Access Gap Cover

What is Access Gap Cover?

Access Gap Cover (AGC) is a billing scheme that aims to reduce or eliminate out-of-pocket expenses to members for doctor and specialist services received in hospital. Doctors may choose to participate in AGC on a patient-by-patient basis, so you should discuss this with your doctor.
Why won't my doctor or specialist participate in Access Gap Cover?

It is up to your doctor or specialist to decide whether to charge you under the Access Gap Cover (AGC) scheme. Even if the doctor has participated in this scheme before it does not automatically guarantee that the doctor has participated in AGC for your treatment. Doctors and specialists are free to choose whether they will participate on a patient-by-patient basis. This decision remains solely with the doctor or specialist.

Benefits / Claiming

Benefit limits are per calendar year. What does this mean?

A calendar year is from 1 January to 31 December. Overall benefit limits are available between this yearly period. Once a benefit limit is reached over the course of a calendar year it will not be refreshed until 1 January of the following calendar year.
How many Extras services can I receive benefits for in one day?

Benefits are limited to one service per patient, per provider, per day.

If a provider performs more than one consultation, the treatment that attracts the higher benefit will be paid.

Where multiple visits/services are performed on the same day at different times by the same provider, then the visit/service that attracts the higher benefit will be paid.
Am I covered for medical procedures in my doctors’ room rather than a hospital?

If you receive services in your doctors' room rather than a day surgery or hospital you are only entitled to benefits from Medicare. We will not pay a benefit for services outside of a hospital for non admitted patients.

Medicare will pay 85% of the Medicare Benefits Schedule (MBS) fee, and you will be required to pay the remainder of the account.
Can I claim benefits back for doctor/specialist appointments?

Your private Hospital cover takes effect when you are admitted to hospital. Any out-of-hospital medical expenses incurred (scans, blood tests, appointments) will not be covered by your private health insurance. They may be covered to some extent by Medicare.
How can I claim for Healthy Lifestyle benefits such as gym membership?

To be eligible to claim for Healthy Lifestyle benefits the program or service must be approved by Nurses & Midwives Health and received as part of a health management program intended to prevent or help a specific health condition. To comply with legislation, we require your health professional (e.g. GP, medical specialist or allied health provider) to sign the Healthy Lifestyle supporting documentation form.

Benefits are not payable for meal replacement products or prepared food.
The benefit limit says 75%, how does this work?

Healthy Lifestyle offers a benefit of 75%. This means that you will receive a benefit of 75% of the cost up to the maximum limit available on your level of Extras cover. For example, if you have Top Extras cover and purchase a 10 pack of Pilates classes you are entitled to 75% of the cost of the Pilates classes up to $200 per person. Essential Extras has an overall limit of $150 per person and StarterPak has an overall limit of $150 per person and $300 per family.




Eg:CostBenefit available for Top Extras coverBenefit received
10 pack Pilates class$25075% up to $200 per person$187.50
What pharmaceuticals am I covered for?

Benefits are payable for drugs prescribed by a doctor that are not covered by the Pharmaceutical Benefits Scheme (PBS) but are approved by the Therapeutic Goods Administration (TGA). You can claim a benefit for the difference between the actual cost of the item and the PBS co-payment amount up to a maximum amount of $60.
What out-of-pocket expenses can I expect for Extras services?

The out-of-pocket expense will be the difference between what the provider charges and the benefit we pay. For example if you see a physiotherapist (second visit) and are charged $70 for a standard consultation you will receive a $40 benefit from Nurses & Midwives Health. This will leave you with a $30 out-of-pocket charge.
What is an increasing limit and how does it work?

Increasing limits are calculated based on years of continuous membership of Nurses & Midwives Health Top Extras cover. This means that the longer you hold Top Extras cover with us the higher the overall benefit will be for major dental and hearing aids. Loyalty limits accrued at other health funds are not transferable.

