       registered training group are not required to
                                                                                      Lifetime Health Cover loadings.                        qualify for benefits. You can only claim
                        Development of the codes commenced in 2003                                                                                                                                     serve waiting periods when transferring to an
                        with a committee formed by AHIA and HIRMAA.                4. Any other characteristic of a person (including        connect reward benefits for inpatient medical
                                                                                                                                                                                                       equivalent or lower level of cover. A letter from
                        That committee had broad representation from                  but not just matters such as occupation or             gap by producing a copy of the letter and
                                                                                                                                                                                                       their school or registered training group
                        funds, so the development has had detailed and                leisure pursuits) that are likely to result in an      completing the form attached to it. These
                                                                                                                                                                                                       confirming the date of completion is required.
                        expert input from a cross-section of the industry             increased need for extras or hospital                  types of claims cannot be processed in
                                                                                                                                             branches on the spot without the member                   Student dependants - end of year school/
                        and from stakeholders. The Minister for Health                treatment.
                                                                                                                                             having received a letter from GMHBA first.                apprenticeship & traineeship leavers: are
                        and Ageing and the Treasurer have endorsed the             5. The frequency with which a person needs                                                                          covered under their parent’s family or single
                        Code. The Code is designed to sit beside the                                                                        S
                                                                                                                                          •		 wimming	lessons,	Orthopaedic	shoes,	joint	
                                                                                      hospital treatment or general treatment.                                                                         parent membership until the 31st of March the
                        current Government acts and regulations within                                                                      supports, Melanoma surveillance photography,
                                                                                   6. The amount, or extent, of the benefits to which       nicotine replacement therapy patches and                   following year. They will not be required to serve
                        which the industry operates and underlines the                                                                                                                                 waiting periods when transferring to an
                                                                                      a member becomes, or has become, entitled             blood pressure monitor claims must be
                        intent of the industry to show its commitment to                                                                                                                               equivalent or lower level of health insurance.
                                                                                      during a period.                                      accompanied by a written recommendation by
                        consumers. The Private Health Insurance Code of
                        Conduct is designed to help you by providing               Compensation or damages                                  a doctor including a health management plan                Group Training is an employment and training
                        clear information and transparency in your                 Where you or your dependants have a right to             and approved by GMHBA.                                     arrangement whereby an organisation employs
                        relationships with health insurers.The Code                claim damages or compensation from any other           Customer Service Charter                                     apprentices and trainees under an
                        covers four main areas of conduct in private               person or body, you are required to pursue that        As testament to our commitment to you, we                    Apprenticeship/Traineeship Training Contract
                        health insurance ensuring:                                 entitlement prior to lodging a claim for benefits      have developed the GMHBA Customer Service                    and places them with host employers. A
                        •	 	 ou	receive	the	correct	information	on	private	
                           Y                                                       with GMHBA. A claim should only be lodged              Charter which is our written assurance to you                registered Group Training Organisation
                           health insurance from appropriately trained             with GMHBA if action at law is unsuccessful.           that we take our service delivery seriously. The             undertakes the employer responsibilities for the
                           staff;                                                  A letter of denial is required. This includes          charter details our promises and guarantee to                quality and continuity of the apprentices’ and
                        •	 	 ou	are	aware	of	the	internal	and	external	
                           Y                                                       WorkCare, TAC, public liability and third party        you as well as what happens in the event                     trainees’ employment and training. To qualify as
                           dispute resolution procedures with GMHBA                claims.                                                something goes wrong. To view the GMHBA’s                    a traineeship and be eligible to attract
                           Health Insurance;                                                                                              Customer Service Charter visit gmhba.com.au                  Commonwealth Government incentives, there
                                                                                   Connect Rewards Plus
                        •	 	 olicy	documentation	contains	all	the	
                           P                                                                                                                                                                           must be a registered training contract between
                                                                                   The Connect Rewards Plus program pays reward           Dependants
                           information you require to make a fully                                                                                                                                     the trainee and the employer. Please contact us
                                                                                   dollars to members on combined hospital and            1. GMHBA membership
                           informed decision about your purchase and all                                                                                                                               on 1300 4 GMHBA (46422) or visit a branch for
                                                                                   extras cover according to the level of hospital
                           communications between you and GMHBA                                                                           Child dependants: are covered up until they turn             more information.
                                                                                   cover and number of years members have been
                           Health Insurance are conducted in a way                                                                        21 years of age if they no longer meet the criteria
                                                                                   with GMHBA.                                                                                                         2. Other funds
                           that ensures appropriate information flows                                                                     for student dependants.
                                                                                   •	 	 MHBA	does	not	recommend	or	endorse	any	
                                                                                       G                                                                                                               Student dependants whose parents are fund
                           between the parties; and                                                                                       Child dependants that do not meet the criteria (of           members of another registered health fund may
                                                                                       health or medical program, therapy or
IMPORTAnT InFORMATIOn




                                                                                                                                                                                                                                                            IMPORTAnT InFORMATIOn
                           A
                        •	 	 ll	information	between	you	and	GMHBA	is	                                                                     a student dependant) will be terminated off the              join GMHBA within 2 months of ceasing to be a
                                                                                       appliance in respect of which connect rewards
                           protected in accordance with national and state                                                                membership from the date they turned 21. They                dependant, on a level of cover equal to or less
                                                                                       plus benefits are offered or paid. Some
                           privacy principles.                                                                                            have 2 months to organise health insurance from              than that held by their parents, without serving
                                                                                       programs, treatments or appliances should not
                        You can download the Code at "http://www.                                                                         this date, however their new membership will                 waiting periods. An acceptable transfer
                                                                                       be undertaken or used without medical advice.
