Frequently Asked Questions

Private Health Insurance is a complex issue and this document provides general guidance only. The Individual Fund Rules will apply and in the event of any inconsistency between the answers to these FAQs and the Fund Rules the Fund Rules will prevail. Individual cases should be discussed with the fund and individuals should consider taking independent advice as to the application of the Fund Rules to their particular circumstances.

This document is compiled based on the benefits available to NAB Group Employees as at April 2019.

1. Joining

1.1 Who can join?

Membership of the NAB Group Employee Health Insurance Benefits is available to all employees of National Australia Bank Group (including MLC, Corporate Centre, Plum, UBank and NAB capital). To be eligible you must be either an Australian Citizen, a permanent resident or have been approved to become a permanent Australian resident. These employees would hold a Blue or Green Medicare Card.

Employees who hold a Green Medicare Card with a yellow band at the top (Reciprocal Health Care Agreement card), or those on working visas (such as the 457, 161, 136, 138, 417, 679, 456 visa) are not eligible for this healthcare cover. These employees should seek Overseas Visitor Health Cover or Overseas Student Healthcare depending on their status.

Children up to the age of 18 – 22 depending on the Health Insurance provider (see 1.7) may be covered on a family policy, and dependants aged up to 25 can also be covered on a family policy if they are completing recognised full time study. Certain health funds may offer a dependant extension option, to cover non-student dependants up to the age of 25 (see 1.7).

1.2 How do I join?

Once you have chosen your desired product, please use the links contained within this website to take you to the personalised extranet of the fund, alternatively you can phone the fund (see 1.6) where you will be either able to join over the phone, or they will send you a dedicated application form. Please note the premiums shown on this website, do not include any Government Rebate (see 2.5) and DO NOT include any Lifetime Health Cover loading (see 9.4).

Alternatively, you may use the links contained in this website to take you to the NAB internet sites of the participating health funds. Once there you may be able to obtain a personalised quote and for most funds, complete an online application.

1.3 Once I have filled out my application form where should I send it?

Once you have completed all sections of your application form, making sure to sign all the relevant sections, you should send your original form directly to the health fund. The appropriate address should be listed on the bottom of the application form or refer below.

Company Postal Address
Medibank Private GPO Box 9999, in your capital city
Bupa Reply Paid 9808, Bupa, GPO BOX 9809, Brisbane, QLD 4001
HCF GPO Box 4242, Sydney, NSW 2001
NIB NIB Health Funds, Locked Bag 2010, Newcastle NSW 2300
HBF Post GPO Box C101, Perth WA 8609

Alternatively, you may fax your application form to the number listed on the bottom of the application form or refer below.

Company Fax Number
Medibank Private (07) 3026 0557
Bupa 134 135
HCF 1800 045 563
NIB (02) 4925 1900
HBF 1300 132 549
1.4 Will I get a membership card?

Yes. Upon joining, all members receive both a welcome kit and membership card that lists their membership number and the names of those covered. You can use your membership card to make on-the-spot claims through the Electronic Claiming system (HICAPS see 7.3) at most extras providers. You should receive your card within 15 working days of your membership start date, however this may vary depending on the health fund.

1.5 Will I receive a second card if I am on a family membership?

For Bupa, HCF and NIB an additional card will automatically be sent out when you apply for a family or couple membership.

For Medibank Private, an additional card can be requested using the online member services or by calling the Member Care Team on 131 680.

For additional or replacement cards, please contact the health fund (see 1.6).

1.6 What should I do if I do not receive a membership card after 15 working days?

Please call the health fund directly to check on the progress of your membership;

1.7 Up to what age are my children covered under my health insurance cover?

On a family or single parent membership, children who are no longer studying full time will be covered up to age 18 (HBF), age 21 (at Medibank Private, Bupa and NIB) and up to age 22 (at HCF).

Dependant children engaged in recognised full time study will be covered on all family or single parent policies up to age 25.

In addition, health funds such as Medibank Private, Bupa and HCF may offer a dependant extension option on some of their products, to cover non-student dependants up to the age of 25, for an additional premium. For more information on whether this is offered on each product, please contact the health fund (see 1.6).

1.8 I don’t really understand my new product. Who should I contact?

Contact the health fund directly on the numbers listed in 1.6.

1.9 What are my various methods of payment?

You may choose to pay your premiums through direct debit withdrawals from a nominated bank account or credit card. Your premiums must be paid at a pre-determined interval either fortnightly, monthly, quarterly, half-yearly or yearly depending on the fund. Premiums must always be paid in advance.

