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Important information
Important information about your Extras Cover
For more detailed information specific to your level of extras cover refer to your policy document which you can download and save for future reference.
Note: For members with products called Hospital Cover & Ancillary Cover or Hospital Cover Level 5 & Ancillary Cover, some of your benefits have different rules. Please refer to your benefits table for specific information about how your benefits apply. More >>
Ambulance transportation
If you have extras cover on its own, this policy only covers you for emergency transportation. This means a sudden or unexpected need for hospitalisation where the only practical way of getting to a hospital is by ambulance.
Note: We don’t pay benefits for ambulance subscriptions and we don’t cover you for non-essential transportation such as:
- transfer between a public and private hospital
- changing hospitals to be closer to home
- travelling from home to hospital for tests.
Broken appointments
The fund doesn’t pay benefits towards broken appointments, so if you’ve been charged for not attending or cancelling an appointment, you won’t be able to claim for it.
Changing your cover
When you change your cover, benefit entitlements you were previously covered for may be affected. If your new level of cover includes additional items or benefits you did not have on your previous cover, you may be required to serve waiting periods for these (see your policy document for more information on waiting periods).
Where limits apply, any benefits already paid on your previous level of cover within the current financial year will be taken into account when you change your cover.
Changing your cover may affect your eligibility or participation in ahm’s disease prevention programs.
Claims
Claims are only payable if:
- the service is performed by an ahm recognised provider
- the service date on the receipt is less than two years old
- an original receipt or invoice is submitted to and kept by ahm
- your claim is not payable or subsidised by a third party such as workers compensation unless an authority has been completed
- your policy is financial on the date of service.
Consultations
You’re able to claim for one face to face consultation with a provider on a given day. This means that if you have two or more consultations with the same provider on the same day, even if they're for different types of services, you’ll only be able to claim for one.
Telephone or video consultations are not eligible for benefits except where approved by ahm.
Dental
Dental benefits are paid by the type of service and according to the category defined by ahm as detailed below. Different benefits are not paid for the type of provider except orthodontics.
Routine
Services include X-rays, examinations or consultations, preventive procedures such as clean and polish, oral surgery for tooth extractions and minor restorative services.
* See separate notes for Ancillary Cover
Complex
Services include periodontics (root planing, oral surgery for prostheses, jaw injuries or non-tooth related surgery) and endodontics (root canal therapy).
Please Note: Benefits for complex dental services are not available with Basic Extras policies.
* See separate notes for Ancillary Cover
Major
Services include indirect restorations, all crowns, bridgework and implants and dentures.
Please Note: Benefits for major dental services are not available with Basic Extras policies.
* See separate notes for Ancillary Cover
Orthodontics
We'll pay benefits for orthodontic services by a General Practitioner (GP) or specialist dentist provided claims are accompanied by a detailed treatment plan.
Please Note: Benefits for orthodontics are not available with Basic Extras policies.
* See separate notes for Ancillary Cover
Disease prevention
Your extras cover enables you to access the following services and we’ll cover the costs so there’s no need to make a claim.
- ahm’s Health Risk Assessment (HRA) is a questionnaire-based assessment of the health risks you face. The assessment will provide you with a Wellness Profile including your Health Age, any major health risks you face and advice on preventive measures.
If you’re 18 years old or over, you can complete the HRA online at www.ahm.com.au. - ahm’s Health Coaching Program is a support program to help you improve or maintain your health or manage a condition. The program involves a series of telephone calls made by qualified clinicians including dietitians, exercise physiologists and occupational therapists over a six month period. It helps you make the changes needed to improve your health. You’ll be provided with information relevant to your health goal and will have access to online support including information, health tips, recipes and goal setting.
If you’re 18 years old or over, call us on 134 246 to access the program.
Note: Falling behind in your payments (arrears) or changing your cover may affect your eligibility or participation in ahm’s disease prevention programs.