                        privatehealth.com.au/codeofconduct.php"                                                                           commence from the date they turned 21. They                  certificate and claims history must be received.
                                                                                     	I
                                                                                   •		 	n	circumstances	where	family/couples/single	
                                                                                                                                          won't have to serve waiting periods when
                                                                                       parents memberships change to a single                                                                          3. Previously uninsured
                                                                                                                                          transferring to an equivalent or lower level of
                                                                                       membership, the existing membership may                                                                         Previously uninsured dependants may join
                                                                                                                                          health insurance.
                                                                                       retain the connect rewards accrued.                                                                             GMHBA within 2 months of leaving school or on

                                                                              60                                                                                                                  61
                        Important information

                        completion of a full-time apprenticeship/                 No excess applies for child dependants under 21           S
                                                                                                                                         •	 	 ervices/treatment	which	is	not	covered	by	             Healthy Start Benefit
                        traineeship, and receive immediate Bronze                 on GMHBA’s Gold Plus, Gold and Silver Hospital            your membership and/or is rendered while the             GMHBA’s Healthy Start Benefit has been
                        Hospital cover benefits, except for any pre-              Single Parents family hospital covers listed in           membership is in arrears or is suspended.                introduced to help cover the obstetricians
                        existing condition/illness (other than for                this member guide.                                        S
                                                                                                                                         •	 	 ervices/treatment	rendered	by	a	practitioner	          medical gap (inpatient service only). For Gold
                        psychiatric, rehabilitation and palliative care)          Exclusions                                                not in private practice and/or not recognised            Hospital product level 0/1/2, an additional benefit
                        and maternity cases for which a waiting period            You cannot claim for the following:                       by bodies approved by GMHBA.                             of $500 (up to the actual fee less the standard
                        of 12 months will apply.                                     B
                                                                                  •	 	 enefits	are	only	payable	on	itemised	and	            P
                                                                                                                                         •	 	 ressure	garments	purchased	for	reasons	                medical benefit and additional gap medical
                        All waiting periods must be served for extras                original account/s. Account/s which have               other than treatment of burns, lymphoedema               benefit) is payable where the episode is for the
                        benefits and hospital benefits which are higher              been altered in any way will not be accepted.          or for postoperative surgery up to 60 days               birth of a child. This benefit will be paid per
                        than those available from the Bronze Hospital                Providers are required to re-issue any                 from hospital discharge only.                            episode and not per child (ie: the additional
                        cover.                                                       account/s or endorse any alterations.                  G
                                                                                                                                         •	 	 MHBA	specified	and	approved	orthopaedic	               benefit is up to $500 for multiple births as well as
                                                                                     T
                                                                                  •	 	 he	supply	of	contraceptives,	fertility	and	IVF	      appliances purchased for support purposes                single births). When you have a hospital
                        Child dependant excess                                                                                              only.                                                    admission which results in an out-of-pocket
                        No excess applies for child dependants under 21              drugs and items available through the
                                                                                     Pharmaceutical Benefit Scheme (PBS).                   H
                                                                                                                                         •	 	 iring	of	equipment	(unless	otherwise	stated).          expense for the birth of a child, we’ll send you a
                        on GMHBA’s Gold Plus, Gold and Silver Hospital                                                                      M
                                                                                                                                         •	 	 ass	immunisation,	services	rendered	in	the	            payment of up to $500 within 60-90 days of your
                        Single Parents family hospital covers listed in              N
                                                                                  •	 	 atural	remedies	(includes	Modifast	&	
                                                                                     Optifast).                                             course of the carrying out of a mass                     hospital discharge. For further information on
                        this member guide.                                                                                                  immunisation.                                            the Health Start Benefit we recommend you call
                                                                                     F
                                                                                  •	 	 ood	supplements.
                        Electronic claiming                                          P
                                                                                  •	 	 harmacy	items,	where	they	are	available	over	        S
                                                                                                                                         •	 	 ervices	not	rendered	face	to	face	(e.g.	               us on 1300 4 46422.
                        When you have GMHBA extras cover you can                     the counter and purchased with or without a            remotely over the phone).
                                                                                                                                                                                                     If things go wrong
                        use your GMHBA membership card to claim                      prescription.                                          F
                                                                                                                                         •	 	 oot	orthotics	provided	by	a	physiotherapist	or	
                                                                                                                                                                                                     Our mission to be your trusted partner in the
                        electronically on the spot when this facility is          •	 	 upply	of	liquid	filled	Temazepam	capsules.
                                                                                     S                                                      chiropractor.
                                                                                                                                                                                                     provision of private health insurance goes
                        available at your health care provider. After the         •	 	 harmaceuticals	purchased	overseas	and	not	
                                                                                     P                                                      A
                                                                                                                                         •	 	 dditional	medical	gap	benefits	where	the	
                                                                                                                                                                                                     beyond providing quality affordable products
                        service has been provided, your membership                   listed on the Australian Register of Therapeutic       medical service is rendered by a medical
                                                                                                                                                                                                     and high levels of customer service.
