Our Health Management Program is only available under Total Extras. These are medical treatments intended to manage a member’s specific health condition that’s been diagnosed by a registered medical practitioner, who is not a family member.

Examples of specific health conditions are asthma, arthritis, unhealthy BMI, high blood pressure and muscular skeletal disorders. Core strengthening, flexibility and wellness are not examples of a specific health condition.

There are strict legal requirements about what can, and cannot, be a Health Management Program under a health insurance product. For example, personal training to reduce an obese member’s BMI would likely be considered a Health Management Program, while a member with a healthy BMI (and no other specific health condition) would be ineligible to claim.

The treatments recognised by our Health Management Program are:

  • Exercise physiology
  • Quitting smoking
  • Acupuncture
  • Weight loss classes
  • Exercise classes conducted at a gym or by a personal trainer
  • Class physiotherapy
How do I claim?

A completed Health Management Program approval form is required for every new/renewed program. A claim form is only required when other treatments are claimed in conjunction with a Health Management Program.

  1. Download the Health Management Program Approval Form, fill it in and have your doctor sign it.
  2. Once you have completed your Health Management Program, submit the form and your receipt to us at PO Box Q1749, Queen Victoria Building, Sydney NSW 1230.

    You can also submit it through our mobile app. Claims through the mobile app need to include a photograph of a completed Health Management Program Approval form.

Health Management Programs are not claimable through HICAPS.

Who can deliver Health Management Programs?

Health Management Programs must be delivered by trained individuals currently registered with a national association to perform the treatment. Exercise physiologists and Royal Australian College of General Practitioner acupuncturists must have a current Medicare provider number for us to provide a benefit.

When can I claim for my Health Management Program benefit?

Benefits are only payable where the specific health condition was present before or when commencing the Health Management Program. Where the Health Management Program is ongoing, or has been paid in advance, a benefit can only be paid on completion of that treatment.

If the ongoing Health Management Program has distinct stages/consultations, such as visits with an exercise physiologist, a benefit is payable on the completion of each stage/consultation.

Receipts need to show the start and end date of each stage/consultation.

Where payment has been made but treatment is not received, no benefit is payable.

Are wellbeing or preventative treatments covered?

Under Government legislation, benefits are only payable when a Health Management Program is undertaken to manage a member’s specific health condition.

In the absence of a specific health condition (such as an undiagnosed condition, genetic predisposition and wellbeing) we are prevented from paying a Health Management Program benefit.

For example, personal training to reduce an obese member’s BMI would likely be considered a Health Management Program, while a member with a healthy BMI (and no other specific health condition) would be ineligible to claim.
 

What is a specific health condition?

A specific health condition is a condition that’s been diagnosed by your usual medical practitioner, who is not a family member. The treatment being claimed must be intended to improve that condition.

Examples of specific health conditions are asthma, arthritis, unhealthy BMI, high blood pressure and musculoskeletal disorders. Core strengthening, flexibility and wellness are not examples of a specific health condition.

We expect your medical practitioner to prescribe treatments in accordance with accepted clinical practice for your specific condition; alternative treatments cannot receive a benefit at this time.

Where insufficient information has been provided to support the effectiveness of the Health Management Program to improve a member’s specific health condition, we may determine that no benefit is available.

What happens if a medical practitioner recommends a program for more than 12 months?

Living with a specific health condition involves ongoing appointments with your usual medical practitioner. This is vitally important to ensure prescribed treatments are working and nothing adverse occurs.

This is why the Health Management Program approval form is only valid for a maximum of 12 months at a time.
 

How often do I need to complete this form?

To continue claiming for a Health Management Program you must provide a new approval form on the expiration of the old one.
 

Can I claim for the cost of getting the Health Management approval form completed?

Costs incurred for the completion of the Health Management Program approval form are not claimable.

I have been prescribed a treatment that is also covered elsewhere under my policy, how is this claim paid?

Where a treatment is listed as both a Health Management Program and a standalone service, a benefit will be paid under the standalone service.

Where the limit for the standalone service has been exhausted, no additional benefit is claimable for that treatment as a Health Management Program.