• Choice! Our Hospital cover doesn’t restrict you to any particular hospital – our full benefits apply in all recognised hospitals for recognised services. In the unlikely event that we cease to recognise a hospital for full benefits, Police Health will advise members likely to be affected and publish the information on our website.
• No excess, benefit limitation periods, co-payments or exclusions.
• We don’t direct you to a particular doctor or any other health care provider.
• We aim to give you the freedom to choose who treats you and where, as long as the provider is recognised by us.

These days many policies are paring back cover, not paying benefits for certain treatments (exclusions) or paying only limited benefits (restrictions). Not at Police Health. Our Hospital cover is comprehensive and covers all treatments and procedures where Medicare pays a benefit.

What is not covered (non-exhaustive list*)

• Services incurred before waiting periods have been served.
• Treatment for which Medicare does not pay a benefit, including cosmetic surgery. (Some benefits may be payable for hospital treatment following this surgery. Please call us for more details.)
• Services that are provided outside of the Commonwealth of Australia.
• Services where an entitlement exists or may exist under any compensation, sports club or third party insurance.
• A claim for a service that is submitted more than two years after the date of service.
• Outpatient services, unless there is an agreement between Police Health and the hospital.
• Pharmaceuticals not related to the reason for hospitalisation or not covered under the agreement with the hospital or provided on discharge.
• Exceptional high cost drugs where no or limited benefits are paid.
• Prostheses items that are not included on the Federal Government approved list.
• Charges greater than the benefit defined in the Federal Government’s Prostheses List.
• Personal and take-home items, e.g. newspapers, toiletries, television, hairdressing, manicure, etc.
• Treatment provided to a person in a private hospital emergency department.
• Aged care and accommodation in an aged care facility.
• If you’re in hospital for more than 35 consecutive days and not classified as an acute care patient, your benefits will significantly reduce.
• Benefits for ambulance services covered by a third party arrangement such as a State/Territory transportation scheme.

* This provides a general description of what is not covered. These are not “excluded or restricted” hospital treatments or services. Should you require information about a particular treatment or benefit please call us on 1800 603 603.

Other funds may apply exclusions (you agree not to be covered at all for certain treatments). For example you may have hospital cover but it excludes joint replacement. Other funds may also apply restrictions (you agree to receive very limited benefits for certain treatments). For example you may be covered for joint replacement only at a public hospital, and if the joint replacement is undertaken in a private hospital, basic accommodation benefits and no procedure benefits are paid. 

At Police Health our Gold Hospital cover has no exclusions and no restrictions (other than where waiting periods apply before benefits or higher benefits, as applicable, are payable).

It’s important to note that all health insurers are governed by the Private Health Insurance Act 2007. This legislation sets out what health insurers can and cannot pay benefits towards. Within the hospital as an inpatient, health insurers can only pay benefits towards treatment and procedures where Medicare pays a benefit. That means for some services, like elective cosmetic surgery, health insurers cannot pay a benefit towards this treatment, and this is not classed as a restriction or an exclusion on a policy.
 

Other funds may charge an excess (an excess is the amount you agree to pay towards the cost of hospital treatment). For example if you have an excess of $500, when you’re admitted to hospital you’ll have to pay the first $500 of the hospital costs on top of anything else not covered by your policy. Similarly some insurers charge a co-payment, which is the agreed amount you’ll pay per day in hospital. At Police Health our hospital cover has no excesses or co-payments (other than where a waiting period applies).

Other funds may also apply benefit limitation periods which pay reduced benefits on one or more services for a set period of time that can be longer than normal waiting periods, then pay full benefits after this period.

At Police Health our hospital cover has no benefit limitation periods.

A waiting period is the period of time you need to be covered before you’re eligible to claim on certain procedures or services. Waiting periods may apply to new or upgraded policies.

If you’re transferring from another health insurer, we offer continuity of cover which means you won’t serve the same waiting periods twice. However, if you’re transferring to us from a lower level of cover, you’ll only be able to claim up to the level you were already covered for until you have served the waiting period.

