Q: How to make a claim?
Q: I’m having a baby. What do I need to do about my cover?
Check with ACA Health as soon as your pregnancy is confirmed, your current level of hospital cover and whether you are still under any waiting periods (12 months for obstetrics). You may need to upgrade to a family or single parent membership.
Single hospital membership for mothers only cover the cost of the birth of the baby but doesn’t cover any costs incurred by the baby. For a baby to be eligible for benefits immediately from birth, the mother must have contributed to a family or single parent membership for at least 2 calendar months prior to the infant’s birth. (Regardless of whether or not the infant is premature)
When the baby is born, he/she will be considered an out-patient and as such, Medicare pays the first 85% of the scheduled fee and you must meet all costs not covered by Medicare. ACA Health is not permitted to pay benefits on these out-patient fees.
Your newborn (nine days old or less) is only classified as an ‘admitted patient’ if the baby:
- is admitted to an Australian Government approved neonatal intensive care unit; or
- is the second or subsequent baby born in a multiple birth; or
- is in hospital without his/her mother.
Q: What if I have to go to hospital as an emergency?
In NSW or ACT, you are covered in full for ambulance transportation with hospital or extras cover. In all other states, ambulance is covered only under general treatment products.
If you go to an emergency department of a private hospital, you will be classed as an ‘out-patient’ and as such ACA Health is not legally permitted to pay benefits on these services or any blood tests or x-rays that may be taken at this time. These fees are instead reimbursed by Medicare, as services provided to “not admitted patients”, at 85% of the Medicare Schedule Fee.
Many private hospitals also charge a ‘facility fee’ for attendance at their emergency department to help off-set their running costs. ACA Health does pay a benefit towards this fee.
If, after emergency treatment, you require admission to the hospital, you will then be covered by your Hospital cover with ACA Health (provided all waiting periods are served and the treatment is covered by your hospital cover).
Q: What do I need to do if I have to go to hospital?
If you need hospital treatment, we recommend the following steps to determine your benefit and the amount of gap fees you may need to pay:
- Contact us straight away to find out your level of hospital cover and whether you will be covered for the treatment you need.
- Ask your doctor(s) whether they participate in the Access Gap Cover Scheme and if so, to bill your accordingly. This may help you avoid or lower your out-of-pocket expenses.
- Check that the private hospital is contracted with ACA Health through the Australian Health Service Alliance (AHSA) by using our Hospital Search.
If your hospital stay is longer than 35 days and your doctor considers that you no longer need acute care, you will need to pay a contribution to your living costs in much the same way as nursing home type residents contribute to the cost of their care. The patient contribution is payable by public and private hospital patients and ACA Health is unable to pay benefits on this fee. Contact us for more information.
Q: I need a statement of benefits for my tax return, what do I do?
You can download your claims history from within your member account portal. This will list all the claims and benefits paid on your membership. Privacy laws require that all persons on the membership need to give permission for the release of their claims information (within reason for age purposes).
Q: Is there a time limit on claiming?
ACA Health require that all claims for benefits need to be received at our office within 24 calendar months from the date of service.
Q: Can I change providers mid-year?
You can change your healthcare provider at any time. If you do choose to change healthcare providers you will be required to get a tax statement from each provider to complete that year’s tax return.
Q: Can I choose my healthcare provider?
Yes, as long at the treatment provider is appropriately qualified and registered with their relevant association.