                        card will be swiped through the terminal, your               Goods.                                                 practitioner employed full-time in the public
                        claim details entered and your claim will usually                                                                   sector.                                                  While we receive many letters of praise about
                                                                                     D
                                                                                  •	 	 ental	procedures	carried	out	and	charged	                                                                     our products and customer service advisors like
                        be processed electronically within seconds. Once             direct to the fund member/dependant by a               T
                                                                                                                                         •	 	 reatment	is	provided	to	themselves,	a	
                        your claim is authorised by GMHBA, you simply                                                                       member of the providers family and/or to a               any organisation we aren’t perfect and on
                                                                                     dental mechanic, other than an advanced                                                                         occasions we also receive complaints. We
                        pay any difference between the full fee for the              dental technician.                                     providers business partner and their family
                        treatment and the amount claimed by GMHBA.                                                                          members or any other people not independent              believe that your complaints are of equal or
                                                                                     A
                                                                                  •	 	 	range	of	dental	procedures	when	provided	                                                                    greater importance than praise.
                                                                                     on the same day e.g. a filling on a tooth that         from the practice. Family members include:
                        If there is an unexpected rejection of your claim
                                                                                     has been removed.                                      wife/husband, brother/sister, children, parents,         As such we have stringent guidelines in place to
                        at point of service, your provider should contact
                                                                                     D
                                                                                  •	 	 ental	procedures	where	a	limit	on	the	               grandparents, grandchildren of the provider/             ensure we acknowledge you in the most efficient
                        GMHBA on 1300 4 GMHBA (46422) to clarify the
                                                                                     number you can have has been exceeded.                 business partners’ and their spouse/partner.             and timely manner.
                        issue at the time of the service taking place.
                                                                                  •	 	 ental	procedures	unless	tooth	identifications	
                                                                                     D                                                      B
                                                                                                                                         •	 	 enefits	for	lifestyle	related	services	that	
                        Excess                                                                                                                                                                       So, in the unfortunate circumstance that you
                                                                                     (ID) are supplied by the provider.                     primarily take the form of sport, recreation or
                        GMHBA’s range of hospital covers often feature                                                                                                                               have a concern or complaint you can contact us
                                                                                  •	 	 ervices/treatment	for	which	the	member	and/
                                                                                     S                                                      entertainment.
                        an excess to let GMHBA members share some of                                                                                                                                 through the following channels and can expect
                                                                                     or dependant has a right to claim damages or           F
                                                                                                                                         •	 	 und	benefits,	payable	under	a	hospital	or	
                        the cost of hospital admissions in return for                                                                                                                                an acknowledgement as indicated below:
                                                                                     compensation from any other person or body.            extras cover shall not exceed the fees and/or
                        lower premiums. The excess is calendar year                                                                         charges raised for any treatment and/or                  1. Talk to a GMHBA representative
                                                                                     T
                                                                                  •	 	 reatment	where	the	member	and/or	
                        based.                                                                                                              services covered for benefits under the                     You can talk to a representative by visiting a
                                                                                     dependant is eligible for free treatment under
                        Excess - Hospital only                                                                                              relevant cover, after taking into account                   branch, calling 1300 4 GMHBA (46422) or
                                                                                     any Commonwealth or State Government Act.
                        An excess is deducted from the benefit paid by                                                                      benefits paid from any other source.                        emailing service@gmhba.com.au. We respond
                                                                                     S
                                                                                  •	 	 ervices/treatment	rendered	more	than	2	years	
                        GMHBA. For example, if GMHBA’s full benefit for                                                                     B
                                                                                                                                         •	 	 enefits	for	services	on	treatment	received	               to all our phone calls immediately, and will
                                                                                     prior to the date of claiming.
                        a hospital stay was $5,000 and the member has a                                                                     overseas.                                                   follow up all e-mail and telephone messages
                                                                                     W
                                                                                  •	 	 here	more	than	one	consultation	and/or	
                        $250 excess on their hospital cover, the benefit                                                                                                                                within 24 hours.
IMPORTAnT InFORMATIOn




                                                                                                                                                                                                                                                            IMPORTAnT InFORMATIOn
                                                                                     treatment type per day has been claimed             Extras services purchased over the internet
                        would reduce by the amount of the excess and                 regardless of provider within the group of          Benefits will be paid for extras services                   2. Write to us
                        an adjusted benefit of $4,750 would be paid.                 chiropractor (excluding x-ray), naturopath,         purchased over the internet from Australian                    We will provide an acknowledgement within 5
                        Where one member on a couples, family or                     homeopath and osteopath.                            providers (optical and pharmaceutical) where a                 working days for written correspondence.
                        single parent excess cover is admitted to hospital           W
                                                                                  •	 	 here	more	than	one	consultation	and/or	           script is provided. Consistent with current                   Where the matter is complex we will attempt
                        they will only pay a maximum amount per                      treatment type per day has been claimed             GMHBA rules, benefits for services on treatment               to finalise within a month. However where the
                        person as opposed to the maximum amount per                  regardless of provider within the group of          received overseas are excluded.                               difficulty of the matter precludes this, we will
                        membership. This is usually half the maximum                 physiotherapy, myotherapy and if eligible,                                                                        inform you of the progress.