Increasing limits also apply to orthodontia. Loyalty limits accrued for orthodontia at other health funds can be transferred to your Nurses & Midwives Health membership when you change funds, this is only applicable to new memberships effective from 1 January 2012 and where evidence of continuous unbroken cover is provided by the member.
My child has been admitted to a public hospital and I am required to stay with him/her in the hospital overnight. Is a benefit payable?

If you have Top Extras cover, a benefit of $30 a day up to a maximum of $200 per person per calendar year is payable.
I need to travel more than 200km (return trip) to receive treatment for a serious medical condition. Is a benefit payable?

If you have Top Extras cover, a benefit of 15 cents per kilometre up to a maximum of $400 per person per calendar year is payable for a serious medical condition requiring treatment that is not available closer to your home and confirmed by a doctor or specialist. A benefit is not payable for ambulance transportation or where the distance is less than 200km return from your home.
Where fund benefits are not payable.

There are certain circumstances that will prevent the payment of a claim including:

  • lodgement of claim two years or more after the date of service

  • when you or someone on your membership has the right to recover costs for a third party or authority, either by law or by statute, or from any insurance or employment benefits scheme

  • when no charge has been raised (services received is free of charge)

  • for any period during which your membership is unfinancial or suspended

  • waiting periods have not been served

  • provider is not recognised by Nurses & Midwives Health at the time the service is received

  • the official receipt is not provided

  • a member has been treated by a provider related to them

  • for services not provided face-to-face (with the exception of telepsychology services provided by a registered psychologist)

  • for hospital and general treatment received, or goods purchased overseas.
What constitutes an official receipt?

A receipt must be on official letterhead or stamped with a provider stamp containing the:

  • name of the practitioner providing the service

  • address where the service was provided

  • contact number for the provider

  • provider number (where available or practical) and/or registration number of provider with professional associations

If an account or receipt is produced electronically it should be signed at the time of issue either by the provider or their representative.

The receipt should be itemised with the following details:

  • the name of the patient receiving the service

  • the date of each individual service provided

  • the type of each individual service provided

  • the cost of each individual service provided

  • a body part identifier, prescription/script number or tooth identification where required
    whether the account has been paid or not

Handwritten provider details and alterations to accounts will not be accepted.

    Excess

    What is an excess?

    An excess is an amount you pay each calendar year when admitted to hospital. Choosing a product with an excess reduces your premium and is only payable if you are admitted to hospital.

    The excess you pay will depend on the level of your cover and excess you choose.
    When do I pay the excess?

    If you have Top Hospital 300/500, Mid Hospital 300/500 or Basic Hospital 300 you will be required to pay an excess towards your hospital admission. This excess is paid directly to the hospital. Be sure to ask the hospital how and when they would like to receive this payment.
    HOSPITAL COVER EXCESS
    Top Hospital 300 $300 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for Family, Couple or Single Parent memberships. Excess is waived for dependants under the age of 21. Only payable when admitted to a private hospital or day surgery.
    Top Hospital 500 $500 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for Family, Couple or Single Parent memberships. Excess is waived for dependants under the age of 21. Only payable when admitted to a private hospital or day surgery.
    Mid Hospital 300 $300 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for Family, Couple or Single Parent memberships. Excess is waived for dependants under the age of 21. Payable when admitted to a private or public hospital or day surgery.
    Mid Hospital 500 $500 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for Family, Couple or Single Parent memberships. Excess is waived for dependants under the age of 21. Payable when admitted to a private or public hospital or day surgery.
    Basic Hospital 300 $300 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for Family, Couple or Single Parent memberships. Payable when admitted to a private or public hospital or day surgery.

    Fraud prevention

    As a not-for-profit organisation, Nurses & Midwives Health exists for our members and we work hard to improve efficiencies, reduce operating costs and keep contribution rates as low as financially sustainable.

    An area that is increasingly impacting on our operating expense is false claims, or more accurately – fraud. Each year we find that the volume of fraudulent claims increase despite our monitoring and audit processes.

