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No benefits are payable by Navy Health for cosmetic surgery or where Medicare doesn’t pay a benefit.
Waiting periods for extras items are detailed on the website and in the health cover brochure and need to be read carefully in conjunction with the conditions of the selected cover.
Hospital benefits are payable after two months of membership on the selected level of cover, excluding pre-existing conditions.
Maternity (or admissions related to the management of) and IVF procedures attract a 12 month waiting period at the selected level of cover.
If you transfer to a higher level of cover new waiting periods will be applied, however benefits at the previous level will still be available whilst the new waiting periods are being served.
Transfers between or from products containing a lesser level or predetermined excess will result in additional waiting periods being applied. Any excess applicable to a higher excess product from which a member is transferring will continue to be applied for a period of up to 12 months after transfer. Dependants are required to complete waiting periods of the same length as members.
The pre-existing condition waiting period provides protection for existing members against people joining or upgrading cover only when they require treatment. This assists Navy Health in keeping premiums as low as possible. Claims and benefits within the first 12 months of joining the insurer or increasing to a higher level of cover are subject to the pre-existing condition rule.
A pre-existing condition is where signs or symptoms of an ailment, illness or condition, in the opinion of a medical practitioner appointed by Navy Health existed at any time during the six months preceding the day on which you joined the insurer or transferred to a higher benefit cover. This is irrespective of whether your medical practitioner, you and/or your dependants were aware of the condition or ailment.
The pre-existing condition rule also applies when resuming a suspended membership and symptoms or signs developed during the suspension period.
* Excludes Psychiatric, Rehabilitation & Palliative care.
There are no qualifying periods if you are accepted for membership after transferring a current membership from another Australian Registered Private Health Insurer and had an equivalent level of cover, and completed all waiting periods.
Normal waiting periods will apply to those aspects of Navy Health cover not covered previously by your previous insurer, and for those items specifically nominated within the products as requiring extended waiting periods.
Navy Health will not pay immediate benefits at a higher level than those provided by the previous insurer. Navy Health annual limits will be reduced by the amount of benefit already paid by the previous insurer for similar services in the current benefit year of transfer. The Clearance Certificate Application may assist you with your transfer to Navy Health.
The excess applies to the cost of in-patient hospitalisation in either a private, public or day hospital facility. The member excess is payable per membership and is deducted from the first or subsequent claims for hospitalisations.
For singles, the excess is only payable once in any rolling 12 month period (once the excess is paid in full). From the day you go into hospital, Navy Health will not charge another excess for a minimum of 12 months, or a partial excess amount if you have not yet paid a full excess amount for that 12 month period.
For families, the excess is payable per admission up to the family maximum of 2 admissions, in any rolling 12 month period.
Note: Reducing your excess is considered to be “upgrading” your membership.
Navy Health’s Member Portal is an easy-to-use portal where you can submit an Extras claim in seconds, update your details, and review your membership information. Simply use your Navy Health login to access the portal.
Navy Health has arranged additional benefits for members who purchase their glasses or contact lenses from any of the preferred optical suppliers below.
For members with extras cover, simply present your Navy Health membership card at any OPSM or Laubman & Pank store and receive 20% off the price of lenses, 20% off lens extras (such as anti-reflective UV coating and tinting), 15% off non-prescription sunglasses, 10% off contact lenses purchased in store and 5% off contact lenses purchased online (Conditions Apply – please see store for details).
Frames & Lenses
25%* discount for 1 pair of complete glasses (frames & lenses) from the $149 range and above purchased at retail stores.
*No discount on two pair deals or complete glasses with less than $149 value.
Optional Lens Extras
20% discount on all extras
Extras include Suntint and UV Filter, Polarising lenses, Transitions lenses, Driving tints, Drive wear lenses, Thin and Light lenses.
Contact Lenses
Free contact lens assessment, Fitting and trial.