                        annual excess per policy.                                    remedial massage.

                                                                             62                                                                                                                 63
                        Important information

                        3. Write to the Member Services Review                      the right to deduct the amount of that liability     Migrants                                                   2. Silver Plus Hospital, Silver Hospital cover,
                           Committee (MSRC)                                         from any monies due by GMHBA to the fund             Migrants who join GMHBA within 2 months of                 Silver Hospital Single Parents cover, Silver
                           If after receiving our response you are still not        member on any account.                               arriving in Australia shall receive the following          Everyday Package and Silver Young Singles
                           satisfied you can write to the Member Services            Medicare levy surcharge                              concessions:                                               Package.
                           Review Committee (MSRC). We have                         The Medicare levy surcharge is a surcharge on        • No 2 month waiting period for any level of               These covers have benefit exclusions and
                           appointed a panel of highly experienced                  individuals and families on higher incomes who         hospital cover.                                          restrictions for a range of services below:
                           employees including Subject Matter Experts,              don’t have eligible private patient hospital cover   • No 12 month waiting period for pre-existing
                           First Line Leaders, a Senior and Executive                                                                      conditions/illnesses will apply to Bronze                                       Benefit exclusions and
                                                                                    (eligible cover). The surcharge is 1% of taxable                                                                 Hospital cover
                                                                                                                                                                                                                               restrictions
                           Manager who meet regularly to discuss any                income in addition to the normal 1.5% Medicare         Hospital cover.
                           issues received from members. The aim of the                                                                  All other waiting periods for hospital and extras                              Obstetrics, IVF and related
                                                                                    Levy. People may have to pay the Medicare levy                                                                   Silver Hospital
                           MSRC is to listen to you and provide decisions                                                                will apply. Proof of residency must be presented                               services, gastric banding,
                                                                                    surcharge if they or any of their dependants do                                                                  Single parents
                                                                                                                                                                                                                        haemodialysis (excluded).
                           that are fair and equitable for all our members.         not have eligible cover and they are:                to GMHBA. Lifetime health cover regulations
                           You will receive an acknowledgement of your                                                                   also apply to migrants. Contact GMHBA for                                      Obstetrics, IVF and related
                           correspondence within 5 working days of the              • A single person - without dependent children       details.                                                                       services, joint replacement,
                                                                                                                                                                                                     Silver Plus
                           committee’s weekly meeting.                                - with a taxable income (including any                                                                                            cosmetic surgery and cataract
                                                                                                                                         Overseas travel                                             Hospital
                                                                                      reportable fringe benefits of $1,000 or more)                                                                                      surgery and corneal
                           You’re welcome to write to the MSRC at PO                                                                     GMHBA does not provide benefits for services or
                                                                                      greater than $80,000.                                                                                                             transplants (excluded).
                           Box 761 Geelong VIC 3220.                                                                                     treatment received overseas.
                                                                                    • A family - including a couple and single parent                                                                                   Obstetrics, IVF and related
                        4. Contact our Member Satisfaction Manager                    - with a combined taxable income (including        GMHBA advises that you take out travel                                         services, joint replacement,
                           If you require further clarification about the              any reportable fringe benefits of $1,000 or         insurance for the set period of your travel and                                gastric banding,
                           decision made at the MSRC please write to the              more) greater than $160,000 (increasing by         that it’s suitable to the destinations you’re               Silver Hospital    haemodialysis, cosmetic
                           Member Satisfaction Manager at PO Box 761,                 $1,500 per dependent child, after the first         visiting. You can purchase a range of travel                                   surgery and cataract surgery
                           Geelong VIC 3220. We will acknowledge your                                                                                                                                                   and corneal transplants
                                                                                      child).                                            insurance options from gmhba.com.au
                           correspondence within 5 days of receipt.                                                                                                                                                     (excluded).
                                                                                    Contact your tax adviser or GMHBA for further        Participating providers
                           Where the matter is complex we will attempt              details about the Medicare levy surcharge.                                                                                          Joint replacement, cataract
                           to finalise within a month, however where the                                                                  A participating provider is a health care provider,
                                                                                                                                                                                                                        surgery and corneal
                                                                                    Membership card                                      with whom GMHBA has entered into an                         Silver Everyday
                           complexity of the matter precludes this, we                                                                                                                                                  transplants, gastric banding,
                                                                                    When you join GMHBA, you’ll receive a                agreement relating to direct billing and/or fees            Package
                           will keep you informed of the progress.                                                                                                                                                      haemodialysis and cosmetic
                                                                                    membership card that identifies you as a              and benefits. These agreements aim to maximise                                  surgery (excluded).
                          If you’re still dissatisfied with the outcome,             member. The card shows your membership               your cover and minimise your out-of-pocket
                          free independent advice is available from                                                                                                                                                     Obstetrics, IVF and related
                                                                                    number and who is covered. GMHBA’s contact           costs.                                                                         services, joint replacement,
                          the Private Health Insurance Ombudsman.                   details are listed on the back of the card. Have     Details of participating private hospitals can be                              cataract surgery and corneal
                          You can contact the Ombudsman on freecall                 your membership card on hand when you                obtained from any GMHBA branch, by calling                                     transplants, gastric banding,
                          1800 640 695 or Suite 2, Level 22, 580 George             arrange admission to hospital, visit a                                                                                              haemodialysis and cosmetic
                          Street, SYDNEY NSW 2000.                                                                                       1300 4 GMHBA (46422) or from gmhba.com.au
                                                                                    participating provider or when you call GMHBA                                                                    Silver Young       surgery (excluded).