Health improvement benefits
To help you better manage your health, we'll pay benefits towards the following:
- Dietitian and nutritionist consultations.
- Cancer Council approved UV sun protection products including 30+ sunscreen, hats, rash vests or suits and sunglasses. This does not include cosmetics or lip sticks/glosses/balms.
- Disease management association fees for the Arthritis Foundation, the Asthma Foundation, the Coeliac Society, Diabetes Australia and the Heart Foundation to help manage and receive support for diagnosed chronic disease.
- Doctor’s health checks and Healthy Heart checks (where not claimable through Medicare, an employer or another party) to assist with early diagnosis and/or prevent an illness or condition. The benefit is not payable when your health check is related to employment (such as pre-employment health checks) or when you can claim it through a third party insurer.
- Exercise classes including gym, yoga, pilates and exercise physiology sessions when part of an ahm or a recognised health management program and by an ahm approved provider. Gym classes must be provided by a Fitness Australia accredited gym. A detailed health management plan must be provided.
- Preventive tests, screenings and scans where not claimable through Medicare to assist with early diagnosis and/or prevent an illness or condition.
- Quit smoking courses and nicotine replacement therapy (patches, gum, lozenges and inhalers) to assist in quitting or reducing smoking with the aim to help improve or prevent an associated health condition.
- Stress management courses by a recognised psychologist or ahm approved provider to manage and prevent health conditions associated with high levels of prolonged anxiety.
- Weight loss classes and courses provided by ahm approved providers Weight Watchers® or Jenny Craig®. Medical evidence of a Body Mass Index (see definition on page 10) of 26 or over must be provided. This can be in the form of a doctor’s certificate, an ahm health profile (provided after completion of an ahm HRA) or a certificate from an ahm approved weight loss provider. If the claim is for a child, evidence of an unhealthy BMI must be provided in the form of a doctor’s certificate/letter.
- Swimming activities for children 0 - 17 years by an Austswim® or Swim Australia accredited swim school for children with asthma, diabetes or an unhealthy Body Mass Index (see definition page 10). Medical evidence of one of these conditions must be provided or a doctor’s recommendation to undertake this activity due to their condition.
Note: Services must be provided by a recognised provider.
Please Note: Benefits for swimming activities are only available with Family and Super Extras policies.
* See separate notes for Ancillary Cover
Limits
Most benefits will have a limit which is a maximum amount you can claim in a specified period of time (see claiming periods below). Limits are outlined in the benefits table of your policy and are per financial year unless otherwise stated. You can check your benefit limits online at any time.
Note: Limits not used in a claiming period do not roll over to the next claiming period.
Claiming periods
- Financial year – 1 July to 30 June. Your benefit entitlements are renewed at the beginning of each financial year
- Rolling year – A rolling year begins on the date a service was first provided with the limit applying to that 12 month period following the date of service.
Limit types
Per person limits
Where applicable, each person on a membership can claim up to the ‘per person’ limit for the claiming period except where:
- A person is on a family policy and the family limit has been reached for the claiming period
- A person is on a family policy and the family limit balance is less than the ‘per person’ limit. For example:
- Benefit ‘xyz’ has a family limit of $1,000 with a ‘per person’ limit of $400
- Of the family limit, $800 has been claimed leaving a balance of $200
- Family member ‘A’ hasn’t used any of their ‘per person’ limit in the claiming period, but will only be able to claim up to $200.
Family limit
Benefits are payable up to the family limit indicated in the benefits table for the claiming period. Per person limits also apply.
Lifetime limit
A benefit with a lifetime limit means that once you reach the limit, you can no longer claim that benefit in any future year of membership, even if you change your cover.
Loyalty limit
Loyalty limits are based on maintaining a policy with ahm for a continuous period of time and apply to benefits in your policy. This means your benefit limit for the claiming period specified will depend on the number of years that the principle policy holder has held the policy. To confirm your loyalty limit entitlement, you need to know the number of years you have continuously held a policy with ahm then refer to the benefits table. You can check your years of policy coverage online in our ‘members’ section (password required) or by calling ahm on 134 246.
