Understanding PHI

Private health insurance (PHI) needs to work for you and your needs.

When choosing your private health insurance, it is important to make sure it suits your particular health needs, as well as your budget.

It is important that you check the product descriptions to make sure they meet your current needs and what you may need in the future.

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Private health insurance doesn’t have to be complicated. To help you get the answers you need you can -

The basic need-to-know facts

 

1. Did you know – Your health Insurance terms can change based on the type of insurance.

When you take out health insurance you are purchasing a product (a health insurance policy) from a private health insurance organisation (a fund).

The extent of insurance cover you obtain depends upon the health insurance product you choose. The money you pay to purchase this insurance cover is called a health insurance premium. The money the fund pays for treatment you receive is called ‘benefits’.

There are two types of private health insurance covers available

  • Hospital cover

    This covers hospital related treatments as a private patient including doctor’s charges and hospital accommodation. The level of benefits you receive depends upon the product you choose.

    Explore hospital cover 

  • Supplementary (or extras) cover

    This helps with the cost of services such as physiotherapy, dental and optical treatment that are not covered by Medicare, nor associated with a hospital admission. There are a range of options available.

    Explore Extras options

2. Did you know – There are different levels of the Federal Government rebate

The Federal Government rebate makes private health insurance more affordable for eligible members by reducing your private health cover premiums.

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3. Did you know – You can reduce your PHI costs

You can reduce the cost of private health insurance by tailoring the product for your unique needs. You can choose a product that has some or all the following features:

 

This is an amount of money you pay towards the cost of hospital treatment, regardless of the number of days of hospitalisation.
For example – Mary, Tom and their children, Mark and Samantha have a family membership with an excess of $500. This means that they are charged a lower premium (the monthly/ annual cost) for their hospital insurance because they have agreed to pay the first $500 of hospital charges if they require hospital care.
When choosing a health insurance product make sure you understand how these excess payments apply.

If you are transferring to Hunter Health Insurance Health Benefits from a cover at another Fund which had an excess/co-payment, and it is deemed to be a pre-existing condition, that excess or co-payment will apply for that hospitalisation for the indicated waiting periods. If it is not deemed a pre-existing condition, then an excess or co-payment may not be payable.

Some lower cost health insurance products specify that certain hospital treatments are not covered, and no benefits are payable. These are called exclusion products.
If you choose an exclusion product, you need to be careful that you do not exclude treatments that you may need in the future. The need for some treatments that are excluded, e.g., for coronary disease, is not always easy to predict.

Some health insurance products allow you to choose to be covered for only a minimum level of benefits for certain treatments in return for a lower premium. Some restricted benefits products sometimes referred to as ‘basic benefits’, only entitle you to basic benefits for accommodation but do not cover any theatre fees, intensive care unit, coronary care unit, labour ward or same day theatre fees.
Other restricted benefits products, pay minimum accommodation benefits and pay some, but not all, of the costs for theatre fees, intensive care unit, coronary care unit, labour ward or same day theatre fees. You should check with your health fund to ensure that you fully understand your benefit entitlements if you choose a restricted benefits product.
You should also be aware that there is generally a significant price difference for hospital accommodation in a public hospital compared with a private hospital.

 

However, when choosing a product where the premium has been reduced through an excess, co-payment, etc, this could lead to a lowering of benefit levels or an increase in what you pay for treatment.

Make sure you read and understand what is covered and what is not. If you are unsure of any of the terms or exact treatments that are excluded or pay limited benefits, ask your fund.

4. Did you know – You should read the fine print when switching funds

You can transfer between funds at the same or a lower level of cover, without serving additional waiting periods. This is sometimes called portability between health funds. The fund you transfer to must give you credit for any waiting periods already served. You may have to serve additional waiting periods if you upgrade your level of cover even if it is with your current fund.

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5. Did you know – Your waiting period can vary

When you join a health fund or upgrade your existing level of hospital cover, you may have to wait some time before you can claim benefits for some services.

This is called a waiting period. Waiting periods that apply to hospital cover include:

Waiting periods on Hospital cover

  • 12 months for treatment related to a pre-existing condition.

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  • 12 months for obstetrics (pregnancy) services

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  • 2 months for all other hospital treatments except accidents.