    Private Healthcare Australia estimates that millions of dollars are lost every year in private healthcare through fraud and inappropriate claiming. Every dollar of this ultimately affects the contribution rates of those holding private health insurance, with fraud causing resources to be diverted away from the payment of necessary services and legitimate claims.
    What is fraud?

    Fraud can occur through a healthcare provider or health fund member providing misleading or false information or withholding information. Examples include:

    - charging for treatment(s) that have not been provided
    - creating false documents
    - altering accounts to increase financial benefits.
    What is Nurses & Midwives Health doing to detect and prevent fraud?

    At Nurses & Midwives Health we have a dedicated investigations team that engages in a variety of activities designed to either prevent such losses, or detect and recover these losses on behalf of our members.
    What can you do?

    To help ensure that your membership is protected from fraud or misuse and help us keep premiums as low as possible, don’t forget to:

    - report any stolen or lost membership cards within 24 hours
    - never leave your membership card with service providers
    - check your limits online
    - keep your online member services password safe and change it regularly
    - always check your receipts including signing for services claimed electronically

    Nurses & Midwives Health and the investigations team will always treat any concerns raised with the utmost confidentiality and protect your identity or respect your right to remain anonymous.

    Members can assist us reduce fraud by reporting any suspicious activity to:
    Email: investigations@nmhealth.com.au

    Going to hospital

    What may I have to pay for during my hospital stay?

    There are some services that you may receive in hospital that are not covered by us. These include:

    - telephone charges
    - TV hire, internet access or other items of a non-medical nature
    - pharmaceuticals that are not covered in the agreement with the hospital or that are listed under the Pharmaceuticals Benefits - Scheme (PBS).
    - x-rays, scans and other tests.
    Am I classified as an in-patient (admitted in a hospital) when having chemotherapy or dialysis on a daily basis?

    You will be covered for chemotherapy or dialysis received on a daily basis as long as the hospital you are receiving the treatment from has an agreement with Nurses & Midwives Health and admits you as a day patient.
    What happens if I get taken to hospital in an emergency?

    In an emergency situation, you will be taken by an ambulance to the nearest accident and emergency department of a public hospital. In this situation you have the right to choose to be treated as a public patient at NO charge, by a doctor appointed by the hospital. You are fully covered for the emergency ambulance transportation provided by a state government service (including state government air ambulance) under Nurses & Midwives Health Hospital and Extras cover.

    If you are taken to an accident and emergency department at a private hospital you will be charged for treatment as an out-patient and there will be no benefits available from Nurses & Midwives Health for medical charges raised by doctors or facility fees raised by the hospital’s accident and emergency department.

    Joining Nurses & Midwives Health

    How can I join?

    Joining Nurses & Midwives Health is fast, easy and hassle free. You can join:

    - online;
    - over the phone, by calling 1300 344 000;
    - or, by completing a printed application form.
    Am I eligible to join?

    As a restricted membership health fund, you must meet the eligibility criteria in order to join Nurses & Midwives Health. Eligible members include:

    Current/Former Nurse or Midwife
    Your eligibility to join Nurses & Midwives Health is based on your membership or associate membership of any of the following nursing/midwifery unions:

    · NSW Nurses and Midwives’ Association
    · Australian Nursing & Midwifery Federation (Victorian Branch)
    · Queensland Nurses’ Union
    · Australian Nursing and Midwifery Federation (SA Branch)
    · Australian Nursing Federation (WA Branch)
    · Australian Nursing Federation (ACT Branch)
    · Australian Nursing Federation (Tasmanian Branch)
    · Australian Nursing Federation (NT Branch)

    Former Nurses and Midwives
    If you were previously a nurse or midwife and during that time you were a member or an associate member of any of the above nursing/midwifery unions, you can also join.