                        Insure? Not sure?                                           with any questions.                                  a) Participating private hospitals                          Singles            Restrictions apply to benefits
                                                                                                                                                                                                     Package            for psychiatric and
                        If you need more information about private                  A new card may be issued when you make               1. Gold Plus Hospital and Gold Hospital covers                                 rehabilitation services are
                        health insurance please refer to the Private                changes to your membership. Please note that                                                                                        payable at the basic (default)
                                                                                                                                         Members of GMHBA’s Gold Hospital covers, who
                        Health Insurance Administration Council (PHIAC)             an existing card will become invalid whenever a                                                                                     level of benefits, which
                                                                                                                                         are admitted to a participating private hospital
                        guide “Insure? Not sure?” Which can be                      new membership card is issued. Keep your card                                                                                       means you’ll have significant
                                                                                                                                         and have served all waiting and benefit
                        downloaded from our website gmhba.com.au or                                                                                                                                                     out-of-pocket costs.
                                                                                    safe and please advise GMHBA if your card is         limitation periods are entitled to cover for
                        http://www.phiac.gov.au/for-consumers/                      lost or stolen.                                                                                                 These excluded services do not attract any
                                                                                                                                         accommodation, theatre, delivery suite, intensive
                        insure-not-sure/                                                                                                                                                            benefits.
                                                                                    Membership for non-residents of Australia            and coronary care and other agreed hospital
                        Liabilities of fund members to GMHBA                        GMHBA hospital covers are designed for people        charges - less any excess (if applicable).                 Limited benefits may apply to cosmetic surgery
                        A fund member can be liable to GMHBA for                    who have full Medicare eligibility. These covers     Members should present their GMHBA                         and high cost drugs. Drugs purchased outside of
IMPORTANT INFORMATION




                                                                                                                                                                                                                                                          IMPORTANT INFORMATION
                        unpaid premiums and for overpayments.                       will not meet the cost of public hospital            membership card when attending a participating             the hospital are not included.
                        Overpayments can be made by GMHBA to a                      treatment, medical treatment or diagnostic           private hospital.
                                                                                                                                                                                                    b) Non-participating hospitals
                        fund member, either through an error in                     services for people who do not have full             Public hospitals: Gold Plus Hospital and Gold
                        completing a claim, or an error in processing a                                                                                                                             Fixed benefits are payable for hospitalisation in
                                                                                    Medicare eligibility. Temporary residents of         Hospital cover provides cover for hospital
                        claim. If an overpayment is made, the fund                                                                                                                                  non-participating private hospitals. Please contact
                                                                                    Australia who do not have full Medicare              accommodation costs when you are admitted to
                        member is liable to repay the amount of the                                                                                                                                 GMHBA on 1300 4 GMHBA (46422) or visit a
                                                                                    eligibility should contact GMHBA on 1300 4           a single or shared room (subject to bed
                        overpayments to GMHBA on demand.                                                                                                                                            branch for further details.
                                                                                    GMHBA (46422) or visit a branch to discuss           availability) as a private patient in a recognised
                        If a fund member is liable to GMHBA for unpaid              appropriate health insurance arrangements.           public hospital.                                           Members of Gold Plus Hospital, Gold Hospital,
                        premiums or overpayments then GMHBA has                                                                                                                                     Silver Hospital Single Parents, Silver Plus
                                                                               64                                                                                                              65
                        Important information

                        Hospital, Silver Hospital, Silver Everyday                practitioner appointed by GMHBA. However, the         from any GMHBA branch, by calling our                          y
                                                                                                                                                                                                    •	 	 ou	have	already	claimed	the	maximum	
                        Package and Silver Young Singles Package cover            fund medical practitioner must consider any           customer service centre on 1300 4 GMHBA                        allowable benefits during a specified period.
                        who are to be admitted to a non-participating             information regarding signs and symptoms              (46422) or by visiting gmhba.com.au                            y
                                                                                                                                                                                                    •	 	 ou	have	transferred	to	GMHBA	from	another	
                        private hospital should contact GMHBA at least 3          provided by your treating medical practitioner/s.     Proof of age                                                   fund and have previously claimed for the
                        business days before admission. GMHBA will                The pre-existing condition rule still applies even    When you join GMHBA and you are not                            service/treatment.
                        then contact the hospital and negotiate fee and           if your ailment, illness or condition was not         transferring from another fund, you (and your                  t
                                                                                                                                                                                                    •	 	 he	health	care	account	has	been	incompletely,	
                        benefit arrangements on the members’ behalf               diagnosed prior to joining the hospital cover.        partner for families) may need to provide one of               incorrectly or inappropriately itemised.
                        with the aim of minimising out-of-pocket costs.           The only test is whether or not, in the 6 months      these acceptable forms of proof of age:                        y
                                                                                                                                                                                                    •	 	 ou	have	an	excess	to	pay	on	your	chosen	
                        Limited benefits may apply to cosmetic surgery            prior to joining your current hospital table signs    •	 Current	passport	or                                         level of cover.
