HIFDomesticCoverPDS-2

Australia’s first certifiedCarbon Neutral health fund.

Our Product Disclosure Statement (PDS)Your HIF Hospital and Extras health cover in detail.

hif.com.au

Visit online to get a quote and join (or switch). Call 1300 13 40 60

What’s inside?

A bit about us, this PDS and health insuranceAt HIF, we aim to make choosing smart health insurance simple and painless. With that in mind, we’ll keep this Product Disclosure Statement (PDS) as short and sweet as possible. No unnecessary information. Just the must-know stuff. We want you to be able to make the right health insurance choice but we don’t want you to fall asleep. So here we go…

About us and you HIF is a not-for-profit private health insurer. That means we don’t have shareholders, so any income we earn after paying for our members’ benefits and covering our operating expenses is available to pay bigger and better benefits. And that’s a good thing.

About this PDS You’ll find lots of useful info about our health insurance in this brochure: what’s covered and what isn’t; details of different cover options; explanations about our services and the terminology we use. All the stuff you need to know when comparing, choosing and reviewing your health cover.

Important Tip When you join HIF or change your level of cover, we will send you a Member Statement confirming your new level of cover. To avoid confusion, it’s a good idea to keep your statement with this brochure.

Keep UpdatedHIF is always reviewing and improving its services and benefits so to ensure you are claiming all possible benefits remember to regularly visit hif.com.au/domesticpds for an updated version of this PDS.

About Australian private health insurance All Australian private health insurers, and residents and non-residents who pay tax in Australia, have potential responsibilities, obligations and entitlements under Australian health insurance laws.

These laws include directions about services that can or must be covered, entitlement to the private health insurance rebate and obligations to pay the Medicare Levy Surcharge (MLS) and the Lifetime Health Cover (LHC) loading.

The legislation or rules that affect your premiums, cover and membership obligations include:

• The Private Health Insurance Act 2007(the PHI Act)

• Fairer Private Health InsuranceIncentives Act 2012

• Fairer Private Health InsuranceIncentives (Medicare Levy Surcharge)Act 2012

• Fairer Private Health InsuranceIncentives (Medicare Levy Surcharge –Fringe Benefits) Act 2012

Under the PHI Act, we are required to document our operating guidelines, known as Fund Rules or Business Rules. All private health funds have to do this.

These rules detail our obligations as a private health insurer, as well as the obligations of our members. As such, when you become a HIF member, you agree to be bound by these rules. If you would like a copy of the rules, simply email [email protected] or call us on 1300 13 40 60.

Want more information?Visit hif.com.au to find out more about our not-for-profit health fund. Alternatively, if you would like to know more about us or the rules and regulations around health insurance, please email [email protected] or call us on 1300 13 40 60.

What’s inside?

A bit about us, this PDS and health insurance 2-3

HIF Hospital Cover Options 4

GoldVital Hospital 8

GoldStarter Hospital 12

GoldSaver Hospital 14

Gold Hospital 16

GoldStar Hospital 18

About our Extras cover 20

Ways to claim 22

Feedback, disputes and privacy 46

Frequently asked questions 48

Glossary 51

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Cover for in-hospital procedures

GoldStarter GoldSaver Gold GoldStar

Choice of Excess

Private Room

Private room (maternity) (3 days) (5 days) (unlimited)

Shared room

Intensive Care

Theatre Care

Same-day Accommodation

Same-day Theatre

Appliances

Prostheses

Pharmacy Drugs

AccessGap

Palliative Care Restricted Restricted

Cardio (heart)** Restricted

Psychiatric Care & Treatment

Restricted Restricted

Joint Replacement Restricted

Assisted Reproductive Technology (e.g. IVF)

Restricted

Eye Surgery (non-cosmetic)

Restricted

Gastric banding & Obesity surgery

Some restrictions and exclusions may apply.

Product Restricted Excluded

GoldStar • Surgery by podiatrists • Cosmetic services*

• Services not covered by Medicare*

Gold • Surgery by podiatrists • Cosmetic services*


GoldSaver • Assisted reproductive technology

• Cardiac (heart) conditions, proceduresor monitoring**

• Eye surgery

• Joint replacement

• Psychiatric

• Palliative care

• Rehabilitation

• Gastric banding and obesity surgery

• Cosmetic services*


• Surgery by podiatrists

GoldStarter • Palliative care

• Psychiatric

• Rehabilitation


• Cardiac (heart) conditions, proceduresor monitoring**

• Eye surgery


• Assisted reproductive technology

• Obstetrics (maternity)

• Cosmetic services*



For restricted services HIF will pay a basic benefit known as the public hospital rate, toward accommodation charges. All other charges raised by the hospital during the stay will be paid by the member. An excluded service means all charges raised during the stay will be paid by the member. * Where a service is deemed by Medicare to be cosmetic and/or does not attract a Medicare rebate, all charges raised

in association with the hospital stay will not be eligible for payment. ** Some examples of cardiac (heart) procedures including medical treatment or surgical procedures for cardiac

conditions, are arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrilators, stent insertion.

HIF Hospital Cover Options Restrictions and exclusions

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When selecting Hospital cover, it’s important to ensure that you understand how each level of cover will apply to you, as well as being aware of details such as limitations, restrictions or exclusions that might also apply to your chosen cover.

AccessGap CoverAccessGap Cover applies to medical accounts for members undergoing in-patient hospital procedures. It’s designed to reduce or eliminate out-of-pocket expenses by allowing doctors to use the scheme on a patient-by-patient basis. If a doctor uses the scheme, he/she agrees to charge you a set fee for each item and will then receive a payment from HIF and Medicare combined, which is more than the Medicare Schedule Fee.

To be eligible for AccessGap Cover, doctors must be willing to participate for your particular surgery and the account must be lodged directly with HIF (not Medicare). To find out more about specific payment amounts for upcoming procedures, or for your doctor to register for the scheme, please call us on 1300 13 40 60.

Healthcare providersHIF covers extras, medical and hospital providers throughout Australia. To confirm if a provider is approved by HIF, go to hif.com.au, email us at [email protected] or call us on 1300 13 40 60.

Benefits will not be paid for any hospital services provided outside Australia, or for services purchased or provided within Australia from a non-Australian recognised provider.

Ambulance servicesHIF is required under New South Wales and Australian Capital Territory legislation to financially contribute toward the cost of operating state or territory-provided emergency ambulance services on behalf of any person who is a permanent state or territory resident and holds any level of HIF Hospital cover. Under this arrangement, our members who are residents of NSW or ACT and hold HIF Hospital cover may submit their resident state or territory emergency ambulance invoice to HIF to claim a benefit toward the fees charged.

Please note that ambulance benefits may not be claimable under a NSW or ACT HIF Hospital cover if the service was not provided by your local state-controlled ambulance service, or if the service was not deemed by the ambulance attendant to be an emergency (medically necessary).

For more information about this, see page 24 or visit hif.com.au and visit the “Ambulance Cover” page within the “Health” section.

Medical GapDifferent medical providers may charge different prices for the same procedure. If you are planning a procedure, we recommend that you ask your medical provider and any associated health provider (e.g. anaesthetist or assistant) if they will participate in our AccessGap scheme to help you avoid or minimise your out-of-pocket expenses.

If your health provider does not confirm your out-of-pocket expenses, we recommend you contact us with your provider’s details, item numbers and charges and we will provide you with a benefit estimate.

The Pre-existing Condition RuleThis standard rule is applied across the health insurance industry. It is designed to ensure that long-term members are not financially disadvantaged by new members who join and claim benefits immediately for pre-existing conditions.

• A pre-existing condition is defined as anailment or condition for which the signs orsymptoms were evident or known at anytime during the 6 months prior to whenthe member joins HIF, or upgrades to ahigher level of cover or the same coverwith a reduced or nil excess.

• HIF is not required to pay benefits for apre-existing condition during the first 12months of a new member’s Hospital cover.

• Where an existing member upgrades toa higher level of cover or the same coverwith a reduced or nil excess, any servicesrelated to the pre-existing condition willbe paid out at the previous level of coverfor the first 12 months.

Restricted servicesWhere services are noted as ‘restricted’ in your Hospital cover, this means that if you receive them in a private hospital, you will only be covered at the basic public hospital benefit rate, which includes:

• The cost of a shared room in a publichospital

• A benefit towards the cost of surgicallyimplanted prosthesis

• AccessGap for in-patient medical services

No other benefits are payable for restricted services, unless specifically listed in the individual product description within this brochure.

Excluded servicesWhere services are noted as ‘excluded’ in your Hospital cover, this means that you are not covered and you must pay all costs.

