How can we help?
Information to help you get started as a Navy Health member.
Understand eligibility, the Medicare Levy Surcharge, the Private Health Insurance Rebate, Lifetime Health Cover and every other in and out of health insurance.
What you need to know about your membership including the different ways you can make a claim.
Important information about your cover including excesses, pre-existing conditions and waiting periods.
Start by selecting a category or searching for what you are looking for.
Am I eligible for Navy Health?
At Navy Health, we like everyone to reap the benefits of a not-for-profit company!
Don't let the word restricted stop you! More than likely you are eligible for Navy Health's low premiums and high benefits.
Once you're a member of Navy Health you are entitled to lifetime membership eligibility. Therefore, if you've been eligible at any stage in your life, you're welcome to join at any time in the future, even if you're leaving the ADF or an Australian Defence contracted company. We call this our Member for Life clause.
Navy Health is a tri-service health fund open to:
|•||Serving or ex-serving members of the Australian
Defence Force (Navy, Army and Air Force)
|•||Ex-dependants of serving and ex-serving members of
the Australian Defence Forces
|•||Employees of organisations contracted to provide
services to the Department of Defence
|•||Employees of the Department of Defence|
|•||Australian Public Service employees assigned to, or
directly engaged to provide services to the Department
of Defence or ADF
|•||Current members or former members of the ADF Reservists|
|•||Current members or former members of the ADF Cadets|
|•||You may also be able to join Navy Health if you are
related to any eligible person (above) or any person
who was a member of Navy Health as at 12 October
2007, in any of the following ways;
If you’re still not sure, call us on 1300 306 289.
Be a Navy Health member for life
Once accepted as a member of Navy Health you are entitled to lifetime membership eligibility. This means that you or your family members can join Navy Health in their own right at ANY time in the future.
Therefore if you:
|•||Discharge from the ADF|
|•||Need a period without Private Health Insurance|
|•||Would rather wait until later in life to take up Private Health Insurance|
...you and your family will still be eligible!
Lifetime eligibility means that you will have access to all the benefits of a not-for-profit organisation that ensures benefits are given back to members allowing for lower premiums and higher benefits.
Check your eligibility using our simple tool.
Forms & Brochures
Before completing the application forms, please ensure you have read and understood the Terms and Conditions of membership, any waiting periods and exclusions that may apply to the cover you have selected, as outlined in the complete health cover brochure.
Veteran White and Gold Cardholders are eligible for a 10% discount off their premiums with Navy Health.
Veteran Cards provide a wide range of access to treatment and services such as hospital treatment, dental care, optical services and more. You may also be covered for certain pharmaceutical needs and rehabilitation devices. A Veteran White Card provides cover and treatment of specifically accepted injuries or conditions that are war caused or service related. A Veteran Gold Card will provide cover for any clinically necessary health care needs, whether they are related to war service or not.
Please find below some frequently asked questions relating to the Veteran Discount. If your question is not answered below please call the Member Services Team on 1300 306 289 for assistance.
What or who is DVA?
DVA stands for Department of Veterans' Affairs'.
How do I apply for the Veteran Discount?
To activate the discount, you will need to send an email to DVACardHolder@navyhealth.com.au with the following information:
|•||Your membership number|
|•||Proof of Veteran status (scan/copy of Veteran Card)|
I’ve been a loyal member why do I not get a discount?
Navy Health is recognising persons that have served in the ADF. As a not for profit insurer we aim to keep costs low for all members and provide more benefits to lessen the out of pocket costs.
I have a Gold Card and my spouse is the only one on the membership. Can we get the discount?
Unfortunately, the discount can only be applied if the person who holds the Veteran Gold Card is covered under the membership. Whilst we understand that as a Gold Card Holder you do not necessarily need to be covered as most of your health costs are already covered. You may however choose to take Extras Only Cover to be covered for those services that DVA may not specifically provide benefits for.
I have been a Veteran Cardholder for xxx can I backdate?
The discount cannot be backdated.
I used to be a Veteran Cardholder, can I still get the discount?
No, it is only available to current Veteran Cardholders.
My Veteran Card is due to become effective when I turn 70, can I get the discount now?
No, it is only available to current Veteran Cardholders.
My father/mother/brother is a Veteran Cardholder, am I entitled to the discount?
No, it is only available to current Veteran Cardholders.
My Veteran White Card covers my heart condition, can that be removed from my policy and retain the discount?
No, Navy Health policies cannot be tailored to suit individual requirements, we can offer a cover review to ensure you are on the most appropriate level of cover for your needs.
I don’t require hospital cover, can I take an Extras only policy and still receive the discount?
Yes, you are able to take an extras only policy and have the discount applied.
I have been issued a Veteran Gold Card – should I remain on the membership?
Members who are or become Veteran Gold Cardholders 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 Veteran Card payment, however the benefit must not exceed the total charge or the Navy Health benefits and annual limits. Member with a Veteran Gold Card has top 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 Veteran Gold Card number and issue date. The cover will be cancelled from the date Navy Health receives written notification. The person holding the Veteran Gold Card may then re-apply for membership to Navy Health without waiting periods or penalties, as their health cover needs have been met by the DVA.
