EXPLAINING YOUR CLAIM LIMITS

YEARLY LIMIT

This is the maximum amount you can claim for a service in a calendar year, from 1 January to 31 December.

If you don’t claim your full limit for the year it does not roll over to the next year – it will reset 1 January. If you claim your full limit in a calendar year, no further benefits will be payable until 1 January the next year.

SUB LIMIT

This is a limit within a limit. It applies to a specific service, per person, per calendar year.

For example if you have Dental Cover, there is a yearly limit for all dental treatment. A sub limit applies to orthodontic of $600 per person, so once you reach that limit you can no longer claim orthodontic for that year. However, you could claim a further $400 in claims for other dental services.

PERSON LIMIT

This is the maximum limit each person on a membership can claim in a calendar year.

If you are on a policy that includes more than one person, each of you have your own individual limit.

MEMBERSHIP LIMIT

This is the maximum amount that can be claimed collectively, by everyone covered by a membership within a calendar year, for a specific service.

Remember that these limits apply in addition to your individual per person limits. This limit may not be high enough for all of the family members to claim their full individual limits. For example, you may have a person limit of $540 with a membership limit of $1080. If there are more than 2 persons on your membership, they may not all be able to claim their full person limit.

LIFETIME LIMIT

A lifetime limit applies to orthodontic treatment and applies to an individual.

Once this limit has been reached, no further benefits will be payable by MHF. This limit does not reset, even if you leave us and start your cover again at a later date.

SERVICE LIMIT

Limitations apply to some types of extras services, in particular dental services.

For example, you can only claim a periodic consultation with your dentist every six months. These limits apply from the date you receive the treatment not from the date you submit the claim.

EXTRAS COVER WHAT YOU NEED TO KNOW

OPTICAL BENEFIT

Covers your prescription glasses and contact lenses that have been prescribed by a registered optometrist.

Non-prescription sunglasses are specifically excluded. Your claim for benefits will be processed as at the date you collect or receive your glasses or contact lenses, not the date that they are ordered. Glasses and contact lens maximums apply per calendar year. See page 18-19 for further information.

AMBULANCE SUBSCRIPTION

Ambulance subscription benefits are payable on the subscription paid to an Ambulance service provider only.

Subscription costs and conditions vary from state to state. See page 32 for ambulance provider information - ‘Ambulance Cover Explained.’

FOOT ORTHOTICS

Foot Orthotics must be prepared for the member by a registered podiatrist or a registered orthotist.

Pursuant to a referral from a registered podiatrist or doctor in the course of private practice. Benefits are not payable on pre-fabricated orthotics.

GROUP THERAPY

Group Therapy benefits are only payable when treatment is provided by a registered Physiotherapist, Exercise Physiologist or Clinical Psychologist.

Group treatment is defined as when a patient does not have the provider’s exclusive attention for the entire therapy session (e.g. more than one patient).

PHARMACY

Our Five Star Extras (E1) cover includes a benefit on Pharmacy. Benefits are only payable for Schedule 4 (S4) and Schedule 8 (S8) non-Pharmaceutical Benefit Schedule (PBS) items prescribed by your doctor.

A benefit will be payable for each eligible pharmacy item after the non-concessional patient contribution PBS amount has been deducted from the charge.

The PBS amount is determined by the Department of Health and is updated on 1 January each year.

ITEMS INCLUDED:

• Contraceptives prescribed for a medical condition
• Travel vaccinations

EXCLUDED ITEMS:

• Medication that is subsidised by the PBS.
• Over the counter, non-prescription pharmacy items.
• Non-TGA approved item.
• Herbal medicines and vitamins.
• Body enhancing medication (e.g., anabolic steroids).
• Experimental drugs.

TO MAKE A CLAIM YOU WILL NEED AN OFFICIAL PHARMACY RECEIPT THAT INCLUDES THE FOLLOWING:

• Name of the drug prescribed
• Date of supply
• Strength
• Quantity
• Confirmation that the medication is subsidised by the PBS
• Pharmacist's name, address and prescription number
• Patient's name and Address

Benefits are not payable for the following

• Extras treatment or services covered by Medicare.
• Treatment or services received within your waiting periods.
• Treatment received at a hospital emergency department.
• Care and accommodation in an aged care facility.
• Treatment or services that are not medically necessary nor clinically relevant.
• Treatment or services received from a provider who is not recognised with Mildura Health Fund i.e. not registered with the Department of Health or the Australian Regional Health Group.
• Treatment or services covered by Work Cover, damages legislation or any type of insurance. (i.e. third party or sports club insurance)
• Treatment, goods or services received or sourced outside of Australia.
• Treatment that has been provided by a family member, relative, business partner, or yourself.
• Treatment or services that has been paid for but not received yet.
• Services that you haven’t been charged for Surcharges, delivery costs and credit card processing fees.
• Services provided for sport, recreation or entertainment.
• Non-Prescription glasses, sunglasses or contact lenses.
• Hire of Health Aids and Appliances with the exception of crutches.
• Purchase of replacement parts or components in relation to Health Aids and Appliances i.e. CPAP mask replacement.
• Purchase of second-hand, pre-owned goods or equipment.
• Health Aids must have 100% manufacture warranty from new purchase date.
• Cosmetic treatment or services.