Miscellaneous

What are full Medicare benefits?

If you are a permanent Australian Resident, you should be entitled to full Medicare benefits and therefore private health insurance with Navy Health (providing you meet the eligibility criteria)

People who reside in Australia excluding Norfolk Island are eligible for Medicare benefits if they meet any of the following four criteria:

  • they hold Australian citizenship
  • they have been issued with a permanent visa
  • they hold New Zealand citizenship,or
  • they have applied for a permanent visa.  Restrictions apply to persons who have applied for a parent visa (other requirements apply).

If you are an overseas visitor from a country in which the Australian Government has signed a Reciprocal Health Care Agreement, you are entitled to restricted access to Medicare in the public system whilst visiting Australia.

If you are not from a country with a Reciprocal Health Care Agreement, you are not entitled to Medicare benefits.

Please visit Medicare Australia’s website at www.medicare.gov.au or phone 132 011 (local call rate) to confirm you Medicare eligibility.

What is the Medical Gap?

If you receive doctors' services in hospital as a private patient, Medicare will cover 75 per cent of the Government's set fee for doctors' charges (this is often referred to as the 'schedule fee') and your health fund will cover the remaining 25 per cent of that schedule fee.

The Government determines the set fee on the basis of what is considered a fair and reasonable price for a particular service. However, the Government does not control doctors' fees and your doctor may charge more than the set fee.

The 'medical gap' arises where doctors charge in excess of the schedule fee. It is the difference between fees charged by doctors for medical services in hospital, and the combined health insurance benefit and Medicare benefit.

Doctors' charges above the set fee may only be covered by health funds where an agreement or gap cover scheme exists, involving the fund, doctors and/or hospital. Without such regulatory measures in place there could be an uncontrolled escalation of medical charges.

Where an agreement or scheme is in place, you will have either no out-of-pocket expenses (this is referred to as "no gap") for doctors' services provided in hospital, or you will know in advance what costs you will bear (this is referred to as a "known gap").

If you want a health insurance policy that covers all or part of the medical gap, you should check whether your health fund offers this kind of product and, if so, which doctors participate in its agreements or gap cover schemes.

It is important to contact your health fund and doctor before admission to hospital treatment to find out if you may be required to pay any out-of-pocket expenses. You may wish to ask your GP to refer you to a specialist who offers no gap, or a known gap, for the medical services he/she provides in hospital. If you are referred to a specialist and are not happy with the costs they indicate, consider asking your GP to refer you to another specialist.

What are Agreement Hospitals?

Navy 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 Navy 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 Navy Health will reimburse to the hospital.

Navy Health strongly recommends the member contact them on 1300 30 6289 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 most hospital related services irrespective of their level of cover.

Do I need Ambulance Cover?

Members of Navy Health who take out any of our Hospital Cover products are 100% covered for all ambulance services within Australia, provided that the service is from a State/Territory registered ambulance service.

What is HICAPS and IBA HealthPoint?

HICAPS and IBA HealthPoint let you enjoy the convenience of easy, on the spot claiming when you visit a participating dentist, optometrist, physiotherapist, osteopath, chiropractor, podiatrist, occupational therapist or psychologist.
HICAPS stands for the “Health Industry Claims and Payment Service”.

It is an electronic system that effectively lets you use your Membership Card to “pay” for a health service instead of using your own money and then submitting a claim.  IBA HealthPoint is a similar type of system that also lodges claims directly with Navy Health so that we can pay the provider for you immediately.

Numerous providers have these facilities. You simply swipe your membership card for instant claims processing, and then only pay the difference between the practitioner’s fee and your Navy Health benefits.

How does Navy Health protect my privacy?

The personal information, including health information that Navy Health obtains from you is collected for the purposes of processing your application and offering and administering your health insurance as well as fulfilling Navy Health’s obligations in developing and informing you of new products, services and special discount offers.

At Navy Health we take the issue of Member Privacy and Security very seriously. We understand that the information you, our members, provide us with is of a highly sensitive nature.

Our commitment to you is that we will always undertake reasonable steps to protect your privacy. It is for this reason we have a Privacy Policy that means we will not discuss any details about a membership except with the policy holder, unless they have given authority for us to do so.

This means should your spouse or partner telephone us to make an enquiry about the policy, we will not be able to discuss anything with them – unless you have called, completed the authority below or written to Navy Health authorising them to do so.

As part of our Privacy Policy we also undertake Security Checks whenever you contact our Member Services Team. This will entail our team asking you a series of questions to confirm we are speaking to the correct person.

Can I claim for visits to my GP and/or specialist?

You can claim for medical services provided by your doctor when you’re admitted to a hospital or day surgery.  Outpatient visits to a doctor or specialist, however, are not covered by health funds.  Medicare rebates 85% of the Medicare Schedule Fee for outpatient medical services.

What are pre-existing conditions?

A pre-existing condition is an ailment or illness where there were signs or symptoms present during the six months prior to joining Navy Health.

For pre-existing conditions, benefits will not be payable for the first 12 months of membership for any illness, ailment or condition, the signs or symptoms of which where known, or which a medical or para-medical practitioner appointed by the company considers, after examining information furnished by the member’s practitioner, and other material relevant to a claim for benefits, were in existence in the member or his/her dependant at any time during the six months preceding the commencement or transfer date.

This is irrespective of whether the member or dependant was aware of the pre-existing illness, ailment or condition, and includes all proposed elective or cosmetic procedures.  Navy Health mat request further medical evidence in determining eligibility for benefits.

What is the PHIO state of health funds report?

The Private Health Insurance Ombudsman (PHIO) publishes the annual State of the Health Funds Report.  This report assists consumers to compare the relative performance and service delivery of their health fund with all other funds.  You can obtain a copy of the report from www.phio.org.au