Waiting periods on Extras Cover

  • Waiting periods for extras services are not regulated by the Government and may vary between products and between health funds. There are usually different waiting periods for different extras services.

What does this mean?

You should check the waiting periods on services carefully when choosing your health insurance fund product and you should also check the limits that apply to each person on the membership.

6. Did you know – There are different Hunter Health Insurance membership options

Types of membership

You become a member of a health insurance fund when you purchase a health insurance product. There are three possible categories of health insurance membership.

  • Single membership – provides cover only for the one person named on the membership application.
  • Couples Membership – provides cover for the member and the member’s nominated partner.
  • Family Membership – provides cover for the member, the member’s nominated partner and/or dependants.

Membership suspension

You can apply for ‘Suspension of Membership’ if you are travelling overseas and will be out of Australia for a continuous period of not less than 2 months to a maximum of 24 months. This will allow you to freeze cover and not have to pay contributions for that period outside of Australia provided all persons listed on that membership will also be travelling for the same period.

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7. Did you know – You need to be aware of ‘Gap payments’

A gap payment is the difference between the fee charged and the benefit paid by your health fund.

Hospital gap payments

All funds now offer gap benefits as part of most hospital insurance products. In most cases these benefits have been added to existing hospital products – so you may already be covered for all or part of the medical fee gap. 

Hunter Health Insurance has gap cover available on all its open hospital component products. This is aimed at eliminating any out-of-pocket expenses to our members. However, this is not always the case, and it is important that members obtain a quote from their practitioners, including other practitioners involved such as anaesthetists or assisting surgeons to determine prior to any procedure if there will be an out-of-pocket expense.

Gap payments for hospital treatment can occur for 3 reasons

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Extras gap payments

Gap payments can also occur if the fee charged by your service provider such as dentist, physiotherapist or optician, is greater than the benefit paid by your fund for that service. The level of benefit health funds pay for extras services is at the discretion of health funds and is not regulated by the Government.

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Get the right cover for your needs in four simple steps

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While our policies can help you avoid high-cost bills there are many other benefits in being a member with Hunter Health Insurance. These include:

Having greater control over your health care

With private health insurance, you can choose your own doctor and hospital from those who participate with Hunter Health Insurance without having to worry about unforeseen costs.

If you have a serious medical condition, you can have greater confidence in getting the very best care in a great facility and have a higher chance of being able to have a private room in the hospital where available 

Avoid having to wait for treatment 

Depending on your needs you may have to wait for long periods to be served in the public system – particularly for elective surgery. When it comes to your health that is something you should really want to avoid. While the public system provides great services in emergency situations, if your condition is not life threatening you may have to wait for months or even over a year to receive your medical procedures. Going private for these services avoids those waits and having a policy with Hunter Health Insurance can give you access to those services at a fraction of the cost.

We have benefits you can pro-actively claim on 

Unlike insurances for items like car, house or life you can add an Extras policy to your cover that you can proactively claim on to help maintain your health. Depending on your policy, you could get money back every time you visit the dentist, physio, chiro, and more. Having an insurance policy can make it easier for you to finance these types of preventative treatments. 

Avoid additional taxes and higher premiums in the future 

Many people will pay lower taxes by taking out health insurance. With hospital cover, you can avoid the Medicare Levy Surcharge if you earn over $90,000 per annum. For some people, taking out basic hospital cover with Hunter Health Insurance could cost less than paying the surcharge while having the benefit of being able to go private if needed. 

In addition, if you take out Private Health Insurance before you turn 31 you can avoid the Lifetime Health Cover Loading. Which is basically a surcharge that gets added to your policy (no matter who you take insurance with) that increases the longer you wait to get cover. 

Peace of mind 

The peace of mind factor cannot be underestimated. We never know what the future holds for us or our families. It’s a concept that we accept when we take out car insurance and hope we never have to use it. But if the time comes, knowing that you have the option to go private, avoid the queues and significantly reducing the potential high costs depending on your chosen level of cover puts you in the drivers seat to get the best outcomes.   

We are local

You won’t find many funds that maintain a local presence in the Hunter where you can pop in and discuss any of your needs face to face. You also won’t find any other fund that purely focuses on our private hospital agreements and other services that best meets the needs of Hunter Valley residents. We were born in the Hunter 70 years ago and that’s where our focus remains.