Example: Sue decides to switch her hospital cover to Police Health. Sue has a $500 excess that currently applies to claims under her previous policy. As she has served all waiting periods with her current fund she only has to serve waiting periods for the level of extra cover provided by Police Health – in Sue’s case the $500 excess. She receives immediate cover on all other aspects of her Police Health hospital policy. Sue must serve the 2 month general and 12 month obstetrics and pre-existing condition waiting periods (as relevant) before the $500 excess does not apply at Police Health.

But rest assured, there are no waiting periods applied for claims resulting from an accident occurring after joining.

Waiting periods for hospital:

• 2 months membership for all benefits, excluding accidents.
• 12 months membership for obstetric treatment.
• 12 months membership for pre-existing conditions, excluding psychiatric care, rehabilitation or palliative care.
• 12 months membership for travel and accommodation (general treatment) and home nursing.
• 12 months membership for aids and appliances.

A pre-existing condition is one where signs or symptoms of your ailment, illness or condition, in the opinion of a medical practitioner appointed by us (not your own doctor), existed at any time during the six months preceding the day on which you purchased your health insurance or upgraded to a higher level of hospital cover.

The medical practitioner we appoint must consider any information regarding signs and symptoms provided by your own treating doctor and specialist.

If you’re new to health insurance, you may need to have held membership for 12 months before cover will be provided for treatment relating to pre-existing conditions.

If you’re transferring your existing health insurance, the 12 month wait on pre-existing conditions may apply to any increased level of cover you take with us. For example, if you have an excess, excluded or restricted treatment under your previous policy, you need to serve 12 months membership with us before your treatment is covered at the higher level of cover.

Psychiatric care, rehabilitation and palliative care are not subject to the 12 month wait on pre-existing conditions.

Hospital benefits are payable 365 days a year. However, if your hospital stay exceeds 35 consecutive days you must obtain and send us an Acute Care Certificate to continue receiving comprehensive benefits. Benefits will be reduced and out of pocket expenses apply where an Acute Care Certificate is not obtained.

The hospital is aware of this and will usually arrange a certificate on your behalf.

Under Police Health Access Gap Cover you may never have to pay a doctor’s bill. Your doctor can forward all accounts to us and we pay them on your behalf.
 

Top Tip

Before you’re admitted to hospital check with your doctor if they are one of 25,000 doctors Australia wide who has an arrangement with us under the Access Gap Cover scheme.

When doctors bill under this arrangement we can pay higher benefits to eliminate or at least reduce your out of pocket costs.

While all doctors can be involved in Access Gap Cover, it is up to individual doctors to participate on a case by case basis.

Please speak with your doctor or specialist to see if they will participate in Access Gap Cover for any planned private hospital treatment. For a list of providers eligible to participate and who have agreed for their details to be published, please call us or use our online provider search.

Then it’s a good time for you to review your health insurance and make sure you understand what your policy does and doesn’t cover.

Waiting periods of up to 12 months can apply for pregnancy, birth and newborn related health services, so if you’re unsure whether you are on the right cover for your growing family, please give us a call on 1800 603 603.

What is Medicare?
Medicare is a publically funded universal health care scheme operated by the Australian Government.

What is the Medicare Benefits Schedule?
The Medicare Benefits Schedule is a list of medical services and procedures provided by doctors and specialists and includes diagnostic imaging and pathology services. It contains the fees recognised by the Australian Government (known as the scheduled fee) and the amount of benefit Medicare will pay you when you receive those services. It is important to note that doctors are free to set fees and charge for their services as they see fit.

Services not recognised by Medicare
There are certain services that are not recognised by Medicare, including some types of cosmetic surgery and sterilisation reversal. If you’re intending to undergo this kind of surgery, please check with us first.

What is Medicare bulk billing?
Bulk billing is when your health professional accepts the Medicare benefit as full payment for a service.

How much does Medicare cover for out hospital services?
Certain out-of-hospital medical services are paid by Medicare and are therefore not covered by private health insurance. These include visits to or by your doctor plus medical services (including pathology and radiology) when provided to you as an outpatient or in a hospital emergency department (as the patient is not admitted). A hospital visit by a paediatrician to a newborn also falls into this category if the baby has not been admitted to the hospital as a patient in their own right.

