Living with a health condition?
A health management program can provide additional support when living with a specific health condition. When one of our recognised treatments is prescribed by your doctor and the program is approved by us, benefits can be claimed with any level of extras cover.
We offer benefits for a variety of treatments under a health management program when undertaken to manage a specific health condition.
What services are covered?
These treatments include exercise physiology, acupuncture, class physiotherapy, weight loss classes, quit smoking and exercise classes conducted at a gym or by a personal trainer. While this is an exclusive list of recognised services, we don’t have any specific programs or providers at Doctors’ Health Fund that you must choose from – we leave it up to you and what your treating practitioner recommends. Your provider just needs to be a trained individual currently registered with a national association and exercise physiologists must have a current Medicare provider number.
What are the benefits?
Health management program benefits are included with every level of extras cover, as outlined below:
Health management program benefits
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| Benefit | Annual limit | Waiting period | |
|---|---|---|---|
| Total Extras | 50% of the cost | $200 per person, $400 per policy for family and single-parent policies | 2 months |
| Essential Extras | 50% of the cost | $100 per person, $200 per policy for family and single-parent policies | 2 months |
| Starter Extras | 50% of the cost | $100 per person | 2 months |
Who is eligible for these benefits?
These benefits are payable when the condition being treated is specific and diagnosed by your usual treating practitioner. Examples of specific health conditions include asthma, arthritis, unhealthy BMI, high blood pressure and musculoskeletal disorders. Goals such as core strengthening, flexibility and wellness aren’t considered specific health conditions and therefore health management program benefits cannot apply is these cases.
What do you need to do for a program to be approved?
If you are interested in accessing these benefits, have your treating practitioner complete and sign the following form, outlining your health condition and the treatment they recommend to manage or improve that condition. Then we ask that you send us a copy of this completed form for review, either by email, post or using our app.
How do I claim if my program is approved?
Once we receive your completed form and if your program is approved, we’ll record this on your policy. This means you don’t need to send us your form every time you want to make a claim, when part of the one program. We will need a new form and for this to be approved for any new or renewed programs.
Simply send us a copy of your invoices for services that occur as part of your approved program, and we’ll pay your benefit the same way we pay all other extras benefits.
Claims that are related to your health management program can’t be claimed via HICAPS, but we’ll process your benefits once your claim is received, typically within 1-2 business days.
How long does my approved form/program last?
Your health management program form includes an expiry date and we cannot hold them for longer than your doctor has recommended. A new form will need to be completed and approved to access additional services after this expiry date.
My program was not approved / my claim was not paid for my approved program. Why is this?
There are strict requirements about health management programs under health insurance legislation, so there are instances where we are unable to approve a form or pay benefits for services related to an approved program. These include:
Approval of a program:
- The information provided on the form is incomplete
- The details provided do not meet the eligibility requirements for a health management program, that is, the treatment prescribed is not treating a specific health condition
- Your treating practitioner is a family member.
Reasons why we may not be able to process your claim for an approved program:
- The services have been paid for in advance, but the treatment hasn’t yet been completed
- The treatment was paid for but didn’t go ahead (i.e. non-attendance)
- The service provider isn’t recognised with a national association or in the case of an exercise physiologist or acupuncturist, doesn’t have a Medicare provider number
- The invoice doesn’t show complete information, being:
- Patient name
- Provider details
- Service received (including description)
- Date of service
- Fee paid
As always, don't hesitate to contact our expert Member Services team if you have any questions about the benefits and limits included with your level of cover.
IMPORTANT: Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy. The information provided in this article is general in nature. You should consider the appropriateness of the information having regard to your own objectives, financial situation and needs.
