- Home >
- Products >
- Health Insurance >
- Extras Covers >
- Important Information
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 »
Important information: From 1 July 2012, we’re increasing the benefits we pay on a range of our most popular Extras services including routine dental, physiotherapy, chiro and osteopathy. Find out 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.
Body Mass Index
Body Mass Index (BMI) is used to estimate your total amount of body fat. It’s an approximate measure of the best weight for health. To calculate your BMI, divide your weight in kilograms by your height in metres squared.
For example, if you weigh 70kg and you’re 1.7 metres tall, your BMI would be 24.2.
70 ÷ (1.7 x 1.7) = 24.2
A BMI between 18 and 25 is within the normal range. A BMI less than 18 means you’re considered underweight and a BMI over 26 and over means you’re considered overweight. If your BMI is above 30, you’re considered obese.
For a child, their age and sex is also taken into account when calculating BMI so only a medical practitioner should determine.
Broken appointments
ahm 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.
Change of cover
When you change your cover, it may affect benefit entitlements you were previously covered for as well as your eligibility or participation in ahm’s disease management programs.
If your new level of cover has additional or higher benefits on services where waiting periods of 12 months or more apply, you will still have to serve these waiting periods. The good news is that ahm doesn’t have 2 or 6 month waiting periods on any of our extras products, so in many cases you’ll be able to start claiming your new benefits straight away. (See your policy document for more information on waiting periods).
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.*
Please note: Benefits for complex dental, major dental and orthodontic services aren't available on Basic Extras.
* See separate notes for Ancillary Cover
Routine
Services include X-rays, examinations or consultations, preventive procedures such as clean and polish, oral surgery for tooth extractions and minor restorative services.
Complex
Services include periodontics (root planing, oral surgery for prostheses, jaw injuries or non-tooth related surgery) and endodontics (root canal therapy).
Major
Services include indirect restorations, all crowns, bridgework and implants and dentures.
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.
Health insurance policy
Acceptance of a policy application and continued eligibility for health insurance is conditional on the requirement that you agree that no person on the policy also has an active extras cover with another private health insurer.
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 Extras 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 isn't claimable.
Note: Outpatient procedure room fees are only applicable for Super Extras.
Overseas claims
Your Extras policy doesn’t cover you for any services received 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.
Note: If you’re planning to be out of the country for more than 30 days, you can suspend your policy for the time you’re away up to a maximum of 2 years at any one time (see Policy Suspension for more information).
Pharmaceutical Benefits Scheme (PBS)
The PBS is the national pharmaceutical benefits scheme funded by the Federal 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 for non-PBS pharmacy items that are:
- prescription only and prescribed by a medical practitioner, including contraceptives for medical conditions, and
- 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 as a co-payment. Items available without a prescription including over the counter, off the shelf, herbal medicines and vitamins can't be claimed.
Policy in arrears (unfinancial)
Benefits aren't payable for services provided during the period in which a policy is in arrears 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.
ahm fund rules require members to be at least one premium payment in advance.
Note: If a member is more than two months in arrears then the policy will be terminated by notice in writing from ahm to the principal member, effective from the last financial date of the policy.
Policy suspension
At ahm, we recognise that we all need to get away sometimes, so if you’re travelling overseas for more than 30 days, you can suspend your policy (to a maximum of 2 years at any one time) 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 before your holiday with a copy of your official itinerary or e-ticket which includes the dates of travel. We’ll get back to you before you leave to confirm the suspended period. We’ll contact you on your return to confirm reinstatement of your policy and reactivating your premiums.
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 policy may result in you being charged the Medicare Levy Surcharge. We suggest you speak to your accountant, tax agent or the Australian Taxation Office for further advice.
Policy termination
Only the principal member 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 member 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 can't terminate the policy.
Cooling off period - If the principal member 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
At ahm, we’re required to ensure that our members receive quality services from recognised providers.
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 recognised by 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 online provider search tool .
Standard Information Statements
A Standard Information Statement (SIS) is a general guide to key benefits and product features of your policy. We send you a copy of your SIS at least once every 12 months when we advise you of changes to your policy and premiums and also whenever there is a detrimental change to a benefit that is listed on the document. You should review the SIS in conjunction with your cover’s policy document to provide a full overview of the benefits available to you.
If you’d like a copy of your SIS, you can call us on 134 246 or download a copy from www.privatehealth.gov.au.
Transferring from another private health insurer
If you’ve transferred from another private health insurer, we’ll recognise the waiting periods you’ve already served for comparable benefits. The good news is that ahm doesn’t have 2 or 6 month waiting periods on any of their extras products, so even if you were still serving 2 and 6 month waiting periods at your previous insurer, with ahm you’ll be able to start claiming straight away.
In accepting a transfer from another private health insurer, we reserve the right to treat any benefits paid by the previous insurer in the current financial year 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 dependent 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 an invoice for your accommodation including the date, plus 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
Note: Benefits for travel and accommodation are only available with Super Extras and Family Extras policies.
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.