Workers Compensation and Dual InsuranceBenefits cannot be claimed and are not payable by HIF where you have or can claim benefits or compensation (in full or in part) for treatment, goods or services from a third party including Workers Compensation or Public Liability sources, your employer or any other Insurance policy.

Transferring and upgrading your coverNew members who transfer Hospital cover from another Australian health fund to an equivalent level of HIF Hospital cover will not have any waiting periods applied for the services for which you were previously covered, providing these were served with the previous fund.

• New members who transfer Hospitalcover from another Australian healthfund to a higher level of Hospital cover, orequivalent level of cover with a reducedor nil excess, will have qualifying periodsapplied for the higher level of cover and/or benefits. During these periods benefitswill be payable at the equivalent level ofcover to that of your previous fund.

• Current HIF members who transferHospital cover to a higher level ofHospital cover, or equivalent level ofcover with a reduced or nil excess, willhave qualifying periods applied for thehigher level of cover and/or benefits.During these periods benefits will bepayable at the lower level of cover.

• Any benefits paid by your previousprivate health insurer will be consideredwhen determining rebates for yourfuture claims.

Things you need to know about our Hospital cover

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GoldVital Hospital

This is our entry-level option for young singles and couples who want cover for vital medical services. It covers treatment after an accident, intensive care and theatre fees, plus other essential services, including surgery to remove tonsils, adenoids, appendix and wisdom teeth.

GoldVital Hospital• Cover for emergency treatment in

hospital resulting from an accidental injury*

• Surgical removal of wisdom teeth, tonsils, appendix and adenoids†

• Minor gynaecological procedures^

• Joint reconstruction and investigation

• Same-day accommodation and theatre fees for approved services

• No maternity cover

• Full cover for the cost of a shared or private room, theatre fees and charges in an HIF contracted hospital anywhere in Australia for approved services

• Full AccessGap Cover for inpatient medical procedures for approved services

• Includes an excess to reduce the premium

• Restrictions and exclusions apply

• Available for singles and couples only

Hospital waiting periods• Treatment received as the result of an

accident – one day

• General hospitalisation – two months

• All treatment related to a pre-existing ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care – 12 months

Services coveredGoldVital Hospital will cover the services outlined in the table on the following page in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check with us prior to admission to ensure that the hospital is an HIF contracted facility.

HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The benefits listed in the table opposite are offered to members who are admitted to those hospitals.

ExclusionsAs an entry-level option, GoldVital provides basic cover for a limited range of vital medical services and essential emergency treatment. As such, it only covers the services listed in the table on page 10 – all other non-emergency and hospital care services are excluded.

• Assisted reproductive technology (eg IVF)

• Cardiac (Heart) procedures including medical treatment or surgical procedures for cardiac conditions such as, arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrillators, stent insertion.

• Eye Surgery (any procedure on the surface or within the structures of the eye)

• Dialysis

• Gastric banding and Obesity surgery including reversal and adjustment procedures


• Obstetrics related services

• Spinal fusion

• Sterility reversals

• Services deemed cosmetic by Medicare and service that do not attract a Medicare rebate

• Services not listed as include are excluded.

Restricted servicesBenefits for the following services will include basic public hospital rate (only) for accommodation. However, full AccessGap coverage for inpatient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient:

• Psychiatric care or attention

• Palliative care

• Rehabilitation

No benefits will be payable for other charges related to these services (e.g. theatre or some pharmaceutical costs), so significant out-of-pocket expenses may apply for these procedures if you are admitted as a private patient.

Applicable excessA mandatory excess of $500 per person, per admission, per year (up to a maximum of $500 per year single policy or $1,000 per year couple policy) is applied to GoldVital Hospital cover to reduce premium costs. The excess applies to overnight and same day admissions

* An accident is an unforeseen event, occurring by chance and caused by an external force or object which results in an injury to the body requiring immediate medical treatment in hospital within 24 hours of the accident. If further hospital treatment (as an admitted patient) is required, the patient must be re-admitted to a hospital within 90 days of the initial hospital treatment.

^ Benefits will be paid for Same Day Procedures only for minor gynaecological procedures. 8 9

Description of charges and benefits

Accommodation Charges Public hospital Full cover in a shared or private room

Private hospital Full cover in a shared or private room

Theatre Fees charges Public hospital Charges are not raised for this service

Private hospital Full cover for theatre charges

Pharmaceutical drugs (does not include discharge drugs)

Public hospital Charges are not raised for this service

Private hospital Charges vary between hospitals depending on the contract that’s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-TGA* approved, experimental or high cost drugs,

Prostheses and consumables Public hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Prostheses items used in relation to relevant exclusion services are not covered.

Private hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses items used in relation to relevant exclusion services are not covered.

Outpatient theatre fees (not emergency department fees)

Public hospital No charge raised

Private hospital Full cover for outpatient theatre fees

Medical Gap For more details please refer to the ‘AccessGap Cover’ section in this brochure, or email [email protected] or call us on 1300 13 40 60

All hospitals and approved day care facilities

Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital.

Applicable Excess Mandatory excess is applied to GoldVital hospital.

GoldVital - $500 per person in a calendar year to a max of $1000 per membership. Excess applies to overnight or same day admissions.

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This is our basic-level private Hospital insurance cover. Like GoldVital, it’s great value and a smart choice if you’re younger and less likely to require things like maternity and cardio procedures, but it also includes a broader range of non-emergency care.

GoldStarter Hospital• No maternity cover

• Restrictions and exclusions apply

• Full cover for the cost of a shared room, theatre fees and charges in a HIF contracted hospital anywhere in Australia for approved services

• Full AccessGap Cover for inpatient medical procedures for approved services


Hospital waiting periods• General hospitalisation – two months


Restricted servicesBenefits for the following services will include basic public hospital rate (only) for accommodation. However, full AccessGap coverage for inpatient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient:


• Palliative care

• Rehabilitation



ExclusionsBenefits are not payable for any charges raised for the following services:

• Assisted reproductive technology (e.g. IVF)

• Cardio (e.g. conditions of the heart requiring surgery, monitoring or other procedures)†

• Eye surgery (any procedure on the surface or within the structures of the eye)



• Obstetrics

• Services deemed cosmetic by Medicare and services that do not attract a Medicare rebate

Services coveredGoldStarter Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check with us prior to admission to ensure that the hospital is a HIF contracted facility.

HIF has negotiated contractual arrangements with most hospitals and day hospital facilities throughout Australia. The listed benefits are offered to members who are admitted to those hospitals.

GoldStarter Hospital Accommodation charges including day patient, intensive care and neonatal care

Public hospital Full cover in a shared or private room.

Private hospital The full cost of a shared room. If you occupy a private room you will be covered up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge.

Theatre fee Public hospital Charges are not raised for this service.

Private hospital Full cover for theatre charges.


Public hospital Charges are not raised for this service.

Private hospital Charges vary between hospitals depending on the contract that’s in place. Please check with the hospital or HIF. Benefits may not apply to, or be restricted for, non-TGA* approved, experimental or high cost drugs.


Private hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses items used in relation to relevant exclusion services are not covered.


Public hospital No charge raised.

Private hospital Full cover for outpatient theatre fees.

Medical Gap For more details, please refer to the ‘AccessGap Cover’ section in this brochure, or email [email protected] or call us on 1300 13 40 60



Applicable excessA mandatory excess is applied to GoldStarter Hospital cover to reduce premium costs:• GoldStarter – $200 per person to a max of $400*** Therapeutic Goods Administration ** Excesses are paid once per person per admission covered under the policy in a calendar year up to the maximum.

Excesses apply to all hospital treatments.† Some examples of cardiac (heart) procedures including medical treatment or surgical procedures for cardiac

conditions, are arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrilators, stent insertion.

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This is our intermediate Hospital cover and is a step up from GoldStarter. It’s great for young couples and families who are likely to need things like maternity cover but not services such as cardio and joint replacement surgery.

GoldSaver Hospital• Intermediate Hospital cover

• Includes maternity services

• Full cover for the cost of a shared room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia for approved services

• Private room for up to 3 days for management of labour and delivery of child

• Full AccessGap cover for inpatient medical procedures


• Some restricted services

Hospital waiting periods• General hospitalisation – 2 months

• All obstetric related services – 12 months


Restricted ServicesBenefits for the following services will include basic public hospital rate (only) for accommodation. However, full AccessGap coverage for in-patient medical procedures and benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding

human tissue) may be subject to a co-payment by the patient:


• Cardio (e.g. conditions of the heart requiring surgery, monitoring or other procedures)†

• Eye surgery (any procedure on the surface or within the structures of the eye)


• Assisted reproductive technology (e.g IVF)

• Surgery by a podiatrist


Exclusions Benefits are not payable for any charges raised for the following services:

• Gastric banding and obesity surgery• Services deemed cosmetic by Medicare

and services that do not attract a Medicare rebate

Services coveredGoldSaver Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility.