Eye Tests
Bulk billed to Medicare plus free Digital Retinal Photography
At Teachers Eye Care, Navy Health members (with extras cover) are eligible for 35% off Frames (must be purchased with prescription lenses), 20% off lenses (when purchased without frames), 25% off sunglasses and contact lenses.
Simply produce your membership card at the time of purchase.
At any Eyebenefit optical supplier Navy Health members (with extras cover) are entitled to 20% discount on 1 pair of complete spectacles (frames & lenses), 15% discount on spectacle lenses only, or 10% discount on contact lenses.
Navy Health is pleased to inform our members that EyeQ have created their own optical network, called Q Optical Network (QON). This new network will allow our members to continue to access great discounts on their optical needs.
The Offer:
The QON is available to members from 1 October 2020 and their optometrist search engine is now available.
Medical Devices and Human Tissue Product appliances or devices surgically implanted during a hospital stay are subject to two benefit types, either ‘no gap’ or ‘gap permitted’. These items are listed on the Commonwealth Prosthesis Schedule .
When a ‘gap permitted’ benefit applies the insurer will pay the recommended minimum benefit as shown on the Schedule. The Schedule will have at least one no gap Medical Devices and Human Tissue Product for every in hospital procedure on the Medical Benefit Schedule (MBS) for which the insurer provides cover.
No benefit is payable where the hospital charges for a Medical Devices and Human Tissue Product appliance or device not listed on the Schedule.
Limited benefits are available when Podiatric Surgery is performed in a contracted hospital by an Australian Government Accredited Podiatrist. For further information, please call Navy Health Member Services on 1300 306 289.
A completed Navy Health claim form must accompany all claims submitted. You can receive payment by direct deposit into a nominated bank account (within Australia and excluding credit cards). Receipts forwarded for benefits will be held by Navy Health on your behalf. Receipts will not be returned to the member.
Electronic Claiming
We use HICAPS and iSOFT, electronic systems that allow you to claim most of your Extras benefits on the spot after your consultation. After a consultation your membership card can be swiped through the electronic claiming facility by the service provider. They will enter the claim details and process the transaction on your behalf. If there is a difference between your Extras benefit and the fee charged by your provider, you will need to pay this amount at the time of service.
Please note that Orthodontic, Ambulance, Medically Prescribed Appliance, and Pharmacy claims cannot be processed through HICAPS or iSOFT.
Online Claiming
If you are unable to claim via HICAPS or iSOFT, we offer three alternative methods for submitting claims. You can submit your claim online through the Member Portal, complete a claim form, or use our Navy Health App, which is available for download from the App Store or Google Play Store.
Natural therapies include Acupuncture, Chinese Herbal Medicine, Myotherapy, Remedial Massage Therapy and Exercise Physiology.
Benefits are only payable for services rendered by a recognised provider in a private practice. Benefits are not payable on any prescribed medications, herbal or dietary preparations, or organised weight reduction programs.
The provider registration process for Natural Therapy services, including the issuing of provider numbers, is managed by the Australian Regional Health Group (ARHG) or Exercise and Sports Science Australia (ESSA) on behalf of Navy Health Limited.
Natural Therapy providers must be eligible members of an association that the ARHG recognises or a member of ESSA for benefits to be payable.
MPA claims must be accompanied by a referral from a registered practitioner. This must be accompanied with a receipt showing your full name, date of purchase, name of device and details of the service provider the device was purchased from. (If purchased from a pharmacy, an official pharmacy receipt will be accepted.) The following are examples of items that can be claimed under the MPA category: Nebulisers*, Humidifiers*, Blood Glucose Monitors*, Heart Rate/Blood Pressure Monitors*, Support Aids/Mobility Aids, Compression Garments, Non-cosmetic Medical Devices and Human Tissue Products (Premium Extras only), and TENS Machine/Circulation Booster*.
The MPA category also covers hire and repairs to appliances that are covered under the category and up to the annual limit.