                        and high cost drugs. Drugs purchased outside of           and symptoms:                                         •	 Current	photo	driver’s	licence	or                           t
                                                                                                                                                                                                    •	 	 he	fund	believes	that	a	patient,	following	a	
                        the hospital are not included.                            •	 	 ere	evident	to	you	or,
                                                                                     w                                                  •	 Original	birth	certificate	or                               review of the case (on the basis of information
                                                                                  •	 	 ould	have	been	evident	to	a	reasonable	
                                                                                     w                                                     S
                                                                                                                                        •	 	 tatutory	declaration	(if	you	have	none	of	the	            provided by the hospital either internally or
                        c) Bronze hospital                                                                                                                                                             using an agreed independent source), is not
                                                                                     general practitioner if a general practitioner        above).
                        Members of Bronze Hospital cover, who are                    had been consulted.                                                                                               receiving acute care after 35 days continuous
                        admitted to a public hospital and have served all                                                               Recommendation or endorsement                                  hospitalisation, GMHBA benefits will be
                        waiting periods are covered for accommodation             When to contact GMHBA                                 GMHBA is a registered health insurance fund                    reduced to Nursing Home Type Patients
                        costs.                                                    If you have less than 12 months membership on         and does not offer health or medical services or               benefits and will be paid in accordance with
                                                                                  your current hospital cover, make sure you            advice. GMHBA does not recommend or endorse                    the default benefit determined by the Health
                        Bronze Hospital and Bronze Young Singles                  contact us before you are admitted to hospital        any medical practitioner, dentist, therapist,                  Department. All Nursing Home Type Patients
                        Package contains exclusions as follows:                   and find out whether the pre-existing condition       hospital, health or medical service provider,                  are required to pay part of the cost of hospital
                                                                                  waiting period applies to you. We need about 5        treatment, therapy or the use of any appliance or              accommodation.
                         Hospital cover           Benefit exclusions              working days to make the pre-existing condition       prosthetic. GMHBA does not endorse or make                     t
                                                                                                                                                                                                    •	 	 he	service/s	is	subject	to	a	waiting	period	or	
                                                                                  assessment, subject to the timely receipt of          any representation whatsoever as to the                        other limit.
                         Bronze              Gastric banding,
                         Hospital            haemodialysis                        information from your treating medical                appropriateness or effectiveness of any service                s
                                                                                                                                                                                                    •	 	 urgery	is	performed	in	hospital	by	a	
                                                                                  practitioner/s. Make sure you allow for this time     or goods for which a benefit or reward is paid.                registered podiatrist/podiatric surgeon.
                                             Cataract surgery and corneal         frame when you agree to a hospital admission
                         Bronze Young        transplants, gastric banding,                                                              Refunds                                                        Contact GMHBA for details.
                                                                                  date. If you proceed with the admission without       You may cancel your GMHBA membership from:                     w
                                                                                                                                                                                                    •	 	 hen	no	MBS	item	number	is	provided	by	the	
                         Single              haemodialysis, obstetrics,
                                                                                  confirming benefit entitlements and we                •	 	 he	date	you	notify	GMHBA,	in	writing	of	the	
                                                                                                                                           t                                                           GP/specialist e.g. cosmetic surgery.
                         Package             joint replacement and IVF
                                             and related services.                subsequently determine your condition to be              cancellation (a transfer certificate will be                w
                                                                                                                                                                                                    •	 	 here	professional	services	are	provided	to	
                                                                                  pre-existing, you’ll have to pay all outstanding         provided to the insured person within 14 days               themselves, the provider or members of the
                        Please note: Benefits for a single room in a              hospital charges and medical charges not                 of request) or                                              provider’s family or to a provider’s business
                        public hospital or for treatment in a private             covered by Medicare.                                  •	 	 our	current	premium	due	date,	whichever	is	
                                                                                                                                           y                                                           partner’s family members or any other people
                        hospital when using Bronze hospital cover will            Emergency admissions                                     the earlier                                                 not independent from the practice, only
                        result in significant out-of-pocket expenses. For         In an emergency, we may not have time to                 w
                                                                                                                                        •	 	 ithin	60	days	of	joining	and	get	a	full	refund	           wholesale material costs involved in the
                        further information on private patient benefits           determine if you are affected by the pre-existing        of any premiums received provided you have                  provision of the service are subject
                        on Bronze Hospital cover, please call on 1300 4           condition rule before your admission.                    not made a claim.                                           to benefits.
                        GMHBA (46422) or visit a branch.                          Consequently if you have less than 12 months                                                                         A
                                                                                                                                                                                                    •	 	 dditional	medical	gap	benefits	where	the	
                                                                                                                                        Replacement rule
                        Payment in advance                                        membership on your current hospital cover you                                                                        medical service is rendered by a medical
                                                                                                                                        A benefit replacement rule applies to a number
                        A fund member (or person paying on their                  might have to pay for some or all of the hospital                                                                    practitioner employed full-time in the public
                                                                                                                                        of items/services covered by GMHBA’s extras
                        behalf) may not make a payment of premiums                and medical charges if:                                                                                              sector.
