About Health Insurance
What is hospital cover?
Hospital cover will insure you towards some of the costs of treatment received in private or public hospitals. Hospital costs span a range of services including doctors' charges, hospital accommodation, operating fees, operating theatre fees and intensive care.
Why should I take out hospital cover?
With hospital cover you get:
- the opportunity to choose your own doctor and specialist
- more choice over the hospital you stay in
Hospital cover will help with:
- avoiding or reduce hospital waiting times on some procedures
- help cover for medical fees not covered by Medicare
- assistance with fees above the Medicare Benefits Schedule (MBS) through GapCover
- avoiding the Medicare Levy Surcharge (MLS) if you're a high income earner
- avoiding the Federal Government's Lifetime Health Cover loading by taking out an ahm Hospital cover before you turn 31
What is extras cover?
Extras cover, often called ancillary cover or general treatment, will insure you against some of the costs of health and medical services that help you lead a healthier lifestyle.
Why should I take out Extras cover?
When you take out Extras cover you will receive benefits towards services not covered by Medicare, such as dental visits, glasses and physiotherapy. Depending on the cover you take out, you may also get benefits towards a range of alternative and complementary therapies, such as acupuncture and remedial massage.
What is combined cover?
Many health insurers offer packaged covers that provide cover for both hospital and extras. Some insurers have pre-packaged cover, while others allow you to mix and match hospital and extras options. For example, you may be able to select a Basic Hospital cover and a comprehensive Extras cover to create your own combined package.
What's the Rebate on Private Health Insurance?
The Australian Government Rebate on private health insurance (AGR) is an amount that the Australian Government may contribute to your health insurance premium (depending on your age and income) to help make it more affordable.
If you are eligible and nominate your rebate tier, we'll reduce the amount you pay for health insurance. Otherwise, if you don't nominate, you'll pay the full premium and your rebate entitlement will be worked out by the ATO when you lodge your income tax return.
What's the Medicare Levy Surcharge (MLS)?
The MLS is a levy that high income earners have to pay if they don't have an appropriate level of private hospital cover.
It's calculated based on 'income for Medicare Levy Surcharge purposes' which includes things like taxable income, exempt foreign employment income, reportable fringe benefits, reportable superannuation contributions and total net investment losses.
If you hold any of the ahm Hospital covers you'll be exempt from paying the MLS.
Visit privatehealth.gov.au for more information on the Medicare Levy Surcharge.
What's the Lifetime Health Cover loading (LHC)?
LHC is an Australian Government initiative designed to encourage people to take out and maintain private hospital cover earlier in life.
If you don't have hospital cover by 1 July following your 31st birthday, you'll pay a 2% loading on your share of the hospital component of the premium for each year you've been without hospital cover. The maximum loading cannot exceed 70%.
The loading may also be applied to your hospital cover if you stop your hospital cover after your 31st birthday for any period of time if those days aren't considered 'permitted days without hospital cover'.
The good news is once you have paid the Lifetime Health Cover loading continuously for 10 years, the loading is removed but you'll need to you retain your hospital cover.
The Australian Government Rebate on private health insurance is not applied to the Lifetime Health Cover (LHC) loading component of your hospital cover premium (if applicable).
Making sure you're covered
What's a Waiting Period?
It's the set amount of time you must wait before being able to claim for benefits on your cover.
Waiting Periods apply when:
- You first join
- You re-join after some time without health insurance
- You change to a higher level of cover or one that has additional services or higher benefits on services where a Waiting Period applies
If you switch to us from another private health insurer, we'll generally recognise any Waiting Periods you've already served for comparable benefits.
Check your Quick Guide to see what Waiting Periods you must serve.
Why do health insurers impose Waiting Periods?
Without Waiting Periods, some people may be more likely to take out health insurance to cover a specific costly treatment – then drop the insurance after the treatment.
If too many people did this, health insurers would have to increase premiums significantly to cover the cost of claims.
What's a partner hospital or day surgery?
If you're treated as a private patient, we have agreements in place with the majority of private hospitals and day surgeries throughout Australia.
These agreements detail agreed theatre and accommodation charges for services included under your cover. This doesn't apply to Restricted or Excluded Services.
If you receive treatment for a Restricted Service in a partner hospital, we'll only pay Limited Benefits and you'll be significantly out-of-pocket. If you receive treatment for an Excluded Service, no Benefits will be paid.
Find an ahm partner hospital or day surgery.
What am I covered for?
You can view what you're covered for in your Quick Guides.
What's not covered
This depends on your ahm cover and whether you're insured for Hospital and/or Extras.
You can check your Quick Guide for more details.
Remember, if you need to go to hospital, it's a good idea to contact us anyway. That way you'll know what you're covered for and how to minimise any out-of-pocket expenses.