Please Note: Loyalty limits apply to Lifestyle, Family and Super Extras policies only.
How loyalty limits work
The loyalty date for the whole policy is determined by the principle policy holder (the first named policy holder of the policy). If a partner or dependant leaves the policy for any reason, including the death of the principle policy holder, they’ll carry their own joining date as their loyalty date.
Some examples:
- Betty (principle policy holder) started an ahm family policy in 1980 and John was put on the policy in 1987 when he was born. John recently turned 21 and left the family policy to start his own single membership with ahm. Because he’s been with ahm since 1987 he’ll start a single membership with 21 years of loyalty (as at 2008).
- Tom (ahm policy holder since 2002) married Betty and joined her policy in 2004. The policy stays in Betty’s name so their loyalty date remains at 1980 and they’re entitled to the highest limits. If the policy had transferred into Tom’s name (he became the principle policy holder) their loyalty date would be 2002 instead of 1980 and their loyalty limits would be less.
- Betty passed away in 2005. When Betty passed away, the membership transferred into Tom’s name. As he is now the primary member, loyalty limits are based on when he joined ahm in 2002.
Note: If a change to a policy is required, it’s important for policy holders to consider who will be the principle policy holder as this will determines the loyalty limits you can claim.
Moving into a higher limit category
As loyalty limits apply to a financial year, the number of years the principle policy holder has been a policy holder as at 1 July each year determines which category of loyalty limit you’re entitled to. For example, although Tom has held continuous cover with ahm for 5 years in December 2007 (he joined in 2002), he won’t be entitled to his 5 years loyalty limits until 1 July of the following year.
Online and telephone claiming
There’s a $400 limit on claims made online or over the phone (TeleClaim) and you can only claim for paid extras and routine dental services, not medical gap or major dentistry.
If you reach the $400 limit, you can’t make any more claims online or over the phone until we have received your receipts. Once we have your receipts, and verified the claims, you can claim up to $400 again.
Orthotics and orthopaedic footwear
We’ll pay benefits for orthotics and orthopaedic footwear only if custom made and supplied by a recognised podiatrist or orthopaedic footwear supplier. Make sure you include a referral from a recognised provider with your claim.
ahm accepts referrals from recognised physiotherapists and chiropractors for orthotic devices.
Note: We don't pay benefits for prefabricated orthotics, including sporthotics or formthotics. Orthotics are not covered by Basic or Lifestyle Extras.
Outpatient procedure room fees
Benefits will be paid towards the charge incurred for the use of a facility or procedure room for an outpatient medical service. The cost of the doctor's fee for the medical service is not claimable.
Note: Outpatient procedure room fees are only applicable for Super Extras.
Overseas claims
Your extras cover doesn’t cover you for any services or goods purchased outside of Australia, including online purchases from overseas companies. If you’re travelling overseas, call us on 134 246 so that we can help you arrange travel insurance at discounted rates. You can also apply online.
Pharmaceutical Benefits Scheme (PBS)
The PBS is the national pharmaceutical benefits scheme funded by the Commonwealth Government where patients pay a set amount towards the cost of a subsidised drug. The PBS is only available to persons with Medicare eligibility.
Pharmacy
We'll pay benefits on pharmacy items that are:
- prescription only and prescribed by a medical practitioner including contraceptives
- essential to treat a particular illness, injury or condition
We’ll pay a benefit for each eligible pharmacy item after you pay the set PBS general patient amount.
Items available without a prescription including herbal medicines and vitamins cannot be claimed.
Policy suspension
If you’re travelling overseas for more than 30 days, you can suspend your policy without it affecting your loyalty. The period of suspension will still count towards the years of continuous cover.