                                                                                                                                        covers. The rule requires that after you claim for
                        that would cause the period of cover to exceed               y
                                                                                  •	 	 ou	are	admitted	to	hospital	and	you	choose	to	   such an item, you must wait a specified period of           Single room guarantee
                        12 months in advance of the contribution due date.           be treated as a private patient; and               time before you can lodge another claim for the             We will pay you $50 per day (up to a maximum
                        Pre-existing conditions (PEC)                                w
                                                                                  •	 	 e	later	determine	that	your	condition	was	       same type of item. The replacement rule applies             of $150 for 3 days) if you stay in a shared
                        A pre-existing condition is one where signs or               pre-existing.                                      to the following items/services: dentures, all              room when you requested a single room. Only
IMPORTAnT InFORMATIOn




                                                                                                                                                                                                                                                           IMPORTAnT InFORMATIOn
                        symptoms of your ailment, illness or condition,           Privacy                                               appliances, hearing aids, nebuliser pumps, blood            available for overnight accommodation in a
                        in the opinion of a medical practitioner                  We value the relationship between GMHBA and           glucose monitors, blood pressure monitors,                  Private Hospital. Day stays are ineligible for this
                        appointed by GMHBA (not your own doctor),                 our members. An important part of this                sleep apnoea monitors, extremity pumps, tens                payment.
                        existed at any time during the six months                 relationship is our commitment to protecting the      monitor, pressure garments, GMHBA specified                 Standard Information Statements
                        preceding the day on which you purchased your             personal information entrusted to us by our           orthopaedic appliances and non-surgical                     A Standard Information Statement (SIS) is
                        hospital insurance or upgraded to a higher level          members.                                              prostheses.                                                 available for every product available to new and
                        of hospital cover and/or benefit entitlement.             This commitment is documented in our privacy          Restrictions                                                existing members of the fund. The content of the
                        The only person authorised to decide that a               policy and summarised in our privacy brochure.        Benefits may not be paid or may be paid at a                SIS will be as outlined in the private health
                        condition is pre-existing is the medical                  You can pick up a copy of our privacy brochure        lower level where:                                          insurance (complying product) rules.
                                                                             66                                                                                                                67
                        Important information

                        An up to date SIS will be forwarded to anyone              Transferring from another health fund                   where the addition/s has already served all      policy, at the same or higher level than the new
                        on request, and at the very least to members               You can transfer your health insurance from             waiting periods with GMHBA or another fund,      policy, waiting periods are no longer than the
                        once every year (without need to be requested).            another health fund to GMHBA without serving          •	 	 xisting	GMHBA	memberships,	and	transfers	to	 balance of any unexpired waiting period for the
                                                                                                                                            E
                        If more than one adult is insured under a single           any new waiting periods for the equivalent cover         GMHBA from another fund where:                  benefit that applied to the person under the
                        policy GMHBA will only provide an SIS to the               provided that you:                                       i the level of cover and/or benefit entitlement policy.
                        primary member on the policy.                                 h
                                                                                   •	 	 ave	served	all	waiting	and	benefit	limitation	          is upgraded or increased;                   For treatment that was covered under the old
                        A newly insured member will be given an up to                 periods with your previous fund and,                  ii any hospital or extras service was not       policy but at a lower level, the member is entitled
                        date copy of the relevant SIS, details about what             t
                                                                                   •	 	 ransfer	to	any	equivalent	or	lower	level	of	            covered by the previous fund and/or;        to the lower benefits on their old cover during
                        the policy covers and how benefits are provided               cover providing you transfer within 30 days of        iii the waiting and benefit limitation periods  the waiting period. Existing members with at least
                        and a statement identifying the referable health              your membership ceasing with your previous                have not been completed.                    12 months membership in total across their old
                        benefits funds when they join.                                fund and,                                          For new memberships (no previous extras cover)     and new cover are entitled to the lower benefits
                        State of the health funds report                           •	 	 rovide	GMHBA	with	an	acceptable	transfer	
                                                                                      p                                                  or where 12 months continuous dental cover has     on their old cover during the waiting period.
                        Every year the Private Health Insurance                       certificate and claims history issued by your      not been in existence, the following dental limits Waiting periods – Pre-existing condition (PEC)
                        Ombudsman publishes a State of the Health                     previous fund within 7 days of transferring        apply within the first 12 months of membership
                                                                                      your cover.                                        with GMHBA:                                        A special waiting period applies to obtain benefits
                        Funds Report. The aim of this report is to give                                                                                                                     for hospital treatment for new members who
                        people extra information to help them make                 GMHBA recommends that your cover starts                  P
                                                                                                                                         •	 	 latinum	Extras	-	$450	per	person	up	to	       have pre-existing conditions. The waiting period
                        decisions about taking up private health                   immediately after your previous cover ends.              $900 per policy.                                also applies to existing members who have
                        insurance. The report provides general                     If your new cover with GMHBA provides higher             G
                                                                                                                                         •	 	 old	Extras	-	$300	per	person	up	to	$600	      recently upgraded their level of hospital cover.
                        independent comparative information on the                 benefits or benefits for services not covered by         per policy.                                     If the ailment, illness or condition is considered
                        performance and service delivery of all health             your previous fund, you’ll be regarded as a new          S
                                                                                                                                         •	 	 ilver	Extras	&	Bronze	Extras	-	$200	per	      pre-existing:
                        funds. It does not provide detailed information            member for those higher benefits, and/or                 person up to $400 per policy.                      n
                                                                                                                                                                                            •	 	 ew	members	must	wait	12	months	for	any	
                        on health fund products.                                   additional services and will be required to serve     Limited benefits may apply on hospital covers for     hospital benefits (other than psychiatric,
                        A copy of this report can be downloaded from               the waiting and benefit limitation periods - but      cosmetic surgery, depending on the medical            rehabilitation and palliative care).