Any person who has previously held a Veteran Gold Card is entitled to join Navy Health without serving any waiting periods. Proof of previous Veteran Gold Card status is required.
Transferring from another Health Insurer
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. Waiting periods will also apply if you join Navy Health after 30 days from leaving your previous health insurer.
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.
*Please note: Waiting periods will apply if joining Navy Health after 30 days from leaving your previous health insurer.
Who is an eligible dependant?
A dependant is defined as a child, legally adopted child or stepchild who is unmarried and who has not attained the age of 22 years.
A student dependant is defined as a child, legally adopted child or stepchild who is under the age of 25 and not married or in a de facto relationship, and who is pursuing a fund approved full-time course of study at school, college or university.
Is my 22-year old dependant child still able to be covered under our family's cover?
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 25 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.
Medicare Levy Surcharge
The Medicare Levy Surcharge (MLS) is a fee placed on Australian taxpayers who do not have an appropriate level of private hospital insurance and who earn above a certain income. The incentive behind the surcharge is to encourage individuals to take out private hospital cover and to use the private hospital system to help alleviate some of the demand on the public Medicare system.
The surcharge is calculated at the rate of 1% to 1.5% of your income. It is in addition to the Medicare Levy of 2.0%, which is paid by most Australian taxpayers. The Medicare Levy Surcharge covers all people on your policy.
Medicare Levy Surcharge Thresholds: Refer to table at the bottom of the page.
Single parents and couples (including de facto couples) are subjected to family tiers. For families with children, the thresholds are increased by $1500 for each child after the first.
You may also be subject to the MLS, if your taxable income is over the threshold and you have a dependent who is not currently covered by an approved health cover.
As an ADF serving member, you would have been exempt from paying the levy if you were single or only paid 1% if you had a family. Although as an ADF member you may not require health insurance, if your combined family income is above $180,000, your family will need to take out private hospital cover to avoid MLS.
If you or your family receive a high income, it is advised to look into private health insurance to avoid the high surcharge.
For further information, please refer to the Medicare Levy Surcharge page on the Australian Taxation Office website.
Lifetime Health Cover
Lifetime Health Cover (LHC) is a Government initiative designed to encourage people to take out hospital insurance earlier in life and to maintain their cover. If you are 30 or over, do not currently hold PHI and have not or are no longer a permanent member of the ADF you may be impacted by Lifetime Health Cover (LHC).
You need to take out a private health insurance hospital policy by the 1st of July following your 31st birthday, to avoid paying LHC loading. For every year you delay, you will pay 2% more for your premium, up to a maximum of 70%. For example, if you take out hospital cover at age 40, you will pay 20% more than someone who first took out hospital cover at age 30.
To cover small gaps, such as switching from one insurer to another, you are able to be without private cover for periods totalling 1094 days (i.e. three years less one day) during your lifetime, without affecting your loading.
Who is exempt from LHC?
|•||if you were born on or before 1 July 1934|
|•||You are a member of the ADF your medical services are provided by the ADF, so you are considered to have hospital cover. If you discharge from the ADF after the 1st of July following your 31st birthday, you have 1094 days to join a health insurer and still pay the base rate. If you discharge from the ADF before the 1st of July following your 31st birthday, then the normal rules apply|
|•||If you hold a Department of Veteran Affairs Gold Card you are considered to have hospital cover from the date it was issued|
|•||You are overseas on the 1st of July following your 31st birthday, you will not pay LHC if you purchase hospital cover upon your return to Australia|
For more information
|•||Visit the Department of Health website|
|•||Visit the PrivateHealth.gov website|
|•||Call Navy Health on 1300 306 289|
Covering the Gap
Navy Health Access Gap Cover Scheme
Going to Hospital can be a stressful time, so the last thing you or your family should need to worry about is excessive out of pocket expenses. This is where Navy Health’s Access Gap Cover scheme can assist.
Navy Health’s Access Gap Cover scheme aims to minimise the difference between the Medicare fee and what your Specialist charges. Specialists can choose to take part in Access Gap Cover on a case-by-case basis; if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be. Even if your Specialist elects not to take part, you are legally entitled to know any out-of-pocket cost before your procedure – ask your Specialist.
What are out-of-pocket expenses?
The Australian Government sets a Medicare Benefits Schedule (MBS) fee for most services. Procedures recognised by Medicare will have a set MBS ’item number’ and fee. However, Specialists can charge their patients more than the MBS fee if they choose to do so. Medicare and Navy Health cover the cost of the MBS fee for in-hospital treatments but any extra amount charged by the provider becomes an out-of-pocket cost to you.