    Family members:
    The family of existing Nurses & Midwives Health members are also eligible to join. Eligible family members include:

    - a partner or former partner, including same-sex and de facto partners
    - dependant and adult children, including their partner and children
    - siblings, including their partners and children
    - grandchildren
    - parents.
    Do you have a 'cooling off' period?

    Our cooling off period means that if you change your mind within 30 days from the date your health insurance policy started, we will cancel your membership and provide a full refund, providing no claims have been paid during this period.
    Transferring to Nurses & Midwives Health.

    If you are already with another fund and would like to switch to Nurses & Midwives Health you just need to join online or complete an application form ensuring you fill out the clearance certificate section. This gives us permission to organise the transfer for you and also understand your level of cover and waiting periods already served.
    What is a Standard Information Sheet (SIS)?

    A Standard Information Statement (SIS) gives a summary of the key product features. Health funds are required by law to provide these statements so you can review your existing policy or compare it to other products. It allows you to see if your broad needs are covered by a product by displaying benefit entitlements, restrictions, and eligibility requirements to join a fund, if any. If you would like a copy of an SIS for any of our products, they are available at privatehealth.gov.au. Further information about our policies and services, please contact Nurses & Midwives Health on 1300 344 000.

    Lifetime Health Cover

    What is Lifetime Health Cover and how can I avoid the loading?

    The Lifetime Health Cover initiative rewards those who take out Hospital cover earlier in life, allowing them to pay a lower contribution compared to others who take out Hospital cover when they're older. If you delay taking out Hospital cover, you will pay a 2% loading on top of the base contribution amount for every year you are over the age of 30 until you first take out Hospital cover.

    Medicare Levy Surcharge

    What is the Medicare levy surcharge?

    The Medicare levy surcharge is an additional 1 – 1.5% surcharge of taxable income imposed on higher income earners who are eligible for Medicare but do not have private Hospital cover. If the surcharge applies to you, your Medicare levy increases from 2.0%, that is paid by most Australian tax payers, to 3.0 – 3.5% of your taxable income.

    The Medicare levy surcharge is means tested based on income.
    How to avoid the Medicare levy surcharge?

    If you are single and earn more than $90,000 a year or a couple/family earning more than $180,000 per year, you can avoid paying the Medicare levy surcharge by taking out any of our Hospital or Combined cover products.
    Medicare levy surcharge Percentage
    Singles less than $90,000 0.0%
    Couples/families less than $180,000 0.0%
    Singles $90,001 - 105,000 1.0%
    Couples/families $180,001 - 210,000 1.0%
    Singles $105,001 – 140,000 1.25%
    Couples/families $210,001 – 280,000 1.25%
    Singles more than $140,001 1.5%
    Couples/families more than $280,001 1.5%

    Medicare Safety Net

    What is the Medicare Safety Net?

    The Medicare Safety Net is there to help you. It provides families and individuals with financial assistance towards high out-of-pocket expenses associated with medical services provided as an out-patient. Once you meet a Medicare Safety Net threshold, you may be eligible for additional Medicare benefits for out-of-hospital Medicare Benefits Schedule (MBS) services for the rest of the calendar year.

    Register for the Medicare Safety Net for free at medicareaustralia.gov.au. This allows Medicare to track your out-of-hospital, out-of-pocket expenses and advise you when you are nearing the threshold.

    Members Area

    What should I do if I have forgotten my password?

    Go to Online Member Services and then click on 'Forgotten password' from the right hand side. Enter the details required and your password will be emailed to you.
    What is Online Member Services?

    Online Member Services provides you with access to your health insurance policy details 24 hours a day, 7 days a week. It is a convenient way of tracking your health cover, obtaining information and making changes to your policy and those covered at a time when it suits you.
    How do I register for Online Member Services?

    Enter the Online Member Services area, select 'Register' on the right hand side, enter your details and submit.
    I want to receive my mail electronically - how do I change my mail preference?