GoldSaver Hospital

† Some examples of cardiac (heart) procedures including medical treatment or surgical procedures for cardiac conditions, are arrhythmias, artery bypass grafts, coronary angioplasty, congenital defects, heart disease, heart transplants, pacemakers and defibrilators, stent insertion.

Accommodation charges including day patient, intensive care and neonatal care


Private hospital Full cover in a shared room. A private room will be fully covered for up to 3 days for maternity stays relating to the management of labour and delivery. If you occupy a private room for maternity stays greater than 3 days, for the fourth and additional days you will be covered up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge.

Theatre fee and labour ward charges


Private hospital Full cover for theatre and labour ward charges.





Private hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables. Prostheses from excluded services not covered.


Public hospital Full cost of the charge raised.





Applicable excessA mandatory excess is applied to reduce premium costs:• GoldSaver – $200 per person to a max of $400*** Therapeutic Goods Administration ** Excesses are paid once per person per admission covered under the policy in a calendar year, up to the maximum.

Excesses apply to all hospital treatments.

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This is our award-winning top shared room hospital insurance cover. You’re fully covered for theatre fees, ward fees and all other services. It’s especially great if you’re planning on having a baby, because our maternity cover includes up to five days in a private room at no extra cost.

Gold Hospital• Top Hospital cover

• Comprehensive cover for all Medicare approved items

• Includes maternity services• Private room for up to 5 days for

management of labour and delivery of child

• Full cover for the cost of a shared room, theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia

• Full AccessGap Cover for inpatient medical procedures

• Choice of excesses to reduce cost

Hospital waiting periods• General hospitalisation – 2 months• All obstetric related services – 12 months• All treatment related to a pre-existing

ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care – 12 months

RestrictionsSurgery performed in a hospital by registered podiatrists is not eligible for Medicare rebates. However, under this level of cover HIF will pay limited benefits toward the podiatrist’s charges. Hospital accommodation and theatre charges will also be limited.

ExclusionsNo benefit is payable for services deemed as cosmetic by Medicare and/or services that do not attract a Medicare benefit.

Services coveredGold Hospital will cover the following services in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility.


Gold Hospital

Excess optionsOptional excesses to reduce premium costs:• Gold Excess 100/200 – $100 per person to a max of $200**

• Gold Excess 200/400 – $200 per person to a max of $400**

• Gold Excess 400/800 – $400 per person to a max of $800**

* Therapeutic Goods Administration * * Excesses are paid once per person per admission covered under the policy in a calendar year, up to the maximum.

The excess is not applied to same-day surgery or to child dependants under the age of 18.

Accommodation charges including day patient, intensive care and neonatal care


Private hospital The full cost of a shared room. A private room will be fully covered for up to 5 days for maternity stays relating to the management of labour and delivery. If you occupy a private room for maternity stays greater than 5 days, for the sixth and additional days you will be covered up to the hospital charge for a shared room and you will be required to meet the balance of the accommodation charge.







Prostheses and consumables

Public hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient.

Private hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables.







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This is our premium hospital insurance cover, with all the bells and whistles. You’re fully covered for everything, including a private room for all services, theatre fees and all ward fees. No worries. Just total peace of mind for you and your family.

GoldStar Hospital Cover• Top Hospital cover• Comprehensive cover for all Medicare

approved items• Includes maternity services• Full cover for the cost of a private room,

theatre fees and labour ward charges in a HIF contracted hospital anywhere in Australia

• Full AccessGap Cover for inpatient medical procedures

• Choice of excesses to reduce cost

Hospital waiting periods• General hospitalisation – 2 months• All obstetric related services – 12 months• All treatment related to a pre-existing

ailment or condition, but not including pre-existing conditions for psychiatric care, rehabilitation or palliative care – 12 months

RestrictionsSurgery performed in a hospital by registered podiatrists is not eligible for Medicare rebates. However, under this level of cover HIF will pay limited benefits toward the podiatrist’s charges. Hospital accommodation and theatre charges will also be limited.

ExclusionsNo benefit is payable for services deemed as cosmetic by Medicare and/or services that do not attract a Medicare benefit.

Services coveredGoldStar Hospital will cover the following services provided in a public hospital or contracted private hospital facility, subject to any waiting periods which may apply and the Pre-existing Ailment Rule. Benefits for non-contracted private hospitals are available from HIF. Check prior to admission to ensure that the hospital is a HIF contracted facility.


GoldStar Hospital Accommodation charges including day patient, intensive care and neonatal care


Private hospital Full cover in a shared or private room.







Prostheses and consumables

Public hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient.

Private hospital Benefits will be paid towards prostheses in accordance with the Commonwealth Prostheses List. Items on the list (excluding human tissue) may be subject to a co-payment by the patient. Benefits may not apply or be restricted for non hospital contract medical treatments or consumables.






Admitted patients are entitled to the difference between the Medicare rebate and the Commonwealth Medical Benefits Schedule fee for all medical services performed whilst the patient is admitted as an inpatient in hospital and may be entitled to a further refund of the AccessGap Cover amount. Funds are not permitted to pay gap cover if the patient is treated as an outpatient or when the patient is not formally admitted to hospital.

Excess optionsOptional excesses are available to reduce premium costs:

• GoldStar Excess 200/400 – $200 per person to a max of $400**



* Therapeutic Goods Administration ** Excesses are paid once per person per admission covered under the policy in a calendar year, up to the maximum.

The excess is not applied to same-day surgery or to child dependants under the age of 18.

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Here at HIF, we pride ourselves on enabling member choice.

So, unlike some health fund insurers who pay lower benefits if you don’t go to their “preferred providers”, with HIF you’re free to visit any Extras provider in Australia.

Our only requirement is that members must visit healthcare providers who are legally qualified to practise in Australia and are therefore approved by HIF.

So as long as your preferred doctor, dental provider, optical provider, physiotherapist, chiropractor or other type of healthcare provider is approved by HIF, you’re free to use whichever one you want.

Our Member Loyalty ProgramHIF recognises and rewards members who retain their Extras cover (excluding Vital Options) each year by providing increasing benefits or annual limits.

Our dental limits increase every year from commencement until the maximum limit is available in your sixth year of membership. Benefits or limits for services like optical, physiotherapy, occupational and speech therapy increase after 5 years and benefits or limits increase for complementary therapies, chiropractic, osteopathic and pharmacy after 3 years.

Where a policy is upgraded to a higher level of Extras cover (excluding Vital Options), annual limits and benefits will automatically move to the next highest loyalty benefit on the new level of cover and progress each year until all maximum benefits and limits are reached.

Annual limits HIF Extras covers have an annual limit for most services, which means there is a limit on how much HIF will pay toward your claims. Most limits are for the calendar year (January to December) but each January your benefit limits will be refreshed, allowing you to claim benefits again for Extras services provided in the new year.

Claiming timeframe limitationClaims must be made within two years of the service being provided.

Approved consultationsUnless stated, to be eligible for HIF benefits all services must be provided by a HIF approved health provider at that provider’s registered practice address in a face-to-face setting, or as otherwise approved by HIF. Video, telephone or online facilitated services, with the exception of HIF approved Hospital Substitute treatment or Chronic Health Disease Management programs, are not approved consultations.

Workers Compensation and Dual InsuranceBenefits cannot be claimed and are not payable by HIF where you have or can claim benefits or compensation (in full or in part) for treatment, goods or services from a third party including Workers Compensation or Public Liability sources, your employer or any other Insurance policy.

Things you should know about our Extras cover

Vital Options

Transferring and upgrading your coverNew members who transfer Extras cover from another Australian health fund to an equivalent level of HIF Extras cover will not have any waiting periods applied, providing these were served with the previous fund.

• New members who transfer Extras coverfrom another Australian health fund to ahigher level of Extras cover, or equivalentlevel of cover with additional or higherbenefits will have qualifying periodsapplied for the higher level of cover and/or benefits. During these periods benefitswill be payable at the equivalent level ofcover to that of your previous fund.

• Current HIF members who transferExtras cover to a higher level of Extrascover, or equivalent level of cover with areduced or nil excess, will have qualifyingperiods applied for the higher level ofcover and/or benefits. During theseperiods benefits will be payable at thelower level of cover.

• Any benefits paid by your previousprivate health insurer will be consideredwhen determining rebates for yourfuture claims.

Vital Options offers great value, entry-level Extras cover for singles and couples only (not available for families).