MBS fee breakdown:
|•||Medicare pays 75% of the MBS fee for in-hospital treatment as a private patient. Navy Health will pay the remaining 25% of the MBS fee.|
|•||Medicare pays 85% of the MBS fee for out-of-hospital services. Australian Private Health Insurers are legally prohibited from, and cannot provide benefits for services provided out of hospital.|
Sally is going to hospital to receive treatment for Medicare item number 12345 which has a set MBS fee of $1000. However Sally’s Specialist, Dr Smith, will be charging $1200 to provide this treatment. In this instance, Medicare will pay $750 (75% of the MBS fee), Navy Health will pay $250 (the remaining 25% of the MBS fee) meaning Sally will have to pay Dr Smith the extra $200. This is Sally’s out of pocket expense.
How can I reduce my costs?
You can ask your Specialist if they will participate in Navy Health’s Access Gap Cover scheme. Our Access Gap Cover scheme allows us to provide benefits to our members to cover some or all of the gap.
Things to note:
|•||There is no requirement for any doctor to participate in Navy Health’s Access Gap Cover scheme;|
|•||You should always ask Navy Health and your Specialist about your Access Gap Cover benefits before you are treated; and|
|•||If there is going to be an amount left for you to pay, the Specialist is legally required to advise you of this before you agree to be treated, wherever practical. They will provide you with a breakdown of costs which will include how much is covered by Medicare and your private health insurance. This is called Informed Financial Consent.|
There are 2 ways the Access Gap Cover scheme can work for you; Known Gap Scheme or No Gap Scheme.
Known Gap Scheme
If your chosen Specialist bills with a Known Gap through Access Gap Cover, your out-of-pocket expenses relating to your in-hospital treatment will be capped. You won’t be charged any additional amounts other than what you’ve agreed to in your Informed Financial Consent before your in-hospital treatment.
No Gap Scheme
If your chosen Specialist chooses to bill you with no gap, you will not have any out-of-pocket expenses for their in-hospital treatment.
Navy Health’s agreements are negotiated by the Australian Health Service Alliance (AHSA).
What if my Specialist does not participate or does not want to participate in the Access Gap Cover Scheme?
You have every right to use your current medical referral to shop around for a Specialist that does participate in the scheme. In this case we also encourage you to call Navy Health to discuss your treatment options.
To find Specialists that may participate in the Navy Health Access Gap scheme, go to healthshare.com.au
Things to remember
|•||Ask your Specialist if they will participate in the Access Gap scheme prior to your procedure;|
|•||Navy Health will only pay for services listed on your policy once you have served the applicable waiting periods;|
|•||The Navy Health Access Gap scheme is only available for inpatient services (i.e. when you are admitted to hospital as a private patient);|
|•||Navy Health has no control of the out-of-pocket expenses set by your Specialist if they are not participating in the Access Gap scheme; and|
|•||It is entirely up to your treating Specialist whether they will participate in the Access Gap scheme or not.|
Changes to the Access Gap Cover scheme from 1 July 2020
Currently, the Access Gap Cover scheme allows Specialists to charge a patient up to $400 for each Medicare item number that is used for treatment in hospital as a private patient. There can be multiple Medicare item numbers used during the procedure, depending on what the patient is being treated for.
A Specialist could also charge a patient a booking or administration fee not associated with the Medicare item number
Effective 1 July 2020, the maximum an individual Specialist can charge under the Access Gap Cover scheme is $500, per admission to hospital (as a private patient). Specialists can no longer charge fees not associated with the Medicare item number.
The changes apply to all Navy Health members that include hospital cover on their membership.
Frequently Asked Questions
What should I ask my Specialist?
Simply ask your Specialist if they will treat you under the Access Gap Cover (AGC) scheme.
If they agree, you will only pay up to $500 per Specialist per hospital stay (as a private patient) ($800 for obstetrics). They may even agree to charge ‘no gap’, which will means you will not have any additional out-of-pocket fees for their services.
Specialists can decide to participate in the AGC scheme on a case-by-case basis, they are not obliged to treat you under this scheme.
What does ‘No Gap’ mean?
‘No Gap’ is where the provider charges the AGC amount with no additional charge to the patient.
What is ‘Known Gap’?
‘Known Gap’ is where the Specialist can charge up to the maximum AGC amount, $500 per individual Specialist ($800 for obstetrics), so the patient has a gap (also known as the ‘out of pocket’).
It is called a ‘Known Gap’ because written Informed Financial Consent (IFC) is required under AGC prior to the procedure, which means the patient ‘knows about the gap’ before they receive their medical bill.
What are additional fees?
If a provider chooses to use AGC, they cannot charge any ‘additional fees’ or hidden fees. These additional or hidden charges include booking fees, management fees, technology fees, administration fees and any other fees that are not a professional service described by the Medicare Benefits Schedule (MBS) item number.
What is a Medicare item number?
The Medicare Benefits Schedule (MBS) is a large listing of medical services covered and subsidised by the Australian government. Each service listed has its own fee, which is set by the Government. Whether you’ve got Private Health Insurance or are a private patient paying for all your own costs, the government provides a rebate on most medical services.