If you're still unsure about what is covered, contact us.
How do I change my level of cover?
Changing your cover is easy.
Please note: if you change to a higher level of cover you may have to serve Waiting Periods before you can claim for some services.
There is a 12 month Waiting Period for pre-existing ailments, illnesses or conditions.
Check out your Member Guide for more information.
How do I switch health insurers?
When you join ahm online or over the phone, just tell us that you're switching and we'll contact your current health insurer and take care of the rest for you. That's it.
I had symptoms before I got health insurance. Am I covered?
You may have what's called a pre-existing condition.
This is an ailment, illness or condition where you had the signs or symptoms (in the opinion of one of our Medical Practitioners) 6 months before you joined private health insurance or changed your cover.
It's determined by an ahm approved Medical Practitioner (not your own).
If you have a pre-existing condition, and you're taking out private hospital cover for the first time or changing to a cover that has additional services or higher benefits, you'll have to wait 12 months before you can claim on your hospital cover.
For more information check your Member Guide or contact us.
What's a pre-existing condition?
A pre-existing condition is any kind of ailment, illness or condition where you had the signs or symptoms (in the opinion of one of our Medical Practitioner) 6 months before you joined private health insurance or changed your cover.
Our appointed Medical Practitioner is the only person authorised to decide if an ailment, illness or condition is pre-existing. They must consider any information that was provided by the medical practitioner who treated the ailment, illness or condition.
Check your Member Guide for more information on pre-existing conditions.
What are Fund Rules?
The Fund Rules are a set of rules that govern our fund.
When you join ahm you agree to our Fund Rules.
These are subject to change from time to time with the agreement of the Minister for Health & Ageing. If any changes adversely affect your cover, we will let you know in writing.
Download a copy of our Fund Rules.
How do I make a complaint?
If you want to make a complaint, please contact us straight away.
Where possible we'll aim to resolve your issue on-the-spot.
If we can't fix your problem then and there, we'll refer the issue to our Customer Advocacy Team. They'll conduct a detailed investigation and do their best to find a solution.
If you're unhappy with the result, you can contact the Private Health Insurance Ombudsman (PHIO) for free independent advice via mail:
Suite 2, Level 22
580 George Street,
Sydney NSW 2000
How do I cancel my cover?
Only the Principal Member, or their authorised third party, has the right to cancel a whole membership.
Cancellation can be requested in one of the following ways:
- contact us (as long as you agree to the call being recorded)
- mail us a signed letter to: ahm Health Insurance, Locked Bag 1006, Matraville NSW 2036
- or email a signed, scanned letter to email@example.com.
We'll cancel your membership from the date that we receive your notice and forward you a refund of any excess premiums.
Cooling off period: If you cancel your cover within 30 days of joining and haven't claimed a benefit during this period, you're entitled to a full refund.
Going to hospital
I'm going to hospital. What am I covered for and what do I do now?
Where will I be covered?
You can choose where you're treated and whether you're treated in a private hospital or as a private patient in a public hospital, in conjunction with your doctor or specialist.
Partner private hospitals and day surgeries
To help you know your costs and benefits up front, we've contracted with most private hospitals which include an agreement on how much they can charge.
Non agreement hospitals and day surgeries
In some instances, we haven't reached an agreement with a private hospital or day surgery. These are referred to as non agreement hospitals.
If you receive treatment for a service that's included or Restricted on your cover at a non agreement hospital we'll only pay a limited benefit and you'll be significantly out-of-pocket. If you receive treatment for an Excluded Service no Benefits will be paid.
We recommend you call us before being treated to clarify your benefit entitlements.
The hospital and doctors treating you should tell you about their costs before you go to hospital, so it's important to ask.
If you're treated as a private patient in a public hospital for included services, you'll be covered for same day admissions and overnight accommodation in a shared room.
If you choose a private room in a public hospital, you may have an Out-of-pocket Expense to pay yourself.
This depends on your cover and what you're going to hospital for.
You can refer to your Quick Guide to see at a glance what you're covered for.
We can help out by confirming:
- Whether any Waiting Periods still apply
- If you're covered for the procedure
- If your condition could be considered Pre-existing
- If you need to pay an Excess or Co-payment
- If the hospital you will be treated at is an ahm partner hospital
Contact us so we can help to answer this question.
What's a co-payment and how does it work?
At ahm, a Co-payment is the daily amount you agree to pay towards the cost of treatment if you go to hospital or day surgery.
It applies to each person on the cover and is capped each membership year.
There are 3 levels of Co-payment, the amount depends on your level of cover:
- $0 Co-payment
- $500 Co-payment - $250 per night up to a maximum of $500 per person and $1000 per family
- $800 Co-payment - $400 per night up to a maximum of $800 per person and $1600 per family
Check your cover details in your Quick Guide for more information, or contact us.
