Hospital

Excluded Services

If a service is excluded, you are not covered for this. There are no benefits payable.

 

Restricted Services

We pay minimum benefits for restricted services. This means that we will pay the minimum default benefit rate for a shared room as set out by the Federal Government, and minimum benefits for Government approved prosthesis list items. If you choose to be treated:

  • In a private hospital – there are no benefits payable for these services in a private hospital
  • In a public hospital as a private patient in a shared room – you may have an out-of- pocket expense to pay, in the event that the minimum benefit is less than your chosen public hospital charges

Regardless of where you are treated, the hospital should advise before you are admitted into or have treatment in the hospital, of your out-of-pocket expenses that you may incur. Seeking your approval beforehand is known as financial consent.

* Access Gap Cover Scheme is available with participating doctors to minimise any out-of-pocket gap costs.

For Bare Essentials Hospital benefits, the Federal Government Default Benefit is applied for restricted services in a Public Hospital. This is the amount of benefit determined by the Federal Government as the minimum amount private health insurers must pay for accommodation in public hospitals. Default Benefits are payable only towards the cost of hospital accommodation and provide no cover for other hospital charges such as operating theatre costs. Please call us on 1300 368 390 if you would like to know if the Default Benefit applies to any treatment you anticipate. 100% cover applies to private hospitals when they are contracted with the fund through the Australian Health Service Alliance (AHSA). This does not involve most licensed private hospitals and day facilities in Australia. To view the hospital contracted with the fund, you can use the Hospital Search when you login to your account on our website at www.acahealth.com.au.

Other Features

  • Qualifies for government incentives:
    • Access to the Federal Government Rebate as a reduced premium
    • Exemption from the Medicare Levy Surcharge (MLS)
    • Exemption from Lifetime Health Cover (LHC) penalties if joining before age 31
  • Ambulance Cover for included services for residents of NSW & ACT in these states (for other states the ambulance cover is available under the General Treatment Products).  No Ambulance cover for Excluded services.
  • Dependants covered to age 21 (or 25 if eligible full time students)
  • Dependant Extension (for dependants who are not full time students aged 21-25 when combined with a general treatments cover)

Note: With this level of cover there is an excess payable of $500 per adult person, per calendar year (whether in a private or public hospital) which does not apply to child dependants.

Waiting Periods

  • Accidents requiring hospital treatment, not related to a pre-existing condition – No waiting period
  • Ambulance – No waiting period
  • Treatment relating to a pre-existing condition – 12 Months
  • All other services – 2 Months

On joining hospital cover for the first time, waiting periods must be served before benefits will be paid. If you have upgraded your hospital cover, waiting periods will apply before the higher benefits will be paid.

What’s Not Covered?

  • Excluded Service (heart surgery, joint replacements, pregnancy & related services, (this includes miscarriages and assisted reproductive services)
  • Surgeon’s fees for podiatric surgery
  • Services for which Medicare pays no benefit e.g. cosmetic surgery & laser-eye surgery
  • Restricted services in a Private Hospital
  • Services while a membership is in arrears
  • Services incurred before waiting periods are served (including any service for a pre-existing condition)
  • Services received as an outpatient, such as in the Emergency Department or visit to your General Practitioner/Specialist
  • Services where there is an entitlement under compensation insurance
  • Pharmaceutical prescriptions
  • Hospital substitute services (i.e. early discharge program)
  • Labour ward fees
  • Accommodation for nursing home type patients
  • Chronic disease management programs
  • Services claimed beyond the 2 years after the service date
  • Services provided in countries outside of Australia
  • No special assistance
  • Allied health services which are not included in the hospital agreement (where no Ancillary cover exists)

Pre-Existing Conditions

If you are suffering from a medical condition, illness or ailment at the time of commencing or upgrading hospital cover there will be a 12-month waiting period before hospital benefits can be paid on claims relating to that condition.

A pre-existing condition is defined as an ailment or illness where, in the opinion of a medical practitioner, the signs or symptoms existed at any time during the six months before, or on the day which a member joins private health insurance or upgrades to a higher level of cover.

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