What services are included?• Chiropractic

• Dental (General)

• Emergency Ambulance

• Endodontic

• Periodontal

• Osteopathy

• Physiotherapy

Please note: Benefits are only payable on the following dental items. There are some items within item code ranges for which HIF does not pay a benefit, or if they are performed with another item in the same course of treatment. If you are planning dental treatment in the future, please call HIF prior to treatment on 1300 13 40 60 to confirm that you will be covered.

• General dental: 011 – 017, 022 – 118, 121,123 – 171, 311 – 399, 511 – 535, 572 – 597,911 – 915, 926, 949 – 986

• Endodontic: 411 – 458

• Periodontal: 213 – 282

How much can be claimed?With a combined annual limit of $800 per person per year, Vital Options gives complete choice as to how the limit is used. This could be used for a quick check-up at the dentist or visits to a chiropractor, for example. Each member can choose the services they’d like to use and Vital Options will pay back 50% on each service claimed until the maximum annual limit of $800 is reached.

For example, one member could claim up to $800 on dental services each year, while another member chooses to split the limit across more of the services covered by Vital Options. For instance, they could choose to use $250 on dental, $400 on osteopathy and $150 on chiropractic treatment.

Emergency ambulance services are included.If urgent ambulance transport is needed, Vital Options cover will pay 50% of the bill up to the maximum annual limit of $800 per person. This can be a valuable benefit as Medicare doesn’t cover urgent ambulance transport, which can cost over $900.20 21

Extras waiting benefits

Type of service Vital Saver Special Super PremiumWaiting Period

Ambulance* 2 months

Auxiliary Home Nursing 2 months

Asthmatic Spacers 2 months

Chiropractic 2 months

Complementary Therapies 2 months

Dental - General Unlimited Limited 2 months

Diabetes Education 2 months

Dietetics 2 months

Healthy Lifestyle 2 months

Occupational Therapy 2 months

Optical 2 months

Orthoptics (Eye Therapy) 2 months

Osteopathy 2 months

Peak-flow Meter 2 months

Pharmacy Drugs 2 months

Physiotherapy 2 months

Podiatry Consultations 2 months

Speech Therapy 2 months

Dental - General Limited** Up to 12 months

Blood Glucose/Pressure Monitor

12 months

Dental - Major 12 months

External Prosthesis/Medical Appliances

12 months

Nebuliser / Humidifier 12 months

Orthotic Appliances 12 months

Psychological Consultations

12 months

Assisted Reproduction Drugs

36 months

Hearing Aids 36 months

From time to time we promote special offers for new members. Visit hif.com.au for more information and to view our current offers.* Does not include inter-hospital transfers or transport to home.** Limited item numbers are covered, please contact HIF for more details

Electronic Claiming Providers with electronic claiming technology (HICAPS or IBA) can settle your account with you on the spot. Simply swipe your HIF membership card and pay any difference.

SmartClaim for mobileMembers who own an Apple or Android mobile device can now submit paid extras accounts of $700 or less by using their mobile’s in-built camera to photograph receipts and invoices. To find out more, visit hif.com.au or download HIF SmartClaim now from the Apple App Store or the Android Market.

Fast-Track e-Claiming (email/fax)For paid Extras accounts of $700 or less, try our quick and easy Fast-Track option. Simply scan your completed HIF claim form and associated receipts and invoices, and email a copy to [email protected] or fax a copy to (08) 9328 1685. To find out more, visit hif.com.au

Hospital and AccessGap Accounts Your doctor may send the accounts to HIF direct. If not, you can send the unpaid account to us for processing the HIF and Medicare benefits payable. We will then send the payment direct to your doctor or hospital on your behalf. Please call us before you go into hospital so we can assist you with your claims.

By postComplete a claim form and post it to:

HIFGPO Box X2221Perth WA 6847

Claim forms can be downloaded from hif.com.au or mailed to you on request.

For more information on the different ways to make a claim, check out the “How to Claim” page on hif.com.au

Ways to claim

22 23

Premium Options Super Options Special Options Saver Options

Type of serviceAdditional information Benefit Person limit

Membershiplimit Benefit

Person limit

Membershiplimit Benefit Person limit

Membershiplimit Benefit Person limit

Membershiplimit

Ambulance As above Emergency: 100%

Non-emergency call-outs and transportation: 100% with a $50 co-payment

Interhospital transfers: No benefit

N/A N/A Emergency: 100%









N/A N/A

Ambulance benefits

Benefit is paid on charges raised for approved ambulance services. On all our Extras cover except Vital Options, HIF fully covers the cost of emergency ambulance transport for cases classified by approved ambulance service providers as requiring urgent attention and where the patient is admitted to the emergency department of a hospital.

A patient co-payment of $50 per service applies to non-emergency call-outs and transportation.

Benefits are not payable for transportation from a hospital to your home, nursing home or other hospital, or for transportation for ongoing medical treatment.

Benefits are not payable for off road or air ambulance.

Vital Options cover will pay 50% of an emergency ambulance bill up to a maximum annual limit of $800 per person per calendar year.

Where a member is eligible for a state or Federal government subsidy, HIF will pay a benefit, less this entitlement.

Note: Ambulance services, charges and levies vary significantly across Australian states and territories:

QLD & TAS Residents are covered for unlimited emergency services provided by their respective state governments. Interstate ambulance service charges for these residents may not apply if reciprocal agreements are in place with the other states where the ambulance service was required.

NSW and ACT Residents who hold HIF Hospital cover are covered for unlimited emergency ambulance services provided in their home state by their state government or territory ambulance service. Interstate emergency services may also be covered if under a reciprocal state agreement.*

All other emergency servicesIn all other locations and circumstances, emergency ambulance services may be claimable from HIF Options covers, subject to the services being provided by the recognised St John or state government controlled ambulance organisation and the service being deemed as medically necessary by the attending ambulance officer.

24 25

Extras benefitsPremium Options Super Options

Type of service Additional information Benefit Person limitMembershiplimit Benefit Person limit

Membershiplimit

Asthmatic spacers

N/A $18 2 per person per year

No limit $18 2 per person per year

No limit

Auxiliary Home Nursing

Benefits must be ordered by a medical practitioner. Contact us for conditions.

$120 $1,800 per year

No limit $75 $1,800 per year

No limit

Blood glucose or blood pressure monitor

A letter of recommendation from the patient’s treating practitioner is required.

75% of cost 1 of either monitor every 3 years

Max: $200

No limit 75% of cost 1 of either monitor every 3 years

Max: $200

No limit

Chiropractic Benefits are paid for spinal manipulation or spinal adjustments carried out by a registered chiropractor approved by HIF.

Spinal adjustment – manipulation

First visit: $30

Visits 2-10: $29

Visits 10+: $18

X-ray: $110

Combined annual limit (chiropractic and osteopathic)

Up to 3 years: $650

Over 3 years: $750

1 x-ray per year


Up to 3 years: $1300

Over 3 years: $1500


First visit: $28

Visits 2-10: $23

Visits 10+: $14

X-ray: $85


Up to 3 years: $550

Over 3 years: $650

1 x-ray per year



Over 3 years: $1300

Special Options Saver Options


Membershiplimit

Asthmatic spacers

N/A N/A N/A No limit N/A N/A No limit

Auxiliary Home Nursing

Benefits must be ordered by a medical practitioner. Contact us for conditions.

N/A N/A No limit N/A N/A No limit

Blood glucose or blood pressure monitor



Chiropractic Benefits are paid for spinal manipulation or spinal adjustments carried out by a registered chiropractor approved by HIF.


First visit: $26

Visits 2-10: $21

Visits 10+: $10

X-ray: $70

Combined annual limit (chiropractic, osteopathic, physiotherapy, podiatry and complementary therapies) $450

1 x-ray per year

Combined annual limit (chiropractic, osteopathic, physiotherapy, podiatry and complementary therapies) $900

Spinal adjustment - manipulation:

First visit: $26

Visits 2-10: $21

Visits 10+: $10

X-ray: $65

Combined annual limit (chiropractic, dietetics, healthy lifestyle, complementary therapies, pharmacy, osteopathic, physiotherapy and podiatry) $350

1 x-ray per year

Combined annual limit (chiropractic, dietetics, healthy lifestyle, complementary therapies, pharmacy, osteopathic, physiotherapy and podiatry) $700

2627



Membershiplimit

Complementary therapies - Naturopathy - Homeopathy - Acupuncture - Traditional

Chinese Medicine

- Remedial massage therapy

- Myotherapy

Benefits are not payable on medicines provided by the practitioner.

The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised.