    To change your mail preference to receive correspondence electronically, follow these simple steps:

    - log in to Online Member Services
    - select Contact details from the My Membership main menu
    - select Edit
    - scroll down to Contact preferences

    From the drop down menu select either of the following:

    - via Member Services area (with email notification)
    - via Member Services area (with SMS notification)
    - select Next to confirm the change
    - tick the declaration and select Submit to finish transaction.

    My membership

    Can my partner manage my membership also?

    Yes. If you would like your partner (who is on your membership) to have authority to operate your membership, ensure that you tick the box for partner authority on the membership application form when you are joining. Otherwise, you can let us know via email or post.
    I am going overseas for a holiday, what should I do?

    We strongly advise you to take out adequate travel insurance as Nurses & Midwives Health benefits do not cover the costs of Hospital treatment or Extras services outside of Australia. If you are travelling overseas for a period of more than two calendar months but less than 36 calendar months you may suspend your health cover while you are away.
    When can I suspend my policy?

    You can suspend your policy if you have been a financial member for a minimum of 12 months and are:

    - travelling overseas for more than 2 months but less than 36 months
    - experiencing financial hardship
    - taking leave without pay

    It is important to note that during a suspension period you will not be able to make any claims and if you develop a condition or illness during the suspension period, you may not be immediately covered. Please contact us to discuss. Downgrading your level of cover might be a better option for you.
    How can I upgrade or downgrade my cover?

    You can upgrade or downgrade your level of cover at any time. Upgrading your cover can done via our Online Member Services area or by calling or emailing us. When upgrading your cover, waiting periods will apply for services that were not previously covered. If you wish to downgrade your cover you will need to do this in writing. When downgrading your cover, it is important to understand what you may no longer be covered for.
    What does Emergency Ambulance transport cover?

    If you have Hospital or Extras cover, you will be covered for emergency ambulance transport. This covers you for the costs of transporting a seriously ill person to the nearest hospital by a state government ambulance service or by a private ambulance service recognised by Nurses & Midwives Health in order to receive urgently needed treatment. This includes transportation from the scene of an accident or the scene of a medical event such as a heart attack or stroke, but does not include transportation to hospital for the routine management of an ongoing medical condition or transportation between Hospitals.

    Emergency Ambulance cover can be taken out on its own if you do not have Hospital or Extras cover.









    ServicesEmergency Ambulance cover
    Transport from the scene to a hospital
    Treatment at the scene by a qualified ambulance officer
    Air ambulance services*
    Transfers from a medical facility to a hospital and vice versa
    Transport from the hospital to home
    Transport to a hospital for routine management of an ongoing illness
    Australia-wide coverage
    Waiting period1 day


    *Air ambulance services administered by state owned ambulance services are covered by Nurses & Midwives Health. Services administered by non-state based ambulance services, Royal Flying Doctors Service, Care Flight Helicopter and Private Air Ambulance will not attract a benefit. Queensland and Tasmanian residents are covered by state funded ambulance services.
    What is a Standard Information Sheet (SIS)?

    A Standard Information Statement (SIS) gives a summary of the key product features. Health funds are required by law to provide these statements so you can review your existing policy or compare it to other products. It allows you to see if your broad needs are covered by a product by displaying benefit entitlements, restrictions, and eligibility requirements to join a fund, if any. If you would like a copy of an SIS for any of our products, they are available at privatehealth.gov.au. Further information about our policies and services, please contact Nurses & Midwives Health on 1300 344 000.
    How can I make a payment?

    Here are three easy ways to make a payment if you need to:

    1. BPAY - contact your financial institution and quote our BPAY reference number (266155) and your BPAY member reference number. If you are unsure of your BPAY member reference number please contact us.
    2. phone - payments can be made using our secure pay-by-phone service by calling 1300 345 876 or (02) 8072 9282 if calling from a mobile phone or from overseas. Accepted credit cards are MasterCard and Visa.
    3. credit card - via our Online Member Services. You may pay your contribution through our secure online member services centre. Accepted credit cards are MasterCard and Visa.