* Navy Health will not pay benefits on any services, treatments or products received outside of Australia or when purchased from a provider without an Australian Business Number (ABN). As a consequence we strongly advise all members to consider travel insurance when travelling overseas to cover emergency expenses wen outside of Australia.
* Any three (3) year period. The maximum three year replacement period applies to any three year rolling period from the first date of purchase.
Gold Card Holders
Members who are, or become Department of Veterans’ Affairs (DVA) Gold Card holders have the option of retaining or cancelling their cover with Navy Health. Where a member chooses to retain their coverage, benefits will be paid on out-of-pocket costs incurred after the DVA payment, however the benefit must not exceed the total charge or the Navy Health benefits and annual limits.
Where a member with a DVA Gold Card has Premium Hospital coverage, Navy Health will pay the supplement (top up) benefit for a private room in a private hospital, as DVA already cover the cost of a shared ward.
Where a member chooses to cancel their coverage, they must advise Navy Health in writing of the issue date. The cover will be cancelled from the date Navy Health receives written notification. The person holding the DVA Gold Card may then re-apply for membership to Navy Health without waiting periods or penalties, as they are deemed to have continuity of cover.
Any person who has previously held a DVA Gold Card is entitled to join Navy Health without serving any waiting periods. Proof of previous DVA Gold Card status is required.
Navy Health aims to close the gap on out-of-pocket in-hospital expenses. A gap payment is the difference between the fee charged by the hospital or doctor and the benefit paid by Navy Health.
Gap payments may arise depending on the following:
When treated as a private patient in a hospital, members may face extra costs when the treating doctor charges more than the Medicare Benefits Schedule (MBS) allows for the service provided.
The Access Gap scheme is designed to help minimise or eliminate these costs. Where there is an agreement in place and the treating doctor chooses to participate in the Access Gap Scheme, the insurer will cover the cost above the MBS fee to an agreed level on the Access Gap fee. If the doctor’s fee is higher than the agreed Access Gap fee, the patient is responsible for paying the balance.
Access Gap Fee is limited to;
If the member receives treatment as a private patient in a hospital from a doctor that chooses not to participate in the Access Gap Scheme, Gap Medical benefits will apply.
Under Gap Medical benefits, Medicare will cover 75% of the MBS fee for the service that has been provided. The insurer will pay the remaining 25% of the MBS fee.
If the doctor charges more than the MBS fee, the member will be responsible for any ‘gap’ payment. The ‘gap’ is defined as the monetary variation between the MBS fee and the doctor’s fee.
Prior to admission please check with your hospital as to whether or not your treatment or service is contracted. Contracted services relate to hospital fees such as accommodation and theatre.
Navy Health has been able to negotiate 100% benefits on most treatments and services at over 490 private hospitals and day facilities. Product excesses still apply. To search for agreement hospitals and specialists in your area, go here.
Medical Devices and Human Tissue Products are payable at 100% of the minimum Government recommended fee. There is at least one Medical Devices and Human Tissue Product available for every surgery with no out-of-pocket expense to the patient.
Drugs prescribed for discharge and drugs not directly associated with the reason for admission are excluded from contracts and are the patient’s responsibility. In addition, if a patient chooses to stay in an executive suite, the patient will be required to pay the difference between the private room benefit and the executive suite charge.
Prior to your admission to a Psychiatric or Rehabilitation Day Program, please check with Navy Health as limits may apply.
Prior to admission please check with your hospital as to whether or not your treatment or service is contracted. Contracted services relate to hospital fees such as accommodation and theatre. If you find that your impending hospital treatment or service is not contracted, we strongly recommend you contact our Member Services team to obtain benefit information prior to admission, as out-of-pocket expenses will apply. Product excesses may also apply.
Please be aware that sometimes service exclusions may apply for hospital services where Medicare does not pay a benefit. To be sure of coverage, please call Navy Health Member Services on 1300 306 289 prior to arranging admission.
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© Navy Health Ltd All Rights Reserved 2023
© Navy Health Ltd All Rights Reserved 2023