                        our website gmhba.com.au or www.phio.org.au                only for the higher benefits/additional services.     justification for the surgery.                        m
                                                                                                                                                                                            •	 	 embers	transferring/upgrading	to	a	higher	
                        Suspension                                                 If you transfer to GMHBA from another fund            Where a member is transferring from another           hospital cover must wait 12 months to get the
                        You can suspend your GMHBA membership for                  before completing the waiting and benefit             product or from another health fund, waiting          higher hospital benefits (other than psychiatric,
                        periods of overseas travel provided you:                   limitation periods with your previous fund, you’ll    periods for hospital (or hospital substitute)         rehabilitation and palliative care).
                           h
                        •	 	 ave	at	least	12	months	continuous	                    need to serve the balance of the waiting and          treatment that was not covered under the old                Existing members with at least 12 months
                           unsuspended membership with GMHBA prior                 benefit limitation periods with GMHBA (see            policy are:                                                 membership in total across their old and new
                           to departure, and,                                      waiting periods page 11 and below under the              1
                                                                                                                                         •	 	 2	months	-	obstetric	or	pre-existing	condition	        cover are entitled to the lower benefits on their
                        •	 	 lan	to	be	overseas	for	at	least	2	months,	and,
                           p                                                       heading ‘waiting periods’).                              (other than for psychiatric, rehabilitation or           old cover.
                           h
                        •	 	 ave	paid	premiums	to	the	date	of	departure,	          When you transfer to GMHBA your benefit                  palliative care).
                           and                                                                                                                                                                       Planning a child
                                                                                   entitlements may be adjusted by benefits already         2
                                                                                                                                         •	 	 	months	-	Psychiatric,	rehabilitation	or	              If you are preparing to start a family and your
                           a
                        •	 	 pply	for	suspension	of	your	membership	               paid by your previous fund. Under lifetime health        palliative care.
                           prior to departure.                                                                                                                                                       hospital cover does not include obstetrics, you
                                                                                   cover, continuity of a member’s/partner’s                2
                                                                                                                                         •	 	 	months	-	Any	other	benefit	for	hospital	              will need to ensure you upgrade your hospital
                        You’ll be required to resume your suspended                certified age at entry (CAE) is possible when            (or hospital substitution) treatment.
                        membership within 2 months of returning to                                                                                                                                   cover to include obstetrics at least 12 months
                                                                                   transferring from another Australian registered       For hospital (or hospital substitution) where a             before you have a child to ensure all waiting
                        Australia and premiums must be paid from the               health fund.
                        date of re-entry. Your passport, boarding pass or                                                                member is transferring from another product                 periods have been served.
                        a statutory declaration may be required to be              Waiting periods                                       or from another health insurer, waiting periods             If all goes well, a new born baby is not admitted
                        presented to GMHBA as proof of travel.                     Waiting periods exist to protect members from         for extras that were not covered under the old              as a patient in hospital, but if you have
                                                                                   claims made by those who join the fund or             policy are:                                                 complications and your baby requires any
                        A 3 year maximum cover suspension period for               increase their level of cover because they have a        1
                                                                                                                                         •	 	 2	months	-	Major	dental,	podiatric	surgery	and	
                        overseas travel applies. Only the balance of                                                                                                                                 accommodation or medical attention, you will not
                                                                                   condition or illness that may require treatment.         orthotics. Other health appliances excluding             be covered for accommodation or medical
IMPORTAnT InFORMATIOn




                                                                                                                                                                                                                                                         IMPORTAnT InFORMATIOn
                        outstanding waiting periods need to be served                                                                       medical aids and nursing aids (where offered in
                        upon resumption of your membership.                        Waiting periods will apply to:                                                                                    services unless your child has served the waiting
                                                                                   •	 	 ew	memberships	(previously	uninsured),
                                                                                      N                                                     the cover).                                              period. So, if you are currently on a singles
                        If you apply to GMHBA to suspend your hospital                                                                      6
                                                                                                                                         •	 	 	months	-	Optical	benefits,	medical	aids	and	          membership, you will need to change to a family
                        cover for a short period of time and we agree,                A
                                                                                   •	 	 dditions	to	a	membership	(unless	the	               nursing benefits.
                                                                                      addition/s has already served all waiting                                                                      membership at least two months before your
                        this period of suspension does not impact on                                                                     •	 2	months	-	Any	other	extras	benefit.                     baby is born. GMHBA recommends that you
                        your LHC loading (you are considered to be                    periods with GMHBA or another fund) except
                                                                                      newborns, adopted and permanent foster             The above waiting periods also apply to                     change to family membership three months
                        maintaining your cover).                                                                                         previously uninsured members.                               before your baby is due, (you can add an unborn
                                                                                      children where the family membership has
                                                                                      been in existence for at least 2 months, and       For treatment that was covered under the old                child as an additional person) in case your baby
                                                                                                                                                                                                     arrives prematurely.
                                                                              68                                                                                                                69

				
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