Your surgeon, anaesthetist and assistant surgeon can each bill their own MBS items for a hospital stay (where you are admitted as a private patient). Together, these MBS items provide a detailed hospital invoice and summary. Before any hospital admission utilising your private hospital cover, it’s a good idea to get an itemised quote of the MBS items applicable to your treatment – known as Informed Financial Consent.
Informed Financial Consent or the written estimate of fees should include:
|•||Details of the proposed procedure including hospital, admission date, procedure details such as MBS items with a description and fee for each;|
|•||Other services or Specialists such as anaesthetist, assistant surgeon, pathologist or radiologist and their fee estimate;|
|•||Prosthetics that may be required and their fee, plus the health fund benefit; and|
|•||Patient or guardian signature and date, as a general acknowledgement of the fees.|
Private Health Insurance Rebate
The private health insurance rebate makes having health cover more accessible and affordable by applying a rebate to your premium.
The rebate is an incentive for individuals and families to take our private health insurance. Depending on your income and age the rebate can help you reduce your premium, so you may pay less while getting the benefits private health cover has to offer.
Will you be affected?
Rebate thresholds from 1st April 2020 to 31st March 2021:
What happens if you claim the wrong rebate amount?
If from 1 July, you claim a higher rebate than you are eligible for on your Navy Health premium, the amount of the wrongly claimed amount will be added as a liability to pay back on your tax return for that year. If you think you'll be affected, we recommend you nominate your rebate amount by logging into Online Member Services.
What happens if you drop your health cover?
If you fall into Tier 1,2, or 3 and you do not have private hospital cover from 1 July, you will incur the Medicare Levy Surcharge (MLS) on your taxable income, which will be applied as per the table above.
If you are a serving member, you are currently exempt from the Medicare Levy, however you are not exempt from the MLS (if you have a combined income with your partner) that will be calculated on your household income test.
So if you decide to cancel your private hospital cover, your combined household income (yourself and your partner) will be used to calculate any MLS that may apply, as per the above table, despite you serving full-time in the ADF. If you have any questions regarding your circumstances, please call us on 1300 306 289.
Your Navy Health Tax Statement
Navy Health will send your Private Health Insurance tax statement direct to the ATO.
This financial year (2019/2020) Navy Health will send your health insurance tax statement directly to the Australian Taxation Office (ATO).
We will also store the tax statement in your Online Member Services portal no later than 6th July 2020.
Accessing your statement in the Online Member Services portal
2. Enter your log in details, register to use or retrieve your password.
3. Click on "My Tax Statement".
4. Choose the year you wish to view and click "Done".
Reading your Navy Health Tax Statement
||30th June 2020 - The official end of the financial year. Navy Health will begin to work on creating your tax statement after this date if you held a hospital policy at any stage in the financial year.|
||3rd July 2020 - Tax statements will be available for members to view or download from the Online Member Services portal.|
||4th July 2020 - Your tax statement will be sent to the ATO where it will be viewable in your tax forms or your My Gov portal.|
Frequently Asked Questions
Why are you not sending the tax statement via email or post?
As per the recent changes to the legislation as part of the government reforms, Navy Health will no longer be mailing or emailing statements to members.
Where can I get a copy of my tax statement for my records?
You can log into the Online Member Services portal and download all of your tax statements from here. Alternatively, you can speak to a Member Services Officer on 1300 306 289. Please note Navy Health estimates it can take up to 10 days for the tax statements to be received via post and recommend you download from the Online Member Services portal.
Will I receive a tax statement?
If you held a hospital policy in the 2019/2020 financial year and you paid premiums toward it then tax statements will be available for members to view or download from the Online Member Services portal.
Why is my tax statement not showing?
If your tax statement is not showing in your Online Member Services portal and it is after the 3rd July 2020, and you held an active hospital cover in the 2019/2020 financial year, please call us on 1300 306 289 so we can look into this for you.
If your tax statement is not automatically showing in your tax return, it is after the 4th of July 2020, and you held an active hospital cover in the 2019/2020 financial year, please log into your Online Member Services portal to download your tax statement to use for your tax return.
Navy Health cannot contact the tax department on your behalf.
Why does my statement have a zero in section J?
This is because Navy Health has not received any contribution payments toward your policy in the 2019/2020 financial year. This can occur if you have paid in advance in previous years.
Why does the benefit code (section L) shown on the statement differ to what I should be claiming?
Your statement will not show you what level of rebate you’re entitled to. This is because we don’t collect information about your income.
All you need is your Navy Health membership card to use the electronic claiming system. After a consultation, your card can be swiped through the electronic claiming facility by the service provider. They will enter the claim details and process the claim on your behalf.
Once the transaction has been authorised by Navy Health electronically you simply pay the balance amount. This is the difference between the fee charged for the treatment and the amount paid by Navy Health. Ask your provider if they are connected to an electronic claiming system.
You can make claims for all extras services (excluding Orthodontic, Ambulance, Medically Prescribed Appliances and Pharmacy) through Online Member Services
Post, email and fax
A completed Navy Health claims form must accompany all claims submitted. You can receive a 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.