To suspend your policy just send us a written or email request including the dates of travel. We’ll get back to you before you leave to confirm the suspended period.
To reactivate your policy you need to provide proof of the date of entry back into Australia within 30 days of your return.Note: You’ll still need to serve any waiting periods you may have had before leaving the country and no benefits will be paid for services provided during the suspension period.
If you have hospital cover with ahm, suspending your membership may result in you being charged the Medicare Levy Surcharge. Consult your accountant, tax agent or the Australian Taxation Office for further advice.
Policy termination
Only the principal policy holder and ahm have the right to terminate the policy. Notice of termination must be given in writing, effective from the date specified in the notice (being a date no earlier than the date of the notice). You’re entitled to a refund of any premiums paid in advance of the date of termination.
Any policy holder or dependant over the age of 16 covered by a policy can terminate their own individual cover by giving notice in writing to ahm, effective from the date specified in the notice (being a date no earlier than the date of the notice) but cannot terminate the policy.
Cooling-off Period
If the principal policy holder terminates their policy within 30 days of joining and hasn’t claimed a benefit during this period, they’re entitled to a full refund.
Recognised providers
It’s important for ahm to register service providers so that you receive quality health care from the providers you choose.
Recognising a provider means we get specific details and credentials from them to make sure they meet legislative and ahm criteria for benefit payment. All service providers must be registered with ahm before we can pay benefits. Recognition of a provider means that ahm may check with the provider on the goods or services supplied to any person on a policy to ensure that appropriate claims and benefits are being paid.
Benefits won’t be paid for services performed or goods supplied by unrecognised practitioners or by a provider on themselves, their partner or dependants, business partners or business partners’ partner or dependants.
Call 134 246 to find out if your service provider is recognised by ahm or use our provider search tool .
Transferring from another private health insurer
If you've transferred from another private health insurer, we'll acknowledge the waiting periods you've already served for comparable benefits.
In accepting a transfer of membership from another private health insurer, we reserve the right to treat any benefits paid by the previous insurer in the current financial as already being used under the limits of your new cover.
Travel and accommodation
Travel and accommodation benefits are available if you need to travel more than 200km return for a specialist medical appointment or an outpatient procedure and there’s no recognised practitioner near where you live. This doesn’t include travel and accommodation related to hospitalisations, dental or extras services including ahm’s Dental and Eyecare Practices and IVF treatment.
Accommodation benefits are only payable for the patient – or a parent if the patient is a dependant child under the age of 18 – for a maximum of one night before, the night of and one night after the appointment. Travel benefits are payable for the patient only.
To claim these benefits you need to supply one of the following:
- statement of attendance from a doctor
- copy of the doctor’s account
- IPTAS (Isolated Patients Travel and Assistance Scheme) forms
- Medicare statement or bulk billing statement
- invoice for your accommodation including the date/s
Note: Benefits for travel and accommodation are only available with Super and Family Extras policies.
Unfinancial policy (arrears)
Benefits are not payable for services provided during the period in which a policy is in arrears (see your policy document for more information) until the premium is fully paid and accepted by ahm.
ahm has the right to refuse to accept premiums if more than two months has elapsed since the financial date of the policy.
NOTE: If a policy holder is more than two months in arrears then the policy will be terminated by notice in writing from ahm to the principal policy holder, effective from the last financial date of the policy.
Waiting periods
When you take out extras cover or change your level of cover, you’ll have to wait a set time before you can claim for services and benefits you weren’t previously covered for.
Where benefits are greater on your new level of cover, we’ll pay the benefit at the amount on your previous level of cover until the waiting period is served.
| Waiting Periods | |
| 1 day |
|
| 2 months |
|
| 6 months |
|
| 12 months |
|
| 3 years |
|
Note: You may not be eligible for some of the benefits mentioned in the above table, please refer to your policy document to see which benefits your policy covers.
This is important information about your policy. Please read this in conjunction with your policy document which you can download and save for future reference.