    Planning a family

    What happens if I am considering getting pregnant but my Hospital cover excludes pregnancy?

    It is important you have Hospital cover that includes pregnancy benefits, such as Top Hospital, as a nine month waiting period applies for all services relating to pregnancy and childbirth. This means, you will need to have held Top Hospital well in advance of your pregnancy.

    Please read the Pregnancy Guide.
    When do I need to add my baby to my policy?

    When you are settled in and have a few moments to spare, give us a call on or log on to the Online Member Services to add your baby to your cover. You will need to advise us of the name, date of birth and sex of your baby. All waiting periods will be waived for your baby if you add him/her to your membership from the date he/she was born, within two months of the birth.

    Please note: If you are on a single membership, you will need to upgrade to a Family or Single Parent membership to add your baby to your cover.
    When is my baby an admitted patient?

    Babies born without complications are generally not admitted to hospital, but treated as an out patient. A newborn baby is classified as an inpatient when one of more of the following criteria are met:

    - the baby is admitted to an approved neo-natal intensive care facility
    - the baby is the second or subsequent born in a multiple birth situation (i.e. twins or triplets)
    - the baby is more than 10 days old and still in hospital.

    Private Health Insurance Rebate

    What is the Private Health Insurance Rebate?

    The Private Health Insurance Rebate reduces your contribution amount, making health insurance more affordable and accessible for you. The rebate is income tested against the income tier thresholds in the table below. Your rebate percentage entitlement will be reduced as your income tier rises.

    View the Private Health Insurance Rebate levels here.
    Who is eligible to claim the Private Health Insurance Rebate?

    The Private Health Insurance Rebate is available to everyone who is eligible for Medicare and has private health insurance and whose taxable income falls within tiers 2 and below.
    How can I claim the Private Health Insurance Rebate?

    You can claim the Private Health Insurance Rebate as:

    - as a reduction on your contribution amount
    - through your annual tax return

    More information about the Private Health Insurance Rebate.
    Do I need to tell Nurses & Midwives Health my income?

    Members will be encouraged but not required to nominate a tier with Nurses & Midwives Health.
    What happens if I select the wrong tier?

    There is no limit to the number of times you can change the tier nomination and no penalties are applied for not making a nomination or making an incorrect nomination.
    What happens if I over claim or under claim the rebate?

    Adjustments will be made through the tax system. Nurses & Midwives Health will not be informed or involved.
    Can Nurses & Midwives Health provide advice to me regarding which tier I should nominate?

    Nurses & Midwives Health is unable to provide financial advice to its members. We encourage you to discuss with your tax agent, financial planner or with the Australian Taxation Office.
    Where can I find more information?

    More information can be found on the Australian Taxation Office website.

    Online claiming

    Member app

    For easy and convenient claiming, Nurses & Midwives Health now offers a mobile claiming app for both Apple and Android devices. Simply take a photo of your receipt to submit your claim! Please note, that you will need to keep your original receipts for two years.

    For more information and to download the app, please click here.
    Is there a time limit on how long I have to lodge a claim?

    Nurses & Midwives Health accepts claims up to two years after the date of service.
    Can I add the delivery charge into the cost of service?

    No. There is no benefit payable for the delivery charge or postage and handling. You may be charged this when purchasing contact lenses online. This charge should not be added to the cost of the contact lenses.

    Orthodontia

    About orthodontia

    In Australia, the fee for orthodontic treatment involving upper and lower braces can vary from $4000 to more than $8000. This fee usually covers the entire treatment including the fitting of braces, adjustments at regular intervals, the removal of braces and the retention and observation periods that follow. This fee does not usually cover the initial consultation, records, photographs, removal of any teeth or other steps to prepare for the fitting of the braces (these fees also attract a benefit under Top Extras dental cover). Your orthodontist should discuss the treatment options and the fee with you before your treatment is commenced.