Claim forms can be downloaded here.
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. 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 Prosthesis (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 consider Navy Health Travel Insurance when travelling overseas to cover emergency expenses when outside of Australia.
CPAP devices cannot be purchased more than once in 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 Veterans Gold Cardholders 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 Veteran Card payment, however the benefit must not exceed the total charge or the Navy Health benefits and annual limits.
Where a member with a Veteran Gold Card has Premium Gold 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.
Going to Hospital
Going to hospital can be daunting whether it be your first time or one of many. This information will take you through the steps of planning your hospital stay, the process of being admitted and what to ask when you leave.
Before going to hospital
Get prepared for your hospital visit by ensuring you’re fully aware of what your treatment will include, your level of cover, your condition and the cost of your treatment.
1. Speak to Navy Health
Contact Member Services at Navy Health on 1300 306 289 and ask:
- Is this classed as a pre-existing condition?
2. Speak to your health insurance provider
It is very important to check your level of cover and ensure you know what you’re covered for and before making any decisions. For example:
• What does my cover include?
• Are all waiting periods served?
• Are my premiums up to date?
If you need help answering any of these questions don’t hesitate to give our member services team a call on 1300 306 289 or log into Online Member Service to check your level of cover.
3. Talk to your GP and Specialist
Your GP or Specialist is generally your first step before you receive hospital admission. They will analyse your condition, level of treatment and whether you will need help from other specialists. It is important to ask questions and discuss any tests or procedures you may need.
Some questions to consider are:
• What do I need to know about my condition i.e. symptoms, tests and treatment?
• How long will I be in hospital?
• What are the expected costs? Will there be out-of-pocket costs?
• Does the specialist participate in Access Gap?
• Do I have the option to see a specialist of my choice?*
• What should I do to prepare for my admission?
• Will I need to take medication and if so, for how long?
• Are there any risks involved with my treatment?
• What is the duration of my admission?
• Are other specialists involved in the procedure?
Your doctor may recommend dates for your treatment or book your hospital admission during your appointment.
When organizing your pre-admission appointment, ensure you receive all the correct details and ask for an admission pack from the hospital outlining all the details.
*Refer to the Find a Specialist page for a free, comprehensive, up-to-date search directory of Australian private practising specialists and allied practitioners.
4. Admission to hospital
As an Australian resident holding a Medicare card, you are entitled to treatment as a public patient by a doctor employed by the hospital, at a time set by the hospital at no cost. All hospital inclusions such as accommodation, meals, medical and nursing care related to the treatment are also covered under Medicare. Because this is funded by Medicare you do not need to have private health insurance to be treated as a public patient in a public hospital.
As a public patient in a public hospital you’re more likely to incur longer waiting lists for elective surgeries, if you don’t mind waiting for your surgery, you may choose to not claim your treatment on your private health insurance and just enlist yourself as a public patient.
In a private hospital, you’re likely to receive treatment sooner. You are also able to nominate your chosen doctor and choose from over 500 private hospitals. Navy Health’s chosen hospitals have an agreed level of fees which is charged by the hospital to Navy Health to be paid on your behalf. If you elect a hospital outside of the 500 affiliated hospitals, you may be subject to out-of-pocket expenses.
Private hospital cover is designed to pay for hospital charges and to contribute to your doctors charges. Costs may be incurred if you have waiting periods, an excess or payments to your treatment practitioners who charge fees higher than those prescribed by the Governments Medical Benefits Schedule. You may be able to reduce these costs if your doctor agrees to use Access Gap Cover.
There are generally two different ways your treating doctors may bill for their services. As a private patient you are entitled to ask your treating doctors to give you Informed Financial Consent. This document will be given to you on request from your doctor and will tell you how much you will be “out-of-pocket” at the end of your planned hospitalization.
When treated as a private patient in hospital, members may face out of pocket expenses if the treating doctor charges more than the Medicare Benefits Schedule (MBS). The Access Gap scheme is designed to help minimise or eliminate these costs. Where an agreement is in place, and the treating doctor chooses to participate in the Access Gap Scheme, Navy Health is able to pay a further benefit towards medical expenses above the MBS. We encourage you to ask your treating doctors to use the Access Gap scheme to help alleviate any out of pocket expenses for your treatment in hospital.
If your treating doctor does not participate in the Access Gap scheme, Gap Medical benefits will apply. Under Gap Medical benefits, Medicare will cover 75% of the MBS and Navy Health will pay the remaining 25% of the MBS. If the doctor charges more than the MBS fee, the member will be responsible for any ‘gap’ payment. The ‘gap’ is the difference between the MBS fee and the doctor’s fee.
Member Benefit Statements
When Member Benefit Statements will be sent
|1.||If you have viewed the Member Benefit Statement online, our system is set up to automatically generate one to your registered email address.|
|2.||If you have had a medical or hospital episode in the past 12 months, it may be because Navy Health has just received and paid the account. If so, this statement is generated to members to inform them.|
Understanding your Member Benefit Statement
The Member Benefit Statement is a notification to inform members of the medical and hospital episodes that Navy Health has received a bill for and what has been paid for on their behalf. The funds were paid directly to the hospital or the medical practitioner. If you have also paid money directly to the hospital or medical provider you will need to contact the hospital or medical provider to seek a refund of the monies you have paid, please contact Navy Health on 1300 306 289 for assistance.