Have I already paid my co-payment this year?
This depends on whether you've been to hospital recently, and how long you stayed.
Your Co-payment resets at the beginning of each membership year – that is the date of the anniversary that you commenced or changed your health insurance cover with ahm.
Contact us if you need to go to hospital. We'll confirm if you need to pay a Co-payment when you're admitted.
What's an excess and how does it work?
On an ahm Hospital cover - this is an upfront lump sum payment that you agree to pay towards your hospital stay or day surgery admission.
This applies to each person on your cover and there is a maximum amount for each person per membership year.
The maximum you'll need to pay each membership year depends on your cover, as detailed below:
- Lite Cover & First Step $500 per person or $1,000 per couple
- Lite Cover Plus, Standard Cover & Mid Cover $500 per person or $1,000 per family
- Budget Hospital $500 per person or $1,000 per family
Please note: If the charge for your first admission is less than the excess amount, any remaining excess must be paid if you're admitted again in the same membership year.
Check your cover details in your Quick Guide for more information, or contact us.
What's a restricted service?
If a service is restricted, or partially covered, it means that we'll only pay a Limited Benefit towards your treatment. The benefit won't cover the full cost of your treatment, so if you're treated at a private hospital or as a private patient in a public hospital you may be left with significant out-of-pocket expenses.
For more information on the types of benefit we pay for Restricted Services, refer to your Member Guide. Always check with us if your procedure is included on your cover before agreeing to treatment.
What are excluded services?
If a service is excluded on your cover it means that we won't pay a benefit towards it and you'll be significantly out-of-pocket.
For these services, you won't receive anything from us towards the costs of treatment so you will have to pay all costs yourself.
Check your Quick Guide for a list of services which are excluded.
Get knowledgeable about medical gaps
What is the 'medical gap'?
Medical gaps exist because some doctors may charge higher fees than set out in the Medicare Benefits Schedule (MBS).
Whilst you are in hospital, Medicare pays 75% of the MBS fee and we pay the remaining 25%. Anything higher than the MBS fee is known as the medical gap, which you will need to pay.
What is GapCover?
GapCover can help reduce or remove the medical gap.
If your doctor chooses to participate in GapCover, we'll provide benefits up to an agreed fee and then you'll have to pay the difference. Under GapCover, the maximum gap that you'll have to pay is $500 per claiming provider (i.e. doctor's account). Use our Find a Doctor search to find doctors who've previously registered to participate in GapCover.
You should always check with your doctor before agreeing to treatment.
Is my doctor registered for GapCover?
Doctors can opt in or out of GapCover as they wish.
Use our Find a Doctor search to see which doctors have previously participated in GapCover.
It is best to ask whether they agree to participate in GapCover for your treatment.
If they haven't agreed to GapCover before, they may do so for your treatment.
How do I calculate my out-of-pocket costs for an operation?
This depends on your doctor's fees.
Here are a couple of steps to help you work this out:
Step 1 Ask if they charge above the Medicare Benefits Schedule (MBS)
Yes they do - if they do charge above the MBS fee, ask them if they will participate in GapCover. If they do, the most you'll pay is $500
If they don't participate in GapCover, then you'll have to pay the difference between the MBS fee and the doctor's bill for any services whilst you're in hospital.
Step 2 Ask them to give you an estimate of all the medical fees – including anaesthetist, assistant surgeon and any other costs to allow you to provide Informed Financial Consent
You can always contact us to get a clearer picture of your out-of-pocket costs.
What should I ask my doctor before going to hospital?
It pays to be prepared before you go into hospital.
Here are some good questions to ask:
- Where you'll be treated? (If it's not a partner hospital we'll only pay a Limited Benefit and you'll be significantly out-of-pocket)
- How long you will I be in hospital?
- Who will be treating you and will they participate in GapCover (to keep your costs to a minimum)?
- What other costs are involved?
- Will there be any other specialists involved, e.g assistant surgeon or anaesthetist, and will they participate in GapCover?
- Will you need any prostheses?
- What are the total costs involved? Your specialist should provide you with an estimate of medicals fees prior to your treatment so that you're fully aware of what you'll have to pay. This will enable you to provide Informed Financial Consent
Ask your doctor for this information if it hasn't already been provided.
Extras claiming at a glance
How does on-the-spot claiming work?
Simply swipe your ahm member card at your health care provider and the claim benefit will be processed electronically on-the-spot. You'll only need to pay the difference between the total amount charged by your provider and the benefit we pay.
How do I make a claim?
You can make your claim in three ways:
- Claim on-the-spot at your health care provider, just swipe your ahm member card and your benefit will be processed on-the-spot. You'll only need to pay the difference between the total amount charged by your provider and the benefit we pay.
