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Excess
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Singles $500 per calendar year. Couples, sole parent family and family memberships $1,000 per calendar year.
$250 of excess is paid per admission until the full amount of excess is paid for the year. The total excess amount applies to the entire membership not for each person covered by the membership.
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Co-payments
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None
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Waiting Periods
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None for accidents
12 months for pre-existing conditions
2 months for everything else covered
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Exclusions
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No benefits are paid for:
Pregnancy related services
Assisted reproductive services
Sterilisation and reversal of sterilisation
Hip and knee replacements
Glaucoma treatment
From 1 February 2010 the following services will also be excluded:
Hip and knee replacement revisions
Cataract treatment
Plastic surgery which is excluded from Medicare coverage
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Benefit restrictions
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Cardio-thoracic surgery limited to delivery as a private patient in a public hospital. Plastic and reconstructive surgery benefits for hospital and medical costs are restricted to services eligible for Medicare benefits. When chosen for cosmetic reasons only default hospital accommodation benefits apply.
From 1 February 2010 the following benefit restrictions will come into effect:
Psychiatric services are limited to 10 days per annum in a private hospital with benefits for any further days limited to delivery as a private patient in a public hosptial shared ward.
Dialysis for chronic renal failure is limited to delievery as a private patient in a public hosptial shared ward.
Rehabilitation services following cardio thoracic, psychiatric, hip and knee replacement and revisions is limited to delivery as a private patient in a public hospital shared ward.
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Ambulance
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National cover for emergency and medically necessary ambulance services when
- an ambulance is called to attend you but you are not subsequently taken to hospital
- it is medically necessary for you to be transported by an ambulance to be admitted to hospital
- you need immediate medical attention at a hospital or other approved facility
- you are an admitted patient and need to be transferred to another hospital
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Accommodation
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In a contracted private hospital or day-only facility, or a public hospital as a private patient all costs of accommodation are covered after the excess is paid. In non-contract hospitals or day-only facilities the lowest contracted benefit is paid and you can expect to have out-of-pocket expenses.
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Hospital services
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After the excess is paid all costs are covered for theatre services while you are an in-patient.
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Medical services
gap cover
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The cost of doctors' services delivered while you are an admitted patient can be covered by the Access Gap Cover scheme which reduces or eliminates your medical services out-of-pocket expenses. When your doctor agrees to participate in the Access Gap Cover scheme the Fund covers the scheme's scheduled amount for your treatment. The doctor may choose to charge you a payment above the scheme's scheduled amount. This may be no more than $400 per service. Most pathology and radiology providers have contracts with us, so while you are an admitted patient most of these services will have no out-of-pocket expense.
Claims using this gap scheme should be submitted directly to the Fund. Check that your doctors have marked any bills sent to you as Access Gap cover accounts. To find doctors who participate in this gap scheme use the Doctor Search facility on this website.
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Pharmaceuticals
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In a contracted private hospital or day-only facility, or a public hospital as a private patient, all costs of PBS pharmaceuticals related to the condition being treated are covered, and the cost of non-PBS items related to the condition being treated are covered as per the contract with the hospital. In non-contract hospitals and day-only facilities the lowest contracted benefit is paid and you can expect to have out-of-pocket expenses.
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Prostheses
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Covers 100% of the minimum cost specified for government approved prostheses.
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Other
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Up to $70 per day for travel and accommodation where a doctor certifies the need for a parent, spouse or child to be with a member in hospital more than 200 kms from home.
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What you can expect to pay if you go to hospital
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Your excess
For personal items such as newspapers and television hire.
The difference between the Medicare Schedule fee and your doctor’s fee. From 1 August 2007 this will only apply if your doctor does not wish to participate in the Access Gap Scheme.
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