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
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
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
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.
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
• 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
• 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
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
• 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
• 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
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
• irectly into the members’ financial institution
Removal of calculus - first visit Removal of tartar from the surfaces of the
photocopy of your membership record of account where these arrangements are in 114
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
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
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
• 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.
• 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
retain the connect rewards accrued. GMHBA within 2 months of leaving school or on
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
• 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
• 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.
provision of private health insurance goes
available at your health care provider. After the • harmaceuticals purchased overseas and not
• 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
• 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
• 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
• 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
• 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/
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
• 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 email@example.com. We respond
• 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
• here more than one consultation and/or
$250 excess on their hospital cover, the benefit within 24 hours.
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.
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
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
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,
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
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
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
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
• 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
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
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.
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
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).
• 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.
• 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
• 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
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