2. Application Form

2.1 Where can I obtain an application form?

Application forms can be found by contacting the health fund (see 1.6).

Once you have received an application, complete the form, sign where appropriate, and send the original to the appropriate health fund (see 1.3).

Alternatively, you may use the links contained in this website to take you to the NAB websites of the health funds. Once there you will be able to obtain a personalised quote and for most funds complete an online application except for HCF (see 1.3).

Please note when viewing this website, the premiums shown are based on monthly contributions with no Government rebate deducted (see 2.5). Premiums quoted DO NOT include any Lifetime Health Cover loading (see 9.4) or factor in any higher rebate levels that may be available for persons aged over 65 (see 2.5). Please contact the fund for more information (see 1.6).

2.2 What is and why do I need to complete the clearance certificate section?

A clearance certificate is a standardised inter-fund document which verifies your previous health insurance details to your new health fund. This document enables your new health fund to recognise any waiting periods already served, current benefit level, claims history and certified age of entry (see 2.3).

By completing and signing this section, your new health fund will be able to obtain information from your previous insurer on your behalf. By doing this, you will not have to re-serve waiting periods all over again for services you already have cover for (see 3.5 and 3.8).

If you do not wish to sign this section of the application form, you may personally request a clearance certificate from your previous health insurer. Please forward this onto your new fund to ensure you receive continuity of cover and don’t have to re-serve waiting periods.

2.3 What does Certified Age at Entry (CAE) mean?

A ‘certified age at entry’ (also referred to in the ‘Lifetime Health Cover loading’ section see 9.4), is established for every person who purchases hospital cover. CAE is based on the age at which you first took out hospital cover, unless a cumulative lapse of more than 1093 days (3 years minus 1 day) has occurred. Lifetime Health Cover rules refer to the CAE to determine if you are required to pay an additional loading on premiums. The threshold CAE is 30.

Please note when viewing this website, the premiums shown are based on monthly contributions with no Government rebate deducted (see 2.5). Premiums quoted DO NOT include any Lifetime Health Cover loading (see 9.4) or factor in any higher rebate levels that may be available for persons aged over 65. Personalised premium may also differ based on your Certified Age of Entry (see 2.4). Please contact the fund for more information (see 1.6).

2.4 CAE calculation?

A person’s actual age on the 1 July prior to purchasing cover from a registered health fund is called their certified age at entry (CAE). This is usually determined by your chosen health fund, or is informed to them by your previous health fund through your clearance certificate (see 2.2). For more information please contact the fund (see 1.6).

Anyone joining hospital cover for the first time will pay the base rate premium for their cover, plus a 2% Lifetime Health Cover (LHC) loading for every year by which their CAE exceeds 30. For a couple or family policy the average age of the two adults will be used to calculate the loading that will apply.

If you obtained private health insurance coverage, prior to the 1st of July 2000, and have held cover continuously since that date, your CAE will be 30 and a loading will not apply to you.

2.5 What is the government rebate? And how does it apply to me?

The Australian Government rebate is an initiative by the Commonwealth Government to encourage the take up of Private Health Insurance. The rebate is available to anyone who is entitled to full Medicare benefits and holds private health insurance.

The rebate has three levels and is calculated by the age of the oldest person on your membership.

The Australian Government introduced changes to the Private Health Insurance rebate for high-income earners effective 1 July 2012. These changes were focused on both the rebate entitlements and the Medicare levy surcharge and introduced an age and means testing regime. From 1 April 2014, the Government will limit any increase in the Government Rebate to a Rebate Adjustment Factor.

The new rebate structure will be applied from 1 April 2019 and eligibility for the rebate will continue to be based upon an income and aged based regime. For the 2019/20 tax year:

Base Tier Tier 1 Tier 2 Tier 3
Singles ≤ $90,000 $90,001–105,000 $105,001–140,000 ≥ $140,001
Families ≤ $180,000 $180,001–210,000 $210,001–280,000 ≥ $280,001
Age Rebate Rebate Rebate Rebate
Under 65 25.059% 16.706% 8.352% 0.000%
65 to 69 29.236% 20.883% 12.529% 0.000%
70+ 33.413% 25.059% 16.706% 0.000%
Medicare Levy Surcharge (MLS) if no private hospital cover
All 0.0% 1.0% 1.25% 1.5%

These thresholds increase annually, indexed by Average Weekly Ordinary Time Earnings, and increase $1,500 for every child after the first. The family thresholds apply to couples and single parent families. The means testing is based on the Australian Tax Office’s (ATO) definition of income for MLS purposes.

Note MLS surcharge does not apply if you hold a complying level of private hospital coverage.

