Important Information

Please refer to the following information for the finer details of membership with Navy Health. If you require further information, please don’t hesitate to contact us on 1300 306 289.

It is important that as a member of Navy Health you read and retain all of the membership information that we send to you or is obtained from this website.

Membership

Single Membership

Cover is for the member only and therefore would need to be adjusted to the family rate if dependants or a partner were to be added. A single membership should be adjusted to the family rate at least two months prior to the expected date of birth of a child if cover for the child is required at birth.

Family Membership

Cover is for the member with a spouse/partner plus; any unmarried children until they attain the age of 22 years or enter into de facto relationship; any unmarried children between the age of 22 and 31 years who are full time students attending an education facility within Australia.

A dependant is no longer eligible for cover under a parent’s membership is able to take out membership in their own right. If the new cover is started within thirty (30) days at an equivalent level, no additional waiting periods will apply.

For more information please call 1300 306 289.

Single Parent Family or Military Family with one serving adult

Cover is for one adult and dependants. For a military family with one serving adult, the serving person is the membership owner but cannot make a claim on the membership.

Dependant(s) Only or Military Family with two serving adults

Cover is for children only. The members (adults) are not entitled to claim benefits on a Dependant(s) Only cover.

When does membership commence?

Membership will only be accepted from the date when the first contribution is received, or on the date on which the application form is received by Navy Health, whichever is the latest. Backdating of membership is not permitted.

How can I change my membership?

Any changes to the status of membership (i.e. level of cover, adding or deleting dependants) cannot be undertaken without Navy Health receiving written or verbal notification of the change.

Likewise, the change cannot be taken as being actioned without the member receiving written acknowledgement from Navy Health.

The application forms supplied by Navy Health can be used for that purpose or the member can use the Navy Health website.

The easiest method of changing details is by calling our Member Services team on 1300 306 289 or emailing query@navyhealth.com.au and informing us of your change.

Cover changes

Upward (increased entitlement) changes in the level of cover will result in the member and any persons covered undergoing new waiting periods. Whilst these waiting periods are in force, benefits will still be payable as they would normally have been under the previous level of cover.

Higher benefits are not payable for ailments or conditions in evidence at the time of transfer (regardless of whether or not they have been diagnosed) until a waiting period of 12 months has been served.

Higher level maternity (and the management of) and IVF procedures benefits will not be payable for a period of 12 months after transfer.

For transfers within the extras products, the waiting periods for higher benefits are those listed for new members. At all times the benefits paid under a previous level of cover are considered when determining residual benefit entitlements.

When are contributions payable?

Payment of contributions are always in advance. Direct debit payments can be made on a fortnightly, monthly, six monthly or yearly basis.

A 2% discount has been applied for members choosing to pay half yearly and a 4% discount has been calculated for those members choosing to pay annually.

Benefit Year

For General Treatment (Extras) the Navy Health benefit year is July 1 to June 30. For hospital products with an excess, the benefit period is a rolling calendar year (i.e. the excess on any of the Premium Gold Hospital, Core Silver+ Hospital or Saver Bronze+ Hospital products is payable once per person, in full, up to the family maximum, in any rolling 12 month period).

When does membership cease?

A membership will cease on a date advised and paid to by the member or automatically when contribution payments are more than one month in arrears.

Young Adults

If a non-student dependant takes up any extras cover within 30 days of being ineligible to continue under a parent’s membership, Navy Health will allow the dependant to retain the hospital cover provided under the existing family membership until they attain 27 years of age, marry, or enter into a de facto relationship.

Continuity of hospital cover, at an equivalent level of cover to that carried over from a parent’s membership will be provided when the dependant seeks cover in their own right provided the parent’s membership is still current and cover is activated within 30 days of being ineligible for inclusion under a parent’s membership.

A dependant can take up membership in their own right at any time after being ineligible to continue under their parent’s cover, however some waiting periods may apply unless membership is taken up within 30 days. The new membership will take effect from the day after they lose their eligibility on their parent’s membership.

Cooling Off Period

Members can choose not to proceed with their Navy Health cover and request to have any premiums reimbursed. This reimbursement is on the provision that the member expresses their request in writing, within 30 days of their cover commencing and that no claims have been lodged or are pending during the 30 day cooling off period.

Suspension of Membership

Navy Health at its absolute discretion may allow, within a clearly defined limited set of circumstances, for a member to suspend their membership for an agreed period.

Where the suspension has been approved in writing by the insurer, members will be advised of the conditions relating to waiting periods and pre-existing condition rules which may be applied upon reinstatement of membership.

The agreed suspension period is not subject to change without written notification to and written confirmation from Navy Health. For more information please go to Suspending Your Cover.

Benefits

When Are Benefits Not Payable?

Benefits are not payable when:

Claims are over 2 years from the date of service;
The provider is not recognised in a private practice or for Natural Therapies the provider is not recognised by the Australian Regional Health Group (ARHG) or HICAPS;
The service forms any part of a payment from Workers’ Compensation, Third Party or any other liability provision. Navy Health reserves the right to seek full reimbursement on any benefits paid in these circumstances;
The procedure does not have an assigned Commonwealth Medical Benefits Schedule item number;
The claim is within a specified waiting or replacement period or annual/sub limits have been reached;
Access Gap providers submit medical claims 2 years after the date of service, unless approved by Medicare Australia for benefits;
Services performed, or products from outside of Australia;
Cosmetic surgery;
During a period of suspension or when membership is in arrears.

Overseas Benefits

Navy Health will not pay benefits on any services, treatments or products received outside of Australia. As a consequence, we strongly advise all members to consider travel insurance when travelling overseas to cover emergency expenses when outside of Australia.

Coverage

Exclusions

No benefits are payable by Navy Health for cosmetic surgery or where Medicare doesn’t pay a benefit.

Waiting Periods

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.

Pre-existing Conditions*

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.

Transfer from other insurers

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.

Hospital Excess

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.

Member Portal

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.

Preferred Optical Providers

Optical Suppliers

Navy Health has arranged additional benefits for members who purchase their glasses or contact lenses from any of the preferred optical suppliers below.

1. OPSM + Laubman & Pank

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).

2. Specsavers

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

3. Teachers Eye Care

At Teachers Eye Care, Navy Health members (with extras cover) are eligible for 35% off Frames (must be purchased with prescription lenses), 25% off sunglasses and contact lenses.

Simply produce your membership card at the time of purchase.

4. Eyebenefit

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.

5. EyeQ

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 EyeQ optometrist search engine is available here.

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 when outside of Australia.

Medical Devices and Human Tissue Product Appliances

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.

Podiatry surgery

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.

Claiming

Making claims

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 and Recognised Providers

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.

Medically Prescribed Appliances (MPA)

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.

Department of Veterans’ Affairs

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.

Medical & Hospital Benefits Explained

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:

Access Gap

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:

– $400 above the Australian Health Services Alliance (AHSA) set fee for all items except obstetrics
– $800 above the AHSA set fee for obstetrics only.

Gap Medical

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.

Private Hospital & Day Facilities

Contracted Facilities

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.

Psychiatric Treatment & Rehabilitation Day Programs

Prior to your admission to a Psychiatric or Rehabilitation Day Program, please check with Navy Health as limits may apply.

Non-Contracted Services

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.

Exclusions

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.