    At Nurses & Midwives Health, benefits are payable for orthodontic treatment if you hold Top Extras cover and have served the 24 month waiting period. We will pay 100% of the cost up to the level of your benefit entitlement. Your benefit entitlement will increase dependant on the number of years that you have held continuous Top Extras cover.

    Increasing limits:
    Year 3: $1500
    Year 4: $2000
    Year 5: $2500

    You also have a lifetime limit of $2500 for orthodontic treatment. Once you reach this lifetime limit you are unable to make any further claims for orthodontia.


    How to claim for your orthodontic treatment

    1. If you are considering orthodontic treatment, please contact Nurses & Midwives Health so we can discuss your benefit entitlements with you.

    2. Send us a copy of your treatment plan. We can use this to quote you an accurate benefit based on the payments you are required to make and the length of your treatment.

    3. Send us your receipts with a completed claim form after the treatment commences. Don’t forget to send your treatment plan if you haven’t already done so.

    Orthodontia cannot be claimed using your Nurses & Midwives Health membership card via HICAPS at your orthodontist. Orthodontia cannot be claimed using online claiming through Online Member Services.


    Important points to remember:

    - Orthodontic benefits are only payable for members on Top Extras cover.
    - No benefit will be paid for services received during the 24 month waiting period.
    - No benefit is payable before the treatment commences, even if you choose to pay for your orthodontic treatment in advance. The benefit can only be paid once the braces or aligners are in place.
    - If you pay for your orthodontia up front, you can continue to claim for orthodontia in the following years as long as you are still undergoing active orthodontic treatment (that is, your braces are still on). We will continue to pay your orthodontic benefits up to your annual limit and the lifetime limits that are applicable to your policy.
    - If you transfer from another health fund and have received orthodontic benefits during the last 5 years this will be deducted from your benefit entitlement with Nurses & Midwives Health. Orthodontic benefits paid in the previous 5 years of cover are recorded on your transfer or clearance certificate from the health fund you have left.

    Restricted and excluded services

    What is a restricted service?

    We pay Minimum Benefits for restricted services. This means that we will pay the minimum default benefit rate for a shared room as set out by the Commonwealth Minister for Health from time to time, and minimum benefits for Government approved Prosthesis List items.
    If you choose to be treated:
    • In a private hospital – the benefits we pay will not cover all hospital costs resulting in significant out-of-pocket expenses
    • In a public hospital as a private patient – you may have an out-of-pocket expense to pay, in the event that the minimum benefit is less than what your chosen public hospital charges
    Regardless of where you’re treated, the hospital should advise you before you are admitted or have treatment, and seek your consent about any out-of-pocket expenses you’ll need to pay. This is known as informed financial consent.


    Mid Hospital, Basic Hospital and StarterPak have restricted services.


    What is an excluded service?

    An excluded service is a service where no benefits are payable - regardless if it is performed in a public or private hospital. If a service is not covered by Medicare (e.g. elective cosmetic surgery) there will be no benefit payable from your Hospital cover.

    StarterPak has additional excluded services including:

    • Pregnancy & birth related services

    • Infertility investigations & treatments

    • Hip & knee replacements

    • Coronary care & cardiothoracic surgery

    • Dialysis procedures & treatments

    • Cataract & eye lens procedures


    If you go to a private or public hospital as a private patient for any of these services you will not be covered.

    Switching funds

    How do I switch to Nurses & Midwives Health?

    Switching to Nurses & Midwives Health is easy. You can notify your current fund yourself or we can do it for you. Simply complete the Clearance Certificate details when you join and we will take care of the transfer. This gives us permission to contact your previous fund to obtain your cover details.


    What is a Clearance Certificate?

    A Clearance Certificate is a certificate issued by a health fund when a member terminates a policy or wishes to transfer to another fund.

