Here’s what you can expect to be covered for under your Prestige (Gold) policy:

• Accommodation for overnight, same day and intensive care in a private or shared room in agreement private and public hospitals.
• Theatre and labour ward fees covered in agreement private hospitals (excluding restricted services – see ‘What we don’t fully cover’).
• Medical expenses related to providers for services while you’re a hospital inpatient. You’re covered for all services that Medicare pays benefits for, and CBHS will cover the difference between the Medicare benefit and the Medicare Benefits Schedule (MBS) fee for services provided as an admitted patient to a hospital. Examples include fees from doctors, surgeons, anaesthetists, pathology, imaging etc. You can choose your doctor/surgeon in a public or private hospital.
• Access Gap Cover with providers (e.g. doctor or surgeon) who choose to participate in CBHS’ Access Gap Cover scheme. The amount over and above the MBS fee is known as a ‘gap’. CBHS covers up to 100% of an agreed amount in excess of the MBS fee, which reduces or eliminates your out-of-pocket medical expenses (i.e. surgeons, anaesthetists, pathology, imaging fees etc).
• Surgically implanted prostheses which are on the Australian Government’s Prostheses List are covered to at least the specified minimum benefit. Medical prostheses include heart valve stents, joint replacement devices, and pacemakers.
• Pharmacy benefit covers most drugs related to the reason for your admission in agreement with private hospitals.
• Boarder accommodation covers 100%, up to $160 per admission, if not already included in the hospital agreement. This is for a support person to stay overnight with you if the hospital allows.
• Emergency ambulance transport for an accident or medical emergency by your state’s approved ambulance providers.
• Hospital services where a Medicare benefit is payable (excluding restricted services. See ‘What we don’t pay for’)
• Better Living programs to help you manage your health and wellness.
• Hospital Substitute Treatment to help get you back into your own bed earlier. There is no extra charge if the services are an appropriate substitute for treatment that would have been fully covered in hospital.
• A Gap Assist medical benefit payment to further help you reduce your out-of-pocket (gap) expenses as a result of hospitalisation. Gap Assist offers $200 per person per calendar year towards the gap.

Prestige (Gold) package will not cover you for:

• Hospital services you receive before you have served waiting periods.
• Nursing home type patient contribution, respite care or nursing home fees.
• Take home/discharge drugs (For non-PBS drugs, you may be eligible for benefits under your Extras cover).
• Healthcare aids e.g. walkers not covered in a hospital agreement (you may be able benefits for these under your Extras cover).
• Services you claim for 24 months after the service date.
• Services provided in countries outside of Australia.
• Prostheses used for cosmetic procedures, where no Medicare benefit is payable.
• Ambulance transfers between hospitals (for residents in VIC, SA and NT).
• Fees raised by public hospitals that exceed Minimum Default Benefits set by the Department of Health for shared room accommodation.

Exclusions:

For treatment listed as an exclusion there is no benefit payable and members may or will likely incur significant out-of-pocket expense for these services. Please review the exclusions on this cover and always check with CBHS to see if you are covered before receiving treatment. The following services are excluded from this cover:

• Cosmetic services

Non-agreement private hospital rates

If you’re admitted into a non-agreement private hospital, CBHS will only pay benefits at the minimum rate specified by law. These benefits may be similar to a public hospital shared room rate. This may not be enough to cover your admissions in a non-agreement private hospital, and that means you would be liable for a gap.

Before going to hospital, it’s best to check to see whether CBHS has an agreement with that hospital. We can help you to locate CBHS agreement hospitals in your area.

Some services are not fully covered under Prestige (Gold). These are called Restricted services.

The services below, when provided in a private hospital, are only eligible for the minimum benefits set out by law. These benefits relate to hospital bed charges and are unlikely to cover the private hospital admission fees. That means there may be a large out-of-pocket (gap) expense for both the bed charge and any theatre fees.

• Podiatric surgery (provided by a registered podiatric surgeon)¹
• Services for which Medicare does not provide a benefit

Understanding which services are restricted in your cover can help you plan more effectively for a hospital stay or medical treatment.

This section covers options which might help you reduce the cost of your premiums.

These include:

• Age-based discounts
• Australian Government Rebate

Age-based discounts

Age-based discounts are an Australian Government initiative designed to help make Hospital cover more affordable for young Australians. If you’re aged between 18 and 29, you are eligible for a discount of up to 10% off your premiums. CBHS is proud to be a fund which supports age-