The below sample contains definitions of fields to assist with your understanding of your Member Benefit Statement. Please note the definitions are for reference only and will not appear on your statement.
If you believe the information shown on your Member Benefit Statement is incorrect, please contact us on 1300 306 289.
Standard Information Statements/Private Health Information Statements
The Standard Information Statements/Private Health Information Statements (SIS/PHIS) are only a brief summary and we recommend you call Navy Health (1300 306 289) before making any decisions based on the statements.
It is a requirement that all Registered Health Benefits Organisations provide a SIS/PHIS for all Complying Health Insurance Products that are offered.
To view and download Navy Health Standard Information Statements, please go to the Private Health Insurance website.
Alternatively, you can request a SIS/PHIS for a particular product by email.
We value our members feedback so whether you want to pass on a compliment or feel that we have failed to meet your expectations we want to hear from you.
Paying a compliment
When you have received exceptional service from a Navy Health Members Services Officer or found something that you liked while using one of our services, we would like to hear from you.
Simply communicate your compliment(s) through one of the contact methods outlined in the Contact Us page.
Please ensure that any documentation is sent to the Chief Operations Officer and marked Private and Confidential.
What should I do if I have a complaint?
If for any reason you are not satisfied with the service you received from Navy Health or feel that it has failed to meet your expectations, we would appreciate your feedback. We are committed to resolving your complaints in a fair and efficient manner and view your feedback as a vital opportunity to improve.
Navy Health provides an accessible, impartial, free-of-charge complaints handling procedure.
To ensure you have the best possible customer experience, please make sure that you:
- Gather all supporting documents and information relating to your complaint,
- Think about any questions you need to answer that will help us resolve the issue more efficiently, and
- Contact us as soon as possible.
How do I lodge my complaint?
You can lodge your complaint in any of the following ways:
- Form: complete a feedback form here
- Phone: 1300 306 289 8:30am-7:00pm (AEST) Mon-Fri
- Email: email@example.com
- Mail: Navy Health Limited, PO Box 172, Box Hill VIC 3128
- Fax: (03) 9880 7939
How will Navy Health handle my complaint?
Navy Health is committed to resolving your complaint the first time you contact us. We understand that it is important to listen to you and address each of your concerns.
We encourage you to discuss your complaint with the first Member Service representative you speak with, however, if you are not satisfied with their response to your complaint it will be escalated to their manager to review and resolve. We are confident that in most cases, our Member Service staff will resolve your complaint to your satisfaction.
If you are not satisfied that your complaint has been fully resolved, you have the option of escalating the matter to our Chief Operations Officer, who is dedicated to resolving issues from our Member Services staff in a fair, prompt and unbiased manner.
The Chief Operations Officer will investigate your complaint and contact you within five business days upon receipt of your correspondence, to resolve or advise you on the status of your complaint.
If I am not satisfied with the handling or resolution of my complaint?
If you believe that Navy Health has not made reasonable attempts to address your complaint or you are not satisfied with our resolution, you have the option of contacting the Private Health Insurance Ombudsman (PHIO).
This organisation is an independent office, appointed by the Federal Government, whose services are free to all health fund members. The PHIO handles enquiries, suggestions and complaints and will assist you in resolving a dispute. For more information on this service visit www.ombudsman.gov.au
If you wish to contact this service you may do so via any of the following channels:
Phone: 1300 362 072
Mail: Private Health Insurance Ombudsman
Office of the Commonwealth Ombudsman
GPO Box 442, Canberra ACT 2601
How to contact us
Phone: 1300 306 289 8:30am-7:00pm (AEST) Mon-Fri
Mail: Navy Health Limited, PO Box 172, Box Hill, VIC 3128
Fax: (03) 9880 7939
If you are contacting us to pay a compliment or make a complaint please ensure that any documentation is sent to the Head of Operations and is marked Private and Confidential.
When are Benefits not payable?
Benefits are not payable when:
|•||claims are over 2 years from the date of service|
|•||from the date the membership has been cancelled or transferred to another fund|
|•||where the supplier does not have a current ABN|
|•||where an item attracts a GST|
|•||the service performed is not included in your policy|
|•||the condition is deemed to be a pre-existing condition|
|•||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|
|•||during a period of suspension or when membership is in arrears|
Navy Health will not pay benefits on any services, treatments or products received outside of Australia. As a consequence, we strongly advise all members consider Navy Health Travel Insurance when travelling overseas to cover emergency expenses when outside of Australia.
Cooling Off Period
Cooling off period for new members
Navy Health allows new members who have not yet made any claims to cancel their policy and receive a full refund of any premiums paid within a period of 30 days from the commencement of their policy.