You can’t claim your private health insurance as a tax deduction. However, you can:

  • Reduce the cost of your policy with the private Health Insurance Rebate – which is the amount the Australian Government contributes towards your premium.
  • Avoiding paying additional taxes via the Medicare Levy Surcharge – depending upon your income.

Depending on the policy you take out, Hunter Health Insurance:

  • Provides treatment in hospital as a private patient
  • Can help pay medical costs that Medicare does not cover
  • We may also pay benefits for Extras (general treatment) to help reduce the cost for those services outside a Hospital setting.

We have a range of policies that cover Hospital, Extras (general treatment) and Ambulance benefits. If you want both you can take out a combined policy or you can choose to just take out one or two of these components. 

Check out our products page to see our range and the detailed benefits.

With private health insurance, you can choose your own doctor and hospital from those who participate with Hunter Health Insurance without having to worry about unforeseen costs.

Depending on your needs you may have to wait for long periods to be served in the Public system using Medicare – particularly for elective surgery. When it comes to your health that’s something you should really want to avoid. While the public system provides great services in emergency situations, if your condition isn’t life threatening you may have to wait for months or even over a year to get serviced. Going Private for these services avoids those waits and having a policy with Hunter Health Insurance can give you access to those services at a fraction of the cost.

Whether you’re taking out a policy for just yourself or for your family, choosing the right policy for your loved ones and/or yourself is important.

However, finding the right policy for a family with a child (or several) can be quite a different process compared to finding the right policy for an individual. It can all depend on your budget, appetite for peace of mind and the types of services you believe you will most likely need.

Get a quick quote to see the various policies, benefits and pricing that may be suitable for you – or if you prefer, give us a call and we can walk you through the options.

Restricted cover is where certain services are specified as being restricted services under a hospital product and where minimum benefits are applicable.

  • In a private hospital: These benefits would not cover all hospital costs and are likely to result in large out-of-pocket expenses.
  • In a public hospital: If the minimum benefits are less than what your chosen public hospital charges, you may have out-of-pocket expenses to pay.

A pre-existing ailment or condition is an ailment, illness or condition where the signs or symptoms existed during the 12 months before you joined Hunter Health Insurance or upgraded to a higher level of cover, even though you may not have been diagnosed.

If there’s any doubt as to whether an ailment or condition is pre-existing, we will appoint a medical practitioner to examine information provided by your doctor, together with other relevant claim details.

If you need treatment for any procedures listed as an exclusion on your hospital cover, you will not receive any benefits from us and may have significant out-of-pocket expenses.

Ensure you have reviewed the exclusions list before buying your cover.

An excess is the amount you choose to pay if you are admitted to hospital for planned treatment. Depending on your level of hospital cover, you can reduce your premium by opting for a higher excess or pay a bit more to get a lower excess.  

You will not pay a hospital excess for dependent children. 

You pay only one hospital excess amount per financial year on a Single Memberships or two on a Family Memberships, if an excess is applicable to your selected cover.

You might need to make a claim after going to hospital, being transported in an Ambulance or using a service from your Extras cover. There are a few different ways you can claim, depending on the service and your chosen health provider.

On the spot: If you have your membership card with you, many of our Extras providers can process your claim immediately at your appointment so you’ll only need to pay the difference of what’s owing. 

Online: You can go to our online Claim Form complete the details and upload your Extras or Ambulance receipt in a few easy steps

In a branch: You can always visit us in person with your Membership Card and your original receipts and we’ll take care of the rest.

Email: Send your original receipts to [email protected]

By post: Send your original claim form and original receipts to Hunter Health Insurance, P.O. Box 183, Cessnock NSW 2325

Before making a claim you’ll need to make sure that you:

  • have provided us with your bank details so we can pay your claims.
  • are covered for that treatment or service and have served any relevant waiting periods
  • have already had the treatment or service and are submitting the claim within 2 years of the service date.

If you are having treatment in hospital, there’ll likely be different parts involved in claiming. Usually, the hospital where you’ve had your treatment will take care of claiming for the costs for things like accommodation, theatre-room hire and prostheses.