You can claim the Government Rebate in two different ways:

3. Waiting Periods and Pre-existing Conditions

Definitions

3.1 What is a waiting period?

If you are new to private health insurance or are upgrading your level of cover waiting periods will apply. A waiting period starts from the date you join. During a waiting period you will not be covered and you will not receive any benefits for treatment requiring a waiting period. Once the waiting period is completed, you will receive the full benefits listed under your level of cover for that treatment type. (Refer to 3.7 and 3.10).

3.2 What is a pre-existing condition?

In accordance with the Private Health Insurance Act, if you have an ailment, illness, injury or condition that you had signs or symptoms of at any point up to six months prior to taking out private health cover (even if you have upgraded), it is a ‘pre-existing ailment’ – even if you had not consulted a doctor about it or were not aware of it at the time. The pre-existing ailment rule may also apply to extras claims.

3.3 Waiting periods for pregnancy?

Pregnancy (childbirth) for new members to Private Health Insurance or those who previously did not have pregnancy on their coverage – is subject to the standard 12 month waiting period – this means for the first 12 months you will not receive benefits for childbirth related services on policies which include this benefit. Additionally, some products also impose a 24 month benefit limitation period which restricts your level of benefit for the first 24 months, for more information see 3.4 or contact your fund (see 1.6).

3.4 What is a Benefit Limitation Period?

During a Benefit Limitation Period (BLP), minimum default benefits (the minimum level of benefit payable as declared by the Minister of the Commonwealth Department of Health & Ageing) will apply to certain procedures, each of which comes with a two-year Benefit Limitation Period, which commences after normal waiting periods have been served.

BLPs only apply to new members to Private Health Insurance, those who have not fully served their waiting periods, or those who are upgrading their level of cover.

Hospital waiting periods

3.5 I already have Private Hospital Health Insurance – will I incur any new waiting periods if I change funds?

If you are transferring onto a NAB employee product, you will receive continuity of cover. This means that previous services and benefits will be recognised and no new waiting periods that have previously been served will apply (if transfer of membership has occurred within 30 days from your paid to date with your previous insurer).

However, if there is an upgrade in your level of cover; for services which you previously did not have;

3.6 What happens when waiting periods are not fully served?

Any duration of the waiting periods you have served will be transferable to your new health fund and you will only need to serve the remaining portion (see 3.5).

3.7 If I have never had Hospital Health Insurance before, what waiting periods will apply?

All members new to Private Health Insurance will be exposed to;

For further information, contact the health fund (see 1.6).

Extras waiting periods

3.8 I already have extras insurance – will I incur any new waiting periods on my extras cover if I change funds?

If you are transferring onto a NAB employee product, you will receive continuity of cover. This means previous services and benefits will be recognised and no new waiting periods that have previously been served will apply (if transfer of membership has occurred within 30 days from your paid to date with your previous insurer).

However, if there is an upgrade in your level of cover, your old level of benefits will apply for the first 12 months on pre-existing conditions, some general dental items, major dental, orthodontics and some health appliances. Some health appliances may be subjected to longer waiting periods (refer to the plan brochure or contact the health fund for details see 1.6).

3.9 I have not fully served my waiting periods – will the time that I have served be recognised?

Yes. Any duration of the waiting period you have served will be transferable to your new health fund and you will only need to serve the remaining proportion. Contact the health fund for further details (see 1.6 and 3.8).

3.10 If I have never had extras Health Insurance before, what waiting periods will apply?

New members will be exposed to;

Please contact the fund for further information see 1.6.

4. Hospital Benefits

4.1 What am I covered for?

Your level of coverage will depend on which product you choose. Please refer to the health fund’s product information brochure contained on this site, or contact the health fund for more details (see 1.6).

4.2 What is the Medical Gap?

The Federal Government sets a dollar amount for each medical service covered by Medicare – known as the ‘Medicare Schedule Fee (MSF)’. When you are treated in hospital as a private patient, Medicare pays 75% of the schedule fee and your Health Fund covers the remaining 25%. Where a doctor or specialist charges more than the Medicare Schedule Fee, this known as the Medical Gap.

4.3 What is Gap claiming?

If a specialist charges more than the Medicare schedule fee for in hospital treatment, the patient is responsible for the gap. Funds offer a ‘No Gap’ system, where the specialist agrees to bill them directly. If there is a ‘Gap’, you will know the maximum amount you will have to pay prior to your treatment. Please consult your health fund and specialist before any procedure to ask about the medical gap.