Visits 1-6: $25

Visits 7+: $17

Up to 3 years: $500

Over 3 years: $600

No limit* Visits 1-6: $20

Visits 7+: $13

Up to 3 years: $250

Over 3 years: $350

$700

Dental See page 44 for more details

Diabetics education

For consultations or information sessions held by Diabetes Association in relation to diabetes.

First visit: $36

Subsequent: $18

6 visits per year

No limit First visit: $36

Subsequent: $18

6 visits per year

No limit

Dietetics Benefits are paid on consultations carried out by a registered dietician approved by HIF.

First visit: $40

Subsequent: $20

Group: $12

$324 per year No limit First visit: $36

Subsequent: $18

Group: $10

$324 per year

* Subject to combined overall person limit of $450 and membership limit of $900 for complementary therapies, chiropractic incl. 1 X-ray per year per person, osteopathic, physiotherapy and podiatry.

# Subject to combined overall person limit of $350 and membership limit of $700 for complementary therapies, chiropractic incl. 1 X-ray per year per person, dietetics, healthy lifestyle, pharmacy, osteopathic, physiotherapy, and podiatry.



Membershiplimit

Complementary therapies - Naturopathy - Homeopathy - Acupuncture - Traditional

Chinese Medicine

- Remedial massage therapy

- Myotherapy

Benefits are not payable on medicines provided by the practitioner.

The treatment must be provided by a practitioner who is registered with HIF in the speciality for which the charge is raised.

Visits 1-6: $16

Visits 7+: $11

Up to 3 years: $100*

Over 3 years: $200*

$400* Visit 1-6: $15

Visits 7+: $10

Up to 3 years: $50#

Over 3 years: $100#

$200#

Dental See page 44 for more details

Diabetics education

For consultations or information sessions held by Diabetes Association in relation to diabetes.


Dietetics Benefits are paid on consultations carried out by a registered dietician approved by HIF.

First visit: $36

Subsequent: $18

Group: $10

$252 per year No limit First visit: $36

Subsequent: $18

Group: $10

Combined annual limit (chiropractic, dietetics, healthy lifestyle, complementary therapies, osteopathy, pharmacy, physiotherapy and podiatry) $350

Combined annual limit (chiropractic, dietetics, healthy lifestyle, complementary therapies, osteopathy, pharmacy, physiotherapy and podiatry) $700

2829



Membershiplimit


Benefits are paid on HIF approved prosthetics items such as artificial limbs, wigs and external mammary prostheses and approved medical devices such as a Tens machine, Circulation Booster and Cam Walker.

Conditions apply so please contact us for details prior to purchasing item.

75% of fee $1,500 per year.

Note: sub limits apply depending upon item.

No limit 75% of fee $1,500 per year.

Note: sub limits apply depending upon item.

No limit

Healthy Lifestyle - Health

management program

- Weight loss program

- Quit smoking plan

- Health assessments

- Skin cancer screening

Benefits are payable for HIF approved programs delivered by registered providers only.

Please contact us prior to commencing the program or paying subscriptions to ascertain if the program is eligible for a rebate.

Single: $125

Family: $250

$125 Single: $100

Family: $200

$100



Membershiplimit


Benefits are paid on HIF approved prosthetics items such as artificial limbs, wigs and external mammary prostheses and approved medical devices such as a Tens machine, Circulation Booster and Cam Walker.

Conditions apply so please contact us for details prior to purchasing item.


Healthy Lifestyle - Health

management program

- Weight loss program

- Quit smoking plan

- Health assessments

- Skin cancer screening

Benefits are payable for HIF approved programs delivered by registered providers only.

Please contact us prior to commencing the program or paying subscriptions to ascertain if the program is eligible for a rebate.

Single: $75

Family: $150

$75 Single: $50

Family: $100

$50 Combined annual limit (chiropractic, dietetics, healthy lifestyle, complementary therapies, osteopathic, pharmacy, physiotherapy and podiatry) $700

3031

Premium Options Super Options


Membershiplimit

Hearing aids Benefits are paid on replacement hearing aids after 5 years from date of supply.

Up to 5 years: $550

5 to 10 years: $600 per ear

10+ years:

$700 per ear

Up to 5 years: 1

Over 5 years: 1 per ear

No limit Up to 5 years: $550

5+ years: $550 per ear

Up to 5 years: 1

Over 5 years: 1 per ear

No limit

Humidifier or nebuliser


75% of cost 1 of either monitor every 3 years. Maximum $180.

No limit 75% of cost 1 of either monitor every 3 years. Maximum $140.

No limit

Occupational therapy

Benefits are paid on consultations carried out by a registered occupational therapist, approved by HIF.

First Visit $60

Subsequent $27

Group $10

Combined limit (orthoptics, physiotherapy and speech therapy)


Over 5 years: $1500


Subsequent: $25

Group: $10

Combined limit (orthoptics, physiotherapy and speech therapy)

Up to 5 years: $900

Over 5 years: $1100

No limit

Optical See page 40 for more details

Orthotics Benefits are paid on items carried out by a registered podiatrist or orthotic supplier, approved by HIF#.

75% of cost $240 – 1 every 2 years from date of supply^

No limit 75% of cost $200 – 1 every 2 years from date of supply^

No limit

Extras benefits

# Note: benefits are not available for orthotics which are not specifically modified and fitted for the individual member’s condition. ^ Orthotic limit includes associated services such as muscle testing, ROM testing and gait analysis.



Membershiplimit

Hearing aids Benefits are paid on replacement hearing aids after 5 years from date of supply.


Humidifier or nebuliser



Occupational therapy

Benefits are paid on consultations carried out by a registered occupational therapist, approved by HIF.


Optical See page 40 for more details

Orthotics Benefits are paid on items carried out by a registered podiatrist or orthotic supplier, approved by HIF#.


# Note: benefits are not available for orthotics which are not specifically modified and fitted for the individual member’s condition.

3233



Membershiplimit

Orthoptics (eye therapy)

Benefits are paid on items carried out by a registered orthoptics supplier, approved by HIF.

Initial: $50

Subsequent: $25

Combined limit with occupational physiotherapy and speech therapy


Over 5 years: $1500

No limit Initial $50

Subsequent $25

Combined limit with occupational physiotherapy and speech therapy

Up to 5 years: $900

Over 5 years: $1100

No limit

Osteopathic Benefits are paid on items carried out by a registered osteopath, approved by HIF.

First visit: $30

Visits 2-10: $29

Visits 10+: $18


Up to 3 years: $650

Over 3 years: $750



Over 3 years: $1500

First visit: $28

Visits 2-10: $23

Visits 10+: $17


Up to 3 years: $550

Over 3 years: $650



Over 3 years: $1300

Peak Flow Meter

N/A $30 1 per year No limit $30 1 per year No limit



Membershiplimit

Orthoptics (eye therapy)

Benefits are paid on items carried out by a registered orthoptics supplier, approved by HIF.


Osteopathic Benefits are paid on items carried out by a registered osteopath, approved by HIF.

First visit: $26

Visits 2-10: $21

Visits 10+: $16

Combined annual limit (chiropractic, physiotherapy, osteopathic and podiatry) $450


First visit: $26

Visits 2-10: $21

Visits 10+: $16

Combined annual limit (chiropractic, dietetics, healthy lifestyle, complementary therapies, osteopathic, pharmacy, physiotherapy & podiatry) $350

Combined annual limit (chiropractic, dietetics, healthy lifestyle, complementary therapies, osteopathic, pharmacy, physiotherapy and podiatry) $700

Peak Flow Meter

N/A N/A N/A No limit N/A N/A No limit

3435



Membershiplimit

Pharmacy Not payable on contraceptives or NHS (PBS) prescriptions or over the counter items purchased with or without a prescription.

Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item.

Up to 3 years: $200

Over 3 years: $400

No limit Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item.

Up to 3 years: $200

Over 3 years: $400

No limit

Physiotherapy Benefits are paid on items carried out by a registered physiotherapist, approved by HIF.

First visit: $45

Visits 2-10: $40

Visits 10+: $30

Hydrotherapy: $15

Antenatal: $15

Group: $15

Combined limit (occupational, orthoptics and speech therapy)


Over 5 years: $1500

$600 sublimit for hydrotherapy, antenatal and group.


Visits 2-10: $29

Visits 10+: $20

Hydrotherapy: $13

Antenatal: $13

Group: $13

Combined limit (occupational, orthoptics and speech therapy)

Up to 5 years: $900

Over 5 years: $1100


No limit



Membershiplimit

Pharmacy Not payable on contraceptives or NHS (PBS) prescriptions or over the counter items purchased with or without a prescription.

Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item.

$200 No limit Member pays PBS contribution. Benefit is 100% of balance up to $80 per script item.

Combined annual limit (chiropractic, dietetics, healthy life-style, complemen-tary therapies, osteopathic, pharmacy, physiotherapy & podiatry) $350

Combined annual limit (chiropractic, dietetics, healthy lifestyle, complemen-tary therapies, osteopathic, pharmacy, physiotherapy and podiatry) $700

Physiotherapy Benefits are paid on items carried out by a registered physiotherapist, approved by HIF.

First visit: $32

Visits 2-10: $24

Visits 10+: $19

Hydrotherapy: $13

Antenatal: $13

Group: $8

Combined annual limit (complemen-tary therapies, chiropractic, physiotherapy, osteopathic and podiatry)

$450


Combined annual limit (complemen-tary therapies, chiropractic, physiotherapy, osteopathic and podiatry) $900

First visit: $32

Visits 2-10: $24

Visits 10+: $19

Hydrotherapy: $13

Antenatal: $13

Group: $8




3637

Premium Options Super Options


Membershiplimit

Podiatry* Benefits are paid on consultations carried out by a registered podiatrist, approved by HIF.

First visit: $32

Subsequent: $25

Consultations that are not performed in the podiatrist’s registered practice: $12

$382 – includes podiatry surgery performed in the podiatrist’s registered rooms only.


Subsequent: $23


$354 – includes podiatry surgery performed in the podiatrist’s registered rooms only

No limit

Psychology Maximum of 2 sessions will be paid on the same date if there is a minimum of 2 hours between sessions. Benefits are paid on consultations carried out by a registered psychologist, approved by HIF.

First visit: $100

Subsequent: $55

Group: $30 per person to a max of $75 per session

$1,000 per year


Subsequent: $55

Group: $25 per person to a max of $75 per session

$740 per year No limit

Speech therapy Benefits are paid on items carried out by a registered speech therapist, approved by HIF.

First visit: $75

Subsequent: $45

Combined limit (occupational, orthoptics and physiotherapy)


Over 5 years: $1500


Subsequent: $45

Combined limit (occupational, orthoptics and physiotherapy)

Up to 5 years: $900

Over 5 years: $1100

No limit

Extras benefits

* Benefits not payable when provided as part of treatment provided in, or arranged by a hospital (including surgery).



Membershiplimit

Podiatry* Benefits are paid on consultations carried out by a registered podiatrist, approved by HIF.

First visit: $32

Subsequent: $23




First visit: $32

Subsequent: $23


Combined annual limit (chiropractic, dietetics, healthy life-style, complemen-tary therapies, osteopathic, pharmacy, physiotherapy & podiatry) $350

Combined annual limit: (chiropractic, dietetics, healthy lifestyle, complemen-tary therapies, osteopathic, pharmacy, physiotherapy and podiatry) $700

Psychology Maximum of 2 sessions will be paid on the same date if there is a minimum of 2 hours between sessions. Benefits are paid on consultations carried out by a registered psychologist, approved by HIF.


Speech therapy Benefits are paid on items carried out by a registered speech therapist, approved by HIF.


* Benefits not payable when provided as part of treatment provided in or arranged by, a hospital (including surgery).

3839

Type of service Additional information Premium Options Super Options Special Options Saver Options

Optical Most common services listed below. Contact us for other services and benefits.

Memberships up to 5 years

Memberships over 5 years







Benefits are paid on items carried out by a registered optometrist or optical provider, approved by HIF.

Benefits are not paid on non-prescription safety glasses, protective glasses, tinting, sunglasses, cosmetic glasses or cosmetic contact lenses, or frames not purchased via a registered Australian optical provider.

Frames (item no 110): $90 $112.50 $70 $87.50 $55 $60.50 $50 $55

Pair Single Vision Lenses (item no 212):

$75 $93.75 $70 $87.50 $45 $49.50 $40 $44

Pair Bifocal Lenses (item no 312):

$100 $125 $95 $118.75 $60 $66 $55 $60.50

Pair Trifocal Lenses

(item no 412):

$150 $187.50 $145 $181.25 $60 $66 $55 $60.50

Pair Progressive Lenses

(item no 512):

$150 $187.50 $145 $181.25 $60 $66 $55 $60.50

Pair Frequently Replaced

Contact Lenses

(item no 852):

$170 $212.50 $150 $187.50 $110 $121 $100 $110

Limit per person

Annual limit, all services

(including frames and

contacts)

$280 $350 $260 $325 $140 $155 $110 $121

Frames sub-limit $110 $140 $85 $110 $65 $71.50 $55 $60.50

Pair frequently replaced

contact lenses sub-limit

$170 $215 $150 $190 $110 $121 $100 $110

Extras benefits: Optical

40 41

Extras benefits: SmartTeeth

Item Number Description First Visit Subsequent Visits

011 or 012 Oral examination 100% 80%

111 or 114 or 115 Removal of plaque, stain or calculus 100% 80%

121Topical application of remineralising agent

100% 80%

151 or 153 Provision of a mouthguard 100% 80%

Please note: These benefits are payable on all our Extras products. The actual benefit amount cannot exceed our set maximum beneft for each dental item, service sub limits or annual dental limit. See the example on page 8 for more information.

Item Number Description

Premium Options

Super Options

Special Options

Saver Options

013 Emergency oral examination 80% 70% 65% 65%

014 Consultation 80% 70% 65% 65%

022Intraoral periapical or bitewing radiograph

80% 70% 65% 65%

118 Bleaching, external – per tooth 80% 70% 65% 65%

161 Fissure sealing – per tooth 80% 70% 65% 65%

311 Removal of permanent tooth 80% 70% 65% 65%

512Metallic restoration – two surfaces – direct

80% 70% 65% 65%

513Metallic restoration – three surfaces – direct

80% 70% 65% 65%

521Adhesive restoration – one surface – anterior

80% 70% 65% 65%

522Adhesive restoration – two surfaces – anterior

80% 70% 65% 65%

523Adhesive restoration – three surfaces – anterior

80% 70% 65% 65%

531Adhesive restoration – one surface – posterior

80% 70% 65% 65%

532Adhesive restoration – two surfaces – posterior

80% 70% 65% 65%

533Adhesive restoration – three surfaces – posterior

80% 70% 65% 65%

575 Pin retention – per pin 80% 70% 65% 65%

577 Cusp capping – per cusp 80% 70% 65% 65%

Please note: The actual benefit amount cannot exceed our set maximum benefit for each dental item, service sub limits or overall annual limit.

Our top 24 SmartTeeth dental services

How will my SmartTeeth dental rebate be calculated?We will pay a percentage of the dentist’s fee, up to a set maximum benefit for each item of service^. For example, with our Premium Options Extras cover you get:

1 Top 24 general dental services: 80% to 100% of the fee, up to a set maximum benefit per item.

2 All other general dental services: 70% of the fee, up to a set maximum benefit per item*.

3 All other (i.e. major) dental services: 60% of the fee, up to a set maximum benefit per item*.

^ Benefits may be limited where potential rebates exceed dental service sub limits or annual limit.

* Contact us on 1300 13 40 60 for details of these services.

This does not apply to Vital Options please see page 21 for more details.

42 43

Extras benefits: Dental annual limitsPremium Options

Item Number Year 1 Year 2 Year 3 Year 4 Year 5

After 5 Years

General - Unlimited

022 311 - 314 511 - 535

No Limit No Limit No Limit No Limit No Limit No Limit

General - Limited

011 - 017 025 - 171 322 - 399 572 - 597 911 - 949 961 - 986

$1,500 $1,800 $2,100 $2,400 $2,700 $3,000

Inlay/Onlay 541 - 555 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500

Denture, Crown, Bridge *

611 - 691 711 - 779 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700

Periodontic & Endodontic

213 - 282 411 - 458 $700 $800 $900 $1,000 $1,100 $1,200

Orthodontic (Lifetime Limit* )

811 - 878 $1,500 $1,800 $2,100 $2,400 $2,700 $3,000

Total annual limits per person

$1,500 $1,800 $2,100 $2,400 $2,700 $3,000

Super Options


After 5 Years

General - Unlimited

022 311 - 314 511 - 535


General - Limited

011 - 017 025 - 171 322 - 399 572 - 597 911 - 949 961 - 986

$1,150 $1,350 $1,550 $1,750 $2,050 $2,350

Inlay/Onlay 541 - 555 $700 $800 $900 $1,000 $1,100 $1,200


611 - 691 711 - 779 $900 $1,000 $1,100 $1,200 $1,300 $1,400


213 - 282 411 - 458 $500 $600 $700 $800 $900 $1,000

Orthodontic (Lifetime Limit *)

811 - 878 $1,300 $1,500 $1,700 $1,900 $2,200 $2,500


$1,300 $1,500 $1,700 $1,900 $2,200 $2,500

Special Options


After 5 Years

General - Unlimited

022 311 - 314 511 - 535


General - Limited

011 - 017 025 - 171 322 - 399 572 - 597 911 - 949 961 - 986

$800 $950 $1,150 $1,350 $1,550 $1,750

Inlay/Onlay 541 - 555 $500 $600 $700 $800 $900 $1,000


611 - 691 711 - 779 $600 $700 $800 $900 $1,000 $1,100


213 - 282 411 - 458 $300 $400 $500 $600 $700 $800

Orthodontic (Lifetime Limit *)

811 - 878 $1,000 $1,200 $1,400 $1,600 $1,800 $2,000


$1,000 $1,200 $1,400 $1,600 $1,800 $2,000

Saver Options


After 5 Years

General - Unlimited

022 311 - 314 511 - 535


General - Limited

011 - 017 025 - 171 322 - 399 572 - 597 911 - 949 961 - 986

$750 $850 $950 $1,050 $1,150 $1,250

Inlay/Onlay 541 - 555Not covered

Not covered

Not covered

Not covered

Not covered

Not covered


611 - 691 711 - 779

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered


213 - 282 411 - 458

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered

Orthodontic (Lifetime Limit*) 811 - 878

Not covered

Not covered

Not covered

Not covered

Not covered

Not covered


$750 $850 $950 $1,050 $1,150 $1,250

* For more information about replacement periods and lifetime limits refer to "Important information about your dental cover" on page 46

44 45

Benefits are only paid on accounts rendered by a registered dentist or dental prosthetist. The dentist or dental prosthetist must be in private practice. Dental prosthetists are allowed to perform a limited range of services for benefit purposes.

There are some items within item code ranges for which HIF does not pay a benefit, or if they are performed with another item in the same course of treatment. Limits apply to the number of times some items, such as bleaching, attract a benefit.

Benefits for replacement dentures and partial dentures are not paid within three years of previous supply.

The applicable benefit is payable on the date the service is rendered e.g. the date braces are fitted.

If you are unsure of your entitlements, please contact us before commencing a course of treatment with full details of the necessary dental items as provided by your dental provider and we will provide you with a benefit estimate.

Annual limits are refreshed on 1 January each year, so if you’re planning a course of treatment it may be financially advantageous to stagger services over two calendar years.

Our Code of Conduct The Private Health Insurance Code of Conduct is a self-regulatory code with the primary goal of enhancing regulatory compliance. We support and apply these industry standards in four fundamental ways:

1. Our employees are trained in privatehealth insurance;

2. The information we provide to you iscommunicated in a way that is easy tounderstand and allows you to make aninformed decision;

3. We openly communicate our proceduresfor resolving any concerns you may haveabout your HIF membership and privatehealth cover; and

4. We ensure that any information youprovide to us is maintained in accordancewith our privacy policy.

To download a full copy of the Code of Conduct, please visit hif.com.au

Cooling Off PeriodWhen you have applied for a HIF membership, you have 30 days to read your policy. If you decide during this time that you do not wish to take up the cover, you may cancel the policy and HIF will give you a full refund, provided you have not made a claim.

Important information about your dental cover

Feedback, disputes and privacy

Compliments and complaintsYour feedback is valuable to us, so don’t be afraid to get in touch. You may wish to comment on your personal experiences with HIF, or you may wish to lodge a compliment (or complaint) about the service you’ve received from our team.

Whatever your feedback relates to, we address each and every compliment/complaint and will always respond accordingly. Your input is a vital part of ensuring our organisation meets or ideally exceeds your expectations at all times.

To submit feedback, simply visit hif.com.au and complete the online feedback form. Alternatively, you can email [email protected] or call us on 1300 13 40 60.

Providing feedback or making a complaintHIF is committed to providing our members with access to the highest possible level of service and we value the feedback that our members provide. As part of HIF’s commitment to continuous improvement if you have a concern regarding your HIF membership, our products, benefits or our service we would be happy to hear from you.

If you have a complaint or concerns, you can discuss this with one of our Customer Service Representatives on 1300 13 40 60 or email your complaint to [email protected] and we will:

• Treat you with respect and deal with yourconcerns promptly

• Resolve any complaints at the first point ofcontact, wherever possible

• Escalate complaints (if necessary) andresolve them swiftly, within two businessdays

• Invite you to further escalate complaintswhich could not be resolved to yoursatisfaction to HIF’s formal Ex-gratiaCommittee (you should address yourcomplaint in writing to Executive Manager– Operations, Health Insurance Fund ofAustralia, GPO Box X2221, Perth WA, 6847)

• Openly share our complaints with you,including external resolutions options,like involving the Private Health InsuranceOmbudsman (you can contact theOmbudsman on 1800 640 695 orwrite to: Suite 2, Level 22, 580 GeorgeStreet, Sydney NSW, 2000) or PrivacyCommissioner

• Resolve complaints in an equitablemanner, with the best interests of allmembers in mind

• Use feedback to improve our products andservices by passing it on to our ProductDevelopment Committee.

Your privacyThe personal information you provide to us will be primarily used by HIF to deliver health insurance products and services as requested by you. The information supplied by you will remain confidential. This information may be disclosed to third parties and authorised government agencies in order to facilitate the delivery of services associated with your health insurance. Failure to provide personal information may result in the failure to process or deliver the service requested.

For a complete HIF Privacy Policy brochure, please contact us on 1300 13 40 60 or download a copy at hif.com.au

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Orthodontic limits are lifetime limits per person. Benefits are not payable in excess of the annual limit shown and include benefits paid under another health insurance policy."

How long can children remain on family policies? With HIF, dependants are covered up until the age of 21, or up to 25 years of age for those registered as full-time students at a recognised educational institution.

If I have health insurance can I still be admitted to hospital as a public patient? Yes. Every public hospital is required to ask if you wish to be treated as a public or private patient. It’s your choice if you use your insurance or not.

Which bills should I claim from HIF and which ones should I claim from Medicare?If you don’t have health insurance, Medicare pays benefits for all medical accounts. For example, accounts for doctors, specialists, eye examinations, X-rays and pathology.

However, if you have HIF Hospital cover, we’ll process your hospital accounts. We also pay up to one quarter of the Medicare schedule fee for any medical accounts resulting from your time as a private inpatient in a hospital. If you have HIF Extras cover, we also process all your bills for extras services, such dental, physiotherapy or optical treatments.

What is the Medicare Levy Surcharge (MLS)?The Medicare Levy Surcharge (MLS) is levied on Australian taxpayers who earn above a certain income and don’t have private Hospital cover. The MLS is a Federal Government initiative designed to encourage individuals to take out private Hospital cover and, where possible, to use the private hospital system to reduce demand on the public system.

Is the Federal Government Rebate on Private Health Insurance means tested?

Yes, since 1 July 2012, the Federal Government Rebate on Private Health Insurance is means tested, as is the Medicare Levy Surcharge (MLS). There are effectively four annual income tiers for single people and couples/families. The rebate you receive for holding private health insurance and the size of the MLS you pay are dictated by your age and annual income.

For instance, if you’re a single person under the age of 65 and you’re earning less than $90,000 a year, you will receive a 30% rebate on the cost of your health insurance. Furthermore, while you have to pay the Medicare Levy (everyone does), you don’t have to pay the MLS. On the other hand, if you’re classified as a high income ‘Tier 3’ earner, you will be taxed 3% of your income if you don’t have private Hospital cover (1.5% MLS plus the standard 1.5% Medicare Levy that everyone pays). See table on page 50.

Frequently asked questions What is the Lifetime Health Cover loading (LHC)?The Federal Government introduced the Lifetime Health Cover loading to encourage Australians to take out private Hospital cover at a younger age. Basically, it recognises the length of time you’ve had private health insurance and rewards that loyalty by offering lower premiums – so the earlier you take out health cover, the cheaper your premiums.

Does everyone have to pay LHC loading?No, you won’t incur the loading if you:

• Had Hospital cover on 1 July 2000 and have maintained it since then; or

• Were born on or before 1 July 1934.

How is the loading applied?For every year over the age of 30 that you don’t have private Hospital cover, a 2% loading is applied to the cost of your insurance (and increases each year until it reaches 70%). For example, a single 37 year old would pay 14% LHC loading – so it really pays to take out private Hospital cover sooner rather than later.

For couples and families, however, the loading is initially calculated based on your respective dates of birth and then halved. For example, a couple aged 33 and 36 years would generate a combined loading of 18% initially (6% + 12%), so the final loading that is applied to their joint policy is 9%.