You will be given a claim form to complete and sign, and the hospital will then send the bill to us. If there’s an excess, or any other out-of-pocket expenses, you’ll usually pay the hospital directly.

There are also medical costs, like surgeons and anaesthetists, not handled by the hospital. Your doctor and anaesthetist will create their own invoice and you’ll need to first claim through Medicare who’ll give you a Medicare Benefit Statement.

We require this Medicare Benefit Statement so we can process our portion of the claim. Sometimes your doctor and anaesthetist will lodge your claim to Medicare and Hunter Health Insurance on your behalf, so ask your practitioner about their billing so you know what to do next.

 

Claiming on your ambulance cover 

If you need to make an Ambulance claim, you can do it through:

  • Online 
  • In a branch; or
  • By post

Ambulance cover will vary from state to state:

 

NSW & ACT members

If you live in New South Wales or Australian Capital Territory, a levy is included in the hospital component of your private health cover. This entitles you to free ambulance transport under the State Government Ambulance Transport Schemes.

If you are sent an invoice for ambulance transport, send it to us and we will settle it. If you have pension or social security entitlements in NSW or the ACT complete that section on the back of the invoice and return it to the ambulance service.

If you fall outside the State-based arrangement for ambulance services and are not otherwise covered, you can claim under your Hunter Health Insurance cover for State Government-provided emergency ambulance services.

Claims that are not paid on the spot (ie Extras) will normally take up to 7 business days to be processed and paid into your chosen bank account.

There are a number of reasons a claim may be rejected, including:

  • The service is not included on your cover.
  • Information is missing from the receipt/s provided.
  • The photo of your receipt was blurry.
  • The claim is for a service you had over two years ago.
  • The service is covered by Medicare, which means you must submit to Medicare first, and then if applicable complete your claim with us.

If you are unsure why your claim has been rejected, please contact us.

If you need hospital treatment, you can choose your doctor.

If you need an operation or medical treatment, you will not need to go on a public waiting list. Hospital cover can quickly get you into a private hospital so you can be treated sooner.

Find a participating hospital

There are several ways you can join:

  • Online: Choose the right product for you by getting a Quote, then complete the online application form.
  • Call: 02 4990 1385

Visit our branch: Come and have a chat to us in person and we’ll help you choose the product that is right for you.

Yes you can and we will recognise any waiting periods that you have already served with your previous fund for like to like benefits so long as you join within 30 days of leaving your previous fund.

Switching to Hunter Health Insurance is easy. First choose the right cover that best fits your needs and then complete your application and interfund transfer. We can also assist you at our retail branch or over the phone on 02 4990 1385.

Once we have the details of your previous fund we’ll ask them to send us an interfund clearance certificate. If they send it to you, please forward it to:  Hunter Health Insurance, [email protected] or alternatively to P.O. Box 183, Cessnock NSW 2325.

If you are switching and upgrading your benefits you will need to serve the necessary waiting periods for your higher entitlements.

Hear what our members have to say

As the Hunter’s first not-for-profit health insurer, we started by serving those in the community most in need — miners and their families.

Stewart

“My family has been with HHI since the beginning & we’ve never had any issues or problems. We like that they’re a not for profit, and community minded. In comparison to other funds, I believe Hunter Health Insurance to be the best value in both member contributions and benefit claims.”

Tracey

“My husband and I are in our 30’s and shopped around for the best health cover. And given we have a newborn baby, health cover was more important than ever. We are delighted with HHI. Their contribution rates are very reasonable, and their service and benefits are reliable.”

Shirley

“My husband was hospitalised and we never saw a bill!
Hunter Health Insurance looked after paying for everything, promptly and efficiently. We were previously with another health fund and now we enjoy the same cover for 20% less contributions!
Doesn’t get much better than that!”

Joy

“I believe Hunter Health Insurance is a marvellous fund. I was in hospital recently for a hip replacement and it didn’t cost me a penny – Hunter Health Insurance paid every bill very quickly.”

Gwen

“My husband and I have recommended Hunter Health Insurance to family and friends for years. We have Silver Plus cover and when my husband spent some time in hospital, the bill was immediately paid by Hunter Health Insurance without fuss.”

Trevor

“We are very happy with Hunter Health Insurance and wouldn’t dream of going to another health fund. They’re friendly and their contribution rates are very competitive.”