4.4 What do I need to know about in-hospital medical/doctor’s charges?

The Commonwealth Government sets the amount of doctors’ charges for the purposes of paying Medicare benefits, known as the Commonwealth Medicare Benefits Schedule Fee (CMBS Fee). Health funds do not pay any amount charged by your doctor above the CMBS Fee (unless there is an agreement in place between your doctor and your fund or your doctor utilises the Gap Cover Scheme see 4.5). This extra amount becomes the ‘medical gap’ and you will be required to pay it out of your own pocket.

4.5 How can I find a ‘No Gap’ specialist?

You may ask your specialist if they participate in a No Gap scheme with your fund.

Going to Hospital

4.6 What is the difference between being a public and a private patient?

As a private patient, you have access to in-hospital treatment in all public hospitals and participating private hospitals. This will allow you to avoid the long waiting lists you may be exposed to in the public system. As a private patient you can select your own specialist and request the time frame in which you would like the procedure done.

As a public patient in a public hospital, you will not have your choice of doctor, and you may be subjected to long waiting lists, typical of the public system.

4.7 What are Participating Hospitals?

‘Participating Hospitals’ are hospitals with which the health fund has negotiated charge agreements for accommodation and hospital-related services.

Please check with your fund to ensure that the hospital that you would like to go to is registered as a Participating Hospital with the fund. If you go to a Non-Participating Private Hospital, this may result in large out-of-pocket expenses. Please note all Public Hospitals have agreements with all funds.

4.8 What are Non-Participating Private Hospitals?

These are Private Hospitals that the health fund does not have an agreement with. If you go to a Non-Participating Private Hospital, the health fund will pay lower benefits that are unlikely to cover the cost of your stay and, as such, you may incur additional out-of-pocket expenses. Please check with your health fund prior to going to hospital to ensure that you are going to a Participating Private Hospital.

4.9 How can I determine if my private hospital is contracted to the fund?

A full list of contracted hospitals is available from each funds website or by calling their customer care line. Please ensure you contact the fund prior to your admission date as agreements with the hospital are subject to change.

5. ‘Extras’ Benefits

5.1 What types of ‘extras’ am I covered for?

Your level of coverage will depend on which product you choose. Please refer to the comparisons on this site. For further information please refer to the health funds’ brochures.

5.2 What are annual limits, and how do they work?

Annual limits, as their name suggests, set a dollar limit on claiming on a particular service or services in a year. Annual limits, unless otherwise stated by the fund, are usually based on a per person, per calendar year basis. Certain funds have increasing annual limits that are capped at a maximum amount and also increase on a per person per calendar year basis unless otherwise stated. Please refer to the health funds product brochure for more details.

5.3 What is the difference between set benefits and percentage of cost?

A set benefit is a specified rebate amount ($ amount) set by the health funds on each type of extras service. A different set benefit amount will be payable on each type of service, regardless of the fee charged by the provider.

Members may receive a percentage based benefit on a cost incurred basis from the provider of their choice. Percentage rebates vary on the level of cover selected by the member and range from 50% to 85% of the amount paid for by the member to their Extras provider.

Both set benefits and percentage of cost rebates are capped at your annual limits. Set benefits differ between health funds.

5.4 How can I claim more on my extras?

Most funds have special agreements with contracted providers or preferred providers. At these contracted providers you may be able to get a higher set benefit, a percentage of cost rebate or a discount on your service charge. To find out if your health fund is currently running any special offers, please check their websites.

5.5 What is a preferred provider?

Preferred providers are an extension of the recognised provider, as health funds have agreements with these providers to offer increased benefits to members on selected ancillary services. Depending on the health fund preferred providers may be individual practitioners or service centres. For more information on individual fund’s preferred providers, contact the fund (see 1.6).

6. Ambulance

6.1 Does my cover include emergency ambulance?

Most hospital covers include an ambulance component. In most cases you will be covered for unlimited emergency ambulance trips, however in some states this arrangement may be different as a result of state based ambulance levies. For more information of the level of ambulance cover in your state and on your policy, please contact the health fund (see 1.6).

7. Claiming

Hospital claiming

7.1 How do I make a claim?

In most cases, hospital claims are settled between the hospital and the health fund.

Medical or Specialist claiming (For Inpatient Services)

7.2 How do I make a claim?

If your specialist is using the ‘No Gap’ system, in most cases these claims are settled between the fund and the provider directly (please see 4.5 for more information). If your provider has advised that they will not be using the ‘No Gap’ system, you will be required to complete a two-way claim form which can be obtained from Medicare, and then submitted directly to Medicare who will forward the form onto your health fund.