    It is a record of your private health insurance cover including details about:

    - type of cover
    - level of cover
    - join and cancellation dates
    - waiting periods served
    - certified age of entry (CAE)
    - a history of recent claims.


    Will I have to re-serve any waiting periods?

    If you are transferring to an equivalent level of cover with equivalent benefits, you will not have to re-serve your waiting periods with Nurses & Midwives Health. If your previous level of cover was lower than your Nurses & Midwives Health cover, waiting periods will apply to any services that were not covered by your previous fund. Waiting periods will also apply to services that are covered at a higher level.

    For example: You switch to Nurses & Midwives Health to Top Extras cover. Your previous level of cover did not include benefits for remedial massage. Top Extras provides benefits for remedial massage under complementary therapy and has a two month waiting period. In this instance you will be required to serve the two month waiting period before you can make any claims for complementary therapies.

    Tax statements

    When will I get my tax statement?

    Tax statements are mailed out to all members during the second week of July each year.


    Can I get my tax statement earlier?

    Tax statements must include details of all payments processed by Nurses & Midwives Health up to and including 30 June. This means that we cannot begin preparing the statements until after that date. A lot of work goes into preparing these tax statements and we endeavour to get them out to you as soon as we possibly can.

    All members can download a copy of their statement through Online Member Services and we will update our website as soon as they are available.

    Waiting periods

    What is a waiting period?

    A waiting period is a period of time you need to wait after taking out your cover before you can receive benefits for services or items covered. Benefits are not payable for services received over the course of a waiting period.
    Who does a waiting period apply to?

    Waiting periods apply to:

    - new members to private health insurance.
    - existing Nurses & Midwives Health members who upgrade to a higher level of cover or reduce their level of excess – in this case you will need to serve the relevant waiting period for the higher benefit entitlement.
    - members who transfer from another health fund who have not already completed the required waiting periods, or who are transferring to a higher level of cover.

    All health funds have waiting periods.
    How long is the waiting period?

    The length of a waiting period will depend on the type of service.

    Hospital waiting periods

    Pre-existing conditions 12 months
    Pregnancy & birth-related services 9 months
    Psychiatric, rehabilitation & palliative care 2 months
    All other hospital services 2 months
    Emergency Ambulance transport 1 day

    Extras waiting periods

    Orthodontia 24 months
    Wheelchair purchase 24 months
    Major dental 12 months
    Medical appliances 12 months
    Optical and Healthy Lifestyle 6 months
    All other services 2 months
    Emergency Ambulance transport 1 day

    Pre-existing conditions

    What is a pre-existing condition?

    A pre-existing condition is an illness, ailment or condition where the signs or symptoms existed at any time during the six months before taking out private health insurance or transferring to a higher level of cover.

    Nurses & Midwives Health will appoint a medical practitioner to determine whether you have a pre-existing ailment, based on information provided by your treating doctor or specialist.
    Who does the pre-existing condition rule apply to?

    This rule applies to:

    - new members
    - existing members who are upgrading their level of cover.

    A 12 month waiting period applies to all pre-existing conditions except psychiatric, palliative care and rehabilitation, which are covered by the two month waiting period.
    What if I have a pre-existing ailment?

    If you are a new member to private health insurance you will have to wait 12 months before you can receive benefits for items or services related to a pre-existing condition. This means that if you receive treatment for a pre-existing condition within the 12 month waiting period, you will not be eligible for benefits.

    If you change to a higher level of cover, you may have to wait 12 months to receive benefits, including benefits for services not previously covered.

    Wisdom teeth

    I need to have my wisdom teeth removed. Am I covered?

    If you are planning to have your wisdom teeth removed by your dentist in a private practice, Top Extras, Essential Extras and StarterPak will provide benefits.

    If you are admitted to a hospital for the removal of your wisdom teeth, your Hospital cover will cover the hospital costs such as accommodation, theatre and anaesthetist fees but Extras cover that offers major dental benefits will still provide benefits for the dentist to do the extraction.