Paying Your Membership
How can I pay for my membership?
Membership premiums can be paid via direct debit, credit card, cheque, money order or via BPAY.
What happens if I miss a contribution payment?
Failure to pay membership contributions within two months of your last "paid to date" (that is, the day to which your membership is paid up), will mean your membership and entitlement to benefits will cease. Once you have paid the arrears amount, your membership will resume and you will once again be entitled to benefits.
Direct Debit Service Agreement
This agreement (“Direct Debit Service Agreement”) outlines the terms and conditions of the direct debit arrangements between the person signing the direct debit request (“you”)
and Navy Health (“us”). You agree to be bound by these terms and conditions upon your execution of the Direct Debit Request.
Direct Debit Arrangements
|•||We will, in accordance with the terms of the direct debit request and any other existing agreement, periodically debit the nominated account for the agreed amount(s)|
|•||The debits will occur according to the frequency you have nominated i.e. fortnightly, monthly or as agreed. The amount debited will vary according to the amount falling due|
|•||If any drawing falls due on a non-business day, it will be debited from the nominated account on the prior business day|
|•||You can change your direct debit arrangements by calling us on 1300 306 289 or log on to member services at navyhealth.com.au at least five (5) business days prior to the next direct debit. Changes include altering arrangements, stopping an individual debit or cancelling a direct debit request completely|
|•||We will give you at least 14 days notice by telephone or writing (including e-mail) of any change to the terms of the direct debit arrangements, unless otherwise agreed|
|•||If you believe we have drawn on your account incorrectly, please contact us on 1300 306 289 so the matter can be resolved. We will make every attempt to resolve the dispute within five (5) business days|
|•||You must ensure that:
→ before completing the direct debit request, you check the account details of your nominated account is accurate (check against a recent statement from your financial institution);
→ your nominated account can accept direct debits (your financial institution can confirm this);
→ nominated account has sufficient clear funds on the drawing date to allow payment to be made in accordance with the direct debit request and any other existing agreement between you and us.
|•||You must advise us immediately if your nominated account is not current|
|•||If any drawing is returned or dishonoured by your financial institution, we may, at our discretion, reprocess the transaction following receipt of the notification of return or dishonour, or request an alternative form of payment from you. We may also charge any dishonour fees back to you|
If you require more information regarding this agreement, please contact Navy Health on 1300 306 289.
Preferred Optical Providers
If you choose to use one of Navy Health’s preferred optical providers, you can receive an additional benefit (subject to the annual maximum). Navy Health's preferred optical suppliers can be found here*.
*Please note: the Optical Providers page is subject to change without notice.
Suspending Your Cover
At Navy Health we understand that from time to time it may be necessary for you to suspend your Health Cover.
Whether you are travelling or working overseas, or simply find yourself in some financial difficulty, Navy Health can assist you with a temporary suspension of your membership.
Suspending your policy will enable you to maintain a restricted membership with the fund, without paying your premiums. Suspension will allow you to re-start your full membership when you return from overseas or get back on your feet again without new waiting periods*. Your membership will continue on as it had before the suspension.
*Excludes pre-existing conditions and pregnancy related services.
To be eligible for suspension to be applied to your policy:
|•||Your membership must be financial and fully paid up to the date of suspension|
|•||Your Navy Health policy must have commenced at least 12 months prior to suspension date|
|•||Your membership has been active for a minimum period of 6 months following a previous suspension (if applicable)|
|•||Both covers must be suspended of you hold hospital and ancillary cover - partial suspensions are not permitted. Individual members can be suspended on a policy.|
A membership can be suspended for the following circumstances:
|•||Financial hardship suspensions are available for a minimum period of three months and a maximum period of 12 months. There is a limit of 3 financial hardship suspensions over the lifetime of a membership. Suspension pre-existing condition waiting periods will apply upon reactivation of policy (see below for further information).|
|•||Overseas travel suspensions are available for a minimum period of one month and a maximum period of 24 months. Suspension pre-existing condition waiting periods will apply upon reactivation of policy (see below for further information).|
|•||Overseas ADF postings suspensions are available for a minimum period of one month and a maximum period of 24 months initially. This can be reviewed if the posting is extended. To avoid any waits on reactivation, the membership must recommence on the day you return to Australia. An International Record of Movement will be requested for each covered adult upon reactivation of membership.|
Upon resumption, a 12 month pre-existing (PEC) waiting period may apply for any condition that arose during your suspension period. PEC waits apply to Hospital cover only. No waiting periods will be applied to your Extras services, provided all waits have been served prior to suspending your cover. Any waiting periods applicable prior to suspension will continue once your policy is reactivated.
To apply for a membership suspension, please download and return a completed Application for Suspension form. This can be emailed to firstname.lastname@example.org. Suspended memberships will automatically reinstate on the date advised and direct debits will recommence automatically.
For further information regarding the suspension of your membership, please call Navy Health on 1300 306 289 or email.
What is a waiting period?