- You can claim through member services, you'll have to be registered though.
- Or download a Claim form and post it to: ahm Health Insurance, Locked Bag 1006, Matraville NSW 2036.
Please note: services with a date greater than two years old aren't claimable.
What pharmacy benefits can I claim?
We'll pay benefits for non-PBS (Pharmaceutical Benefits Scheme) pharmacy items that are:
- Prescription only and prescribed by a medical practitioner, including contraceptives for medical conditions
- Essential to treat a particular illness injury or condition
For more information, check your Quick Guide.
What's my limit on a particular service?
To find out more about your benefit limits, call us on 134 246.
When do my limits renew?
A limit is the total amount you can claim towards extras included in your cover in a specific period of time.
Most limits are renewed at the start of the financial year (1 July).
Some services covered by Family Extras and Super Extras, such as pre and post natal services, are based on a rolling year. This starts on the date the service is first provided, with the limit renewed 12 months later.
For more information on your limits, refer to your Quick Guide.
What are Health Improvement Benefits?
Health Improvement Benefits are benefits paid for services which may improve your health such as exercise classes, swimming lessons etc.
In Australia, Private Health Insurers can only pay benefits for most Health Improvement Benefits to assist with the management and treatment of already identified health conditions.
This means that in order to claim for Health Improvement Benefits, such as exercise classes, swimming lessons etc., you'll need to provide us with some supporting documentation from your medical or other practitioner.
To enable you to make a claim we will send you a Health Improvement Benefit Approval form, which you can take to your medical practitioner to discuss and complete.
Please note: Health Improvement Benefits aren't available on all ahm Extras covers.
Please check your Quick Guide to see what's included on your cover.
For more information on Health Improvement Benefits contact us.
Can I claim exercise classes? If so, how?
You can claim towards exercises classes provided by a Fitness Australia® accredited gym or personal trainer. You can also claim towards yoga, Pilates and exercise classes with an ahm recognised provider.
Here's what you need to do to make a claim:
Step 1 - See your GP or health practitioner every 12 months
Together with your doctor or health practitioner, you need to complete our Health Improvement Benefit Approval form.
Make sure the date on your Health Improvement Benefit Approval form, or letter from your GP or health practitioner is before your first class or session.
Otherwise, your doctor or health practitioner can provide a letter explaining your condition and how the exercise classes will manage it.
You will need to provide us with a new form or letter every 12 months.
Step 2 - Choose a recognised provider
You need to go to a gym or personal trainer that's a member of Fitness Australia, or a recognised Exercise Physiologist.
Step 3 – Send your Claim form
When you're ready to claim, simply complete a standard ahm Claim form and attach a receipt for exercise classes.
Mail your Claim form, receipt and completed Health Improvement Benefit Approval form to: ahm Health Insurance, Locked Bag 1006, Matraville NSW 2036. Or email us the claim form.
Please note: To find out if you're eligible for Health Management Services, please check out your Quick Guide
For more information contact us.
How can I find a recognised gym, yoga or Pilates instructor?
What extras am I covered for?
This depends on your level of cover.
Check out your Quick Guide to see what you're covered for.
If you're still unsure about what you're covered for, email or contact us.
How do I make a routine dental claim?
The easiest way to claim is by presenting your member card at the dentist and your claim is processed on-the-spot.
If your dentist doesn't have on-the-spot claiming, or you forget your member card, you can claim online:
Step 1 Enter your details and your provider details. You can claim for most general dental services including Dentists, Endodontists, Oral Surgeons and Peridontists.
Step 2 Select the correct service and item number and enter the amount paid. Remember, you need to enter each item separately with the right charges.
When you have finished your claim you'll be shown a summary of all your services. That's it.
Please note: High cost dental services including orthodontics can't be claimed online, they need to be emailed or mailed to us. You can mail your claim to: ahm Health Insurance, Locked Bag 1006, Matraville NSW 2036
If you're having problems with dental claims or any other health insurance claim, make sure you contact us.
My child needs braces. What do I do now?
Make sure you have the right Extras cover and have served all Waiting Periods.
So we can work out how much to reimburse you, we need some information from your orthodontist. Please see your orthodontist for a treatment plan, then send through the treatment plan, outlining:
- The type of banding or appliance
- The length of treatment
- Total cost of the treatment
- How your payment is required (upfront or instalments)
Make sure you send us the treatment plan before the treatment starts. You can send to: ahm Health Insurance, Locked Bag 1006, Matraville NSW 2036.
Then you'll need to send us any accounts and/or receipts on a Claim form. Claims will be paid according to the payment date.
Please note: Orthodontics cannot be claimed online.
Don't forget you need to keep the appropriate level of Extras cover for the duration of the treatment.
Still need more answers? Please contact us.