If you find that you will incur a loading, you will be required to pay this on top of the base premium that you’re initially quoted for your Hospital cover. If you decide to join HIF, your loading will automatically be applied to the quoted amount once you provide your date of birth.

What if I’m already over 31?If you’re over 31, it still makes sense to take out Hospital cover. Remember, the sooner you join, the smaller the loading you will pay. And once you’ve held continuous private Hospital cover for 10 years, your loading will be removed (as per the Private Health Insurance Act 2007).

What isn’t covered by private health insurance? Private health insurance doesn’t cover you for outpatient services. These services include visits to your GP and consultations with specialists, as well as X-rays and blood tests (unless they’re taken once you’re admitted to hospital).

What are waiting periods?Waiting periods are the time you need to be a member of a health fund before you can claim a benefit. They’re there to protect the fund and its existing members from people who simply join a fund to make a big claim, only to cancel their membership afterwards.

But there’s good news. If you join us from another Australian health fund and take out an equivalent level of cover with us, you don’t have to re-serve any waiting periods that you’ve already served. Even better, it’s really easy to switch – we’ll take care of all the paperwork for you.

The waiting periods for Hospital and Extras cover can be found in our health insurance brochure or at hif.com.au

To read all these FAQs (and more) online, visit hif.com.au/faqs

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Federal Government Rebate

Annual Income Thresholds

Policy Type Unchanged Tier 1 Tier 2 Tier 3

Single <$90,000 $90,001 - 105,000 $105,001 - 140,000 >$140,001

Families <$180,000 $180,001 - 210,000 $204,001 - 280,000 >$280,001

Age Applicable Private Health Insurance Rebate

Under 65 29.04% 19.36% 9.68% 0%

65 - 69 years 33.88% 24.20% 14.52% 0%

70 and over 38.72% 29.04% 19.36% 0%

Medicare Levy Surcharge (applicable if Hospital cover is not held)

All ages 0% 1.0% 1.25% 1.5%

Medicare Levy

1.5% for everyone

Note: The thresholds increase annually, based on growth in Average Weekly Ordinary Time Earnings. Single parents and couples (Including de facto couples) are subject to the family tiers. For families with children, the thresholds are increased by $1,500 for each child after the first.

* This will be updated July each year.

Federal Government Rebate (Refers to FAQ on page 42)

AccessGap Cover AccessGap Cover is our Medical gap cover arrangement, designed to minimise or eliminate out-of-pocket expenses for medical services when you’re an inpatient in a registered overnight hospital or day facility.

AccidentAn accident is an unforeseen event, occurring by chance and caused by an external force or object which results in an injury to the body.

Accident - GoldVital HospitalAn accident as defined above and requiring immediate medical treatment in hospital within 24 hours of the accident. If further hospital treatment (as an admitted patient) is required, the patient must be re-admitted to a hospital within 90 days of the initial hospital treatment.

AdmissionThe period of time during which a person is admitted as an inpatient for a condition or illness into an approved hospital/day facility for the purpose of receiving hospital treatment until the time they are discharged from the hospital/day facility.

Annual limitThe maximum limit of benefits payable to a member in a calendar year, commencing 1st January and ending 31st December.

Approved service providerA provider or service that’s approved by HIF. If you’re unsure about the status of a hospital, medical or extras provider, contact us on 1300 13 40 60. Unless stated, extras services are not approved unless the health provider and HIF member (patient) are both physically present in the health provider’s registered practice at the time of a consultation.

Basic benefitWhen the benefit payable is equivalent to the benefits available if the service was provided in a shared room in a public hospital.

BenefitThe payment due to the primary member for services received by an approved provider.

CouplesA couples membership includes one Adult member and Partner only. It does not include dependents.

DependantA person dependent upon the primary member. This includes:

• Domestic partners, your own children, stepchildren, legally adopted children to whom the primary member is the legal guardian (they must be under the age of 21, unmarried and not in a de facto relationship, nor the child of a dependant child).

• Student dependants – children, stepchildren, legally adopted children and children to whom the primary member is the legal guardian, where the dependant is under the age of 25 years, unmarried, not in a de facto relationship and enrolled in a full-time course of study at a recognised educational institution.

ExcessThe amount selected on a Hospital cover which the primary member agrees to pay before a benefit will be payable.

Excluded serviceServices that are not covered by a benefit, so all costs will be paid by you.

ExtrasAt HIF, we call ancillary cover ‘Extras’ – it’s our name for all those day-to-day health care services, such as dental, optical and physio, plus a whole host more, including emergency ambulance cover.

Federal Government RebateThe proportion of private health cover premiums that the Government contributes for permanent Australian residents.

HICAPS/ISOFTProviders with HICAPS or ISOFT technology can electronically claim your benefit directly from HIF.

Glossary

50 51

InpatientA person who has been admitted into an approved hospital or day facility, allocated a bed and then discharged following treatment.

Lifetime Health Cover AgeThe age that each member of a health fund is assigned when they first purchase Hospital cover from a registered health fund. The certified age at entry is based on a person’s actual age at the time of joining a hospital fund table.

Medicare Benefit Schedule (MBS)The schedule of benefits produced by the Department of Health and Aged Care, listing eligible services, fees and benefits for Medical Services, including inpatient services. The MBS is used to calculate the 75% Medicare benefit payable in respect to inpatient services.

Non-contracted hospitalA private hospital not contracted by the Australian Health Services Alliance or HIF to provide services to HIF members. Out-of-pocket costs cannot be guaranteed in these hospitals (basic default benefit applies).

Out-of-pocket The amount remaining to be paid by the member after the HIF and/or Medicare benefits have been paid.

OutpatientAn outpatient is someone who has received medical treatment in a doctor’s surgery or casualty department and has not been admitted into hospital. Benefits for outpatient services are only payable by Medicare Australia.

PartnerMeans a person who lives with a Fund Member of the same or different gender in a marital or de facto relationship and who is covered under the same Fund Membership notwithstanding the Primary Fund Member and a Partner may live apart temporarily.

Policy holderA holder of an insurance policy who is referable to HIF. A holder of a HIF insurance policy is referred to as the ‘primary member’.

Practitioners in private practiceA practitioner who does not:

a) Use any publicly funded hospital, clinic, health centre or other such facility, including a facility provided by a municipal authority for, or in connection with, the provision of an extras service for which a benefit is claimed under the extras table

b) Receive publicly funded assistance or support, whether by way of remuneration, subsidy or otherwise, in connection with the provision of the extras service, except where the extras service is provided at the clinics of strategic alliance partners, joint ventures or HIF’s clinics

Pre-existing conditionIn accordance with HIF’s Fund Rules and The National Health Act, a pre-existing condition is an ailment, illness or condition of which the signs or symptoms, in the opinion of a medical practitioner appointed by HIF, existed at any time during the 6 months ending on the day on which the member commenced cover with HIF for:

1. Benefits in accordance with the applicable benefits arrangement; or

2. If applicable, benefits in accordance with a previous benefits arrangement.

In forming an opinion referred to above, the medical practitioner appointed by the organisation must have regard to any information relating to the ailment, illness or condition that was given to him or her by the medical practitioner who treated the ailment, illness or condition.

This rule applies whether the ailment, illness or condition was known to the member or not.

Primary memberThe first named member, irrespective of who pays contributions to HIF for the provision of health cover. The primary member also holds the legal responsibility to ensure the membership is kept financial at all times, and holds the right to add or remove dependants from the membership. In the instance that the primary member wishes to provide authority for another person to act on their behalf, a spousal/agents authority is required.

Qualifying periodsAny period occurring immediately after joining the fund or joining a higher benefiting table, during which either some or all fund benefit is not payable.

Recognised educational institutionAn Australian educational institution such as a school, college or university, recognised by the Commonwealth, State or Territory Governments.

Restricted serviceHospital services which are only covered for payments at the basic benefit level.

Transfer certificateThe document transferred between registered health funds, detailing the member’s fund history (including Certified Age at Entry), confirmation of the financial status of the member and claims history.

Waiting periodsThe standard period which applies before a member becomes eligible for benefit.

For more glossary terms, visit hif.com.au

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At HIF we’re allabout choice.Call, email or contact us online.

hif.com.au

1300 13 40 60

[email protected]

GPO Box X2221 Perth WA 6847

Australia’s first certifiedCarbon Neutral health fund.

The information in this brochure is correct as at 1 February 2014. Minor changes may occur after that date. If major changes occur, a separate insertion will be included in the brochure or the brochure will be reprinted. HIF members are encouraged to regularly download the latest copy of this brochure from hif.com.au, or contact us and we will send one to you.

Health Insurance Fund of Australia Ltd (HIF) ACN 128 302 161An Australian public company limited by guarantee. A registered private health insurer.

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