A waiting period is an initial period of your health insurance membership whereby no benefit is payable for certain procedures or services. Waiting periods apply to both hospitals and extras cover. You may have a waiting period if:
|•||You join a health fund for the first time you will be required to serve the applicable waits on the hospital and/or extras|
|•||You upgrade to a higher level of cover, you will attract new waiting periods, however benefits at the previous level will still be available whilst the new waiting periods are being served. This also includes reducing or removing an excess|
|•||You transfer from another fund before completing equivalent waiting periods|
** The 2 month waiting period may be waived for psychiatric care for persons upgrading to a higher level of cover, to specifically access in-patient mental health services. The following conditions apply:
|•||The person must have already served the 2 month waits on policy they are upgrading from (the restricted cover)|
|•||This waiver is only available once in a person's lifetime|
Hospital Cover Waiting Periods
|•||12 months for pre-existing conditions|
|•||12 months for obstetrics (pregnancy)|
|•||2 months for psychiatric care, rehabilitation and palliative care|
Extras Waiting Periods
Can vary between insurers, however typical waiting periods include:
|•||2 months for general dental and physiotherapy|
|•||6 months for optical services|
|•||12 months for major dental|
|•||12 months for high cost procedures such as orthodontics & CPAP devices|
What constitutes a pre-existing condition?
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 (6) months preceeding 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 and Palliative care.
What is an excess?
Where a policy has an excess, the excess applies to the cost of in-patient hospitalisation in either a private, public or day hospital facility.
If your hospital cover comes with an excess, each adult on the policy is liable to pay the excess for a hospital admission once only within a 12-month period. There is no excess payable for children.
For singles, the excess is only payable once in any 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.
Please note: reducing your excess is considered to be “upgrading” your membership. You will pay the higher excess amount for any hospital admissions within 12 months of upgrading
Important Information to know
It is important that as a member of Navy Health you read and retain all the membership information that we send to you or is obtained from this website.
As a member of Navy Health, it is your responsibility to notify us of any changes to your policy, including but not limited to address changes, bank account details or adding and removing people from the policy.
|Membership||Information on membership types, changing your details, paying your premiums, covering your children and suspending your membership|
|Benefits||When benefits can be paid, when benefits are not paid and overseas benefits|
|Coverage||Waiting periods, pre-existing conditions, hospital excesses, using online member services, optical suppliers, prosthetic appliances and podiatry surgery information|
|Claiming||How to make claims, natural therapy claiming, MPAs conditions and Veteran Gold Cardholders|
|Covering the Gap||An explanation of the 'gap' and how you can reduce any potential out-of-pocket expenses when going to hospital|
If you require further information, please don't hesitate to contact us on 1300 306 289.
Medically Prescribed Appliance (MPA)
Medically Prescribed Appliance (MPA)
Medically Prescribed Appliance claims must be accompanied by a referral from a registered practitioner.
The following are examples of items that can be claimed under the MPA category:
|•||Blood Glucose Monitors|
|•||Heart Rate/Blood Pressure Monitors|
|•||Support Aids/Mobility Aids|
|•||Non-cosmetic Prosthesis (Premium Extras only)|
|•||TENS Machine/Circulation Booster|
The MPA category covers the purchase, hire and repairs to appliances that are covered under the category 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).
Changing My Level of Cover
Changing your level of cover
For existing members, you can change your level of cover anytime. However, please note that if upgrading your level of cover, some waiting periods may apply.
How to change your level of cover
To change your level of cover contact our Members Services team on 1300 306 289.
To add dependants to your policy, this can be conducted via Online Member Services.
In relation to newborns, to ensure your new addition has full coverage, it is important to notify us within two months of the birth.
What happens if I am considering parenthood but am on a hospital cover that excludes pregnancy?
You should change your cover as soon as possible to a family version and one that includes obstetrics benefits. A 12 month waiting period applies for all services relating to pregnancy and childbirth.
Prosthesis 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 prosthesis or device item 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 prosthetic 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 on 1300 306 289.
Your extras policy will only cover pharmacy items that meet the following criteria:
|•||Not supplied or already covered under the PBS (pharmaceutical benefits scheme);|
|•||Are fully approved by the TGA (therapeutic good administration);|
|•||Are not experimental drugs or are part of a drug trial;|
|•||Prescribed by an Australian registered medical practitioner, including dentists and nurses;|
|•||Supplied by a registered Australian Pharmacist and are schedule 4 or 8 medicines only;|
|•||Are not vitamins, weight loss drugs, contraceptives, herbal medicines, over the counter pharmacy or non-prescription drugs.|
Please note: any drugs administered in-hospital that are not on the PBS may incur out-of-pocket expenses to be paid by you. Please ensure the hospital provides you with informed financial consent.
Medicare does not cover Ambulance cover and different states have different arrangements. Navy Health includes comprehensive ambulance cover on all policies. We cover 100% benefit for ambulance services within Australia provided by a state/territory registered ambulance service, by either Air/Sea or Land. We do not provide benefits for privately run patient transport services, such as Flying Doctor Services, Care Flight, etc.