In all these cases, claims should be lodged with Medicare for payment.

Medicare pays 85% of its Scheduled Fee for medical services provided to people who have not been admitted to hospital.

How much does Medicare pay for in medical services?
Medicare pays 75% of the Scheduled Fee for medical services provided to people who have been admitted (in-patient).

Who pays the difference?
For medical services provided to you as a hospital in-patient, Police Health pays the gap between the Medicare benefit and the Scheduled Fee.

In the vast majority of cases where medical services are billed under our Access Gap Cover scheme, we can also cover the difference between the Scheduled Fee and actual fee charged. Where the fee exceeds that covered by Access Gap Cover, the service provider should advise you of any gaps that exist and what you will need to pay.

What about out-of-pocket costs?
We strive to minimise treatment costs to members. While we have succeeded in covering most situations, there are some occasions when members will incur a charge from the service provider:

• Charges greater than the Scheduled Fee that do not fall within the Access Gap Cover.
• Charges greater than those recognised for Access Gap Cover.
• Non in-patient medical services, including those medical services provided while treated in the emergency department of a hospital.
• Visits by a paediatrician to a newborn who has not been admitted to hospital as a patient in their own right.

For more information on what Medicare covers visit medicareaustralia.gov.au

The Australian Government Rebate on private health insurance (Rebate) is an incentive whereby you’re offered a Rebate on your private health insurance premiums. The level of Rebate on private health insurance is based on your household income and the age of the oldest person covered by the policy.

If you’re eligible for a Rebate you can choose to receive it either as a reduced premium or in a lump sum at tax time. Most people choose to take advantage of the lower premiums. See your State Premiums & Benefits Guide to help you work out which Rebate Tier may be applicable to you.

For more information on how to claim at tax time, visit ato.gov.au

The Lifetime Health Cover (LHC) Loading is a legislated requirement that encourages you to take out private hospital cover early on in your life. You’re rewarded with lower premiums for taking out cover and maintaining it.

This is how it works: if you wait until you’re aged 31 and take out private hospital cover in the following financial year, premiums will be 2% more expensive. This increases by 2% for each subsequent year you delay taking out private hospital cover. This additional percentage is called the LHC Loading.

For example, if you wait until you’re 40, you end up paying 20% more on your private hospital cover. Similarly if you wait until you’re aged 50, you end up paying 40% more.

The LHC Loading is capped at 70% at age 65, and removed after 10 continuous years of appropriate private hospital cover.

In other words, the earlier you take out private hospital cover, the better, as deferring your decision can be costly.

Medicare Levy Surcharge (MLS) is a levy you should be aware of. Most Australian taxpayers are charged a 2% Medicare Levy. However, those who do not have appropriate private hospital cover may have to pay an additional levy called the Medicare Levy Surcharge (MLS).

A 1% MLS applies to couples or families without hospital cover who have a combined annual income greater than $180,000*, and singles earning more than $90,000*. This increases aligned to the income tiers as shown in your State Premiums & Benefits Guide. Family thresholds are increased by $1,500 for the second and subsequent dependent child.

Both partners must have hospital cover; otherwise both have to pay the levy. If you have dependent children they also need to be covered by a policy or you may have to pay the levy, even if you’re separated. If you’re unsure how this might affect you, we recommend you seek further advice from your tax advisor or the Australian Taxation Office.

For details on what income is included in the assessment please contact the ATO or refer to their website.

*Effective for 2019/20 and 2020/21 income years

Police Health has agreements with most private hospitals that are likely to be accessed by members. These agreements ensure that an agreed schedule of fees (including in-patient accommodation, theatre and special unit accommodation fees as appropriate) is charged by the hospital and paid by Police Health on the member’s behalf. Please note that a member’s benefit entitlements will be affected by factors such as their level and type of cover and the financial status of their membership. This will affect the amount Police Health will reimburse to the hospital.

Police Health strongly recommends the member contact us on 1800 603 603 to confirm their benefit entitlement prior to receiving hospital treatment.

NB. Members who choose a non-agreement hospital may incur out-of-pocket expenses for hospital related services irrespective of their level of cover.