If the specialist has not been paid by you, both Medicare and your health fund will send cheques in the specialist’s name to you to be forwarded to the relevant specialist, with any shortfall to be covered by yourself. If, however you have paid the claim, these cheques will be made in your name. Please note that for if your specialists does not use the ‘No Gap’ system you may incur out-of-pocket expenses.

Extras claiming

7.3 How do I make a claim?
On-the-spot (HICAPS)

93% of all claims are settled by HICAPS (on the spot claiming system). Nationwide, there are now more than 23,000 health service providers that offer on-the-spot electronic claiming to health fund members for services covered by ‘extras’ cover.

It’s simple. The provider will swipe your membership card after treatment, and you will pay the relative outstanding balance. If the provider does not offer HICAPS you have the following alternatives available to you:

  1. Online
    Most health funds have developed an online claims system to submit your ‘extras’ claims via their website. Most extras claims may be settled in this manner, although some funds do impose an online claiming maximum. For further information on the online claiming process please contact your chosen fund (see 1.6).
  2. Mail
    Claims can be mailed directly to the health fund and benefits will be paid directly into the member’s nominated bank account.
  3. Fax
    Alternatively, mail claims can also be faxed to the health fund for payment. (see 1.3).
  4. Branch
    Members can visit their nearest branch to make a claim, and members can search on the web for their nearest branch. Much like the banking industry, the utilisation of online claiming facilities have dramatically reduced the need for branch outlets, and as such there has been a continual decline in the number of retail outlets.
  5. SmartPhone applications
    Some funds have developed smartphone applications to allow you to submit your ‘extras’
How long do I have to submit a claim after a service has been delivered or performed?

You can submit a claim for a service up to two years after the date of service has been provided.

7.4 Where can I get a claim form?

Corporate claim forms can be obtained from the health funds website directly or by calling the fund.

7.5 How can I claim without my card?

If your application has been submitted to the health fund and processed and you subsequently need to claim a benefit prior to receiving your card, you are still able to do so.

8. Going Overseas

8.1 Does my Private Health Insurance cover me when I’m traveling overseas?

No. Your Health Insurance does not cover you for any services rendered overseas for either hospital or ‘extras’. Please seek travel insurance for this purpose.

8.2 I am transferring to an overseas posting for a couple of years. What do I need to do?

Contact your health fund (see 1.6).

9. Miscellaneous

9.1 What should I do if I have lost my membership card?

Please contact your health fund and they will issue you with a new card. Your new card can take up to 10 – 15 working days to arrive. (see 1.6)

9.2 How do I add/remove a partner or children, or notify a change in address, name, etc?

Please contact your health fund. They will have to re-issue another card that can take up to 10 – 15 working days. (see 1.6)

9.3 I am travelling interstate – does my Private Health Insurance cover me outside my state?

Yes. Your Health Insurance is valid in other states and territories whilst travelling.

9.4 What is the Lifetime Health Cover (LHC) loading?

The LHC loading was introduced by the Federal Government in an attempt to encourage people to take out Health Insurance before the age of 30. If you do not take out private hospital cover by 1 July following your 31st birthday, or for new migrants 12 months after your eligibility for Medicare, you will have to pay an additional 2% loading on your premium each year you delay taking out cover. The maximum loading applicable is 70%. The loading is removed once a compliant hospital product is held for 10 continuous years.

9.5 Do Lifetime Health Cover loadings apply to ‘extra’ (ancillary) products or ambulance cover?

No. Lifetime Health Cover loadings do not apply to ‘extra’ (ancillary) products and ambulance cover. Only hospital cover is subject to Lifetime Health Cover loadings.

9.6 What is the Medicare Levy Surcharge? And how does it apply to me?

The Medicare Levy Surcharge is levied on Australian taxpayers who do not have private hospital cover and who earn above $90,000 (single) or $180,000 (couples or families). The family income threshold increases by $1,500 for every child after the first. The surcharge is calculated at the rate of between 1% and 1.5% of taxable income. It is in addition to the Medicare Levy of 1.5% which is paid by most Australian Taxpayers. To avoid the surcharge, you must have a hospital cover policy with a low front-end deductible or excess, equal to or less than $500 per annum for single policies, or $1,000 per annum for families/couples. For more information on the thresholds, see see 2.5

10. Disputes

10.1 Whom should I contact in case of disputes?

If you have any concerns, problems or complaints regarding your health insurance, contact your health fund directly who will do their best to resolve the issue to your satisfaction. In the event that you are not satisfied with the outcome, you may contact the Private Health Insurance Ombudsman on 1800 640 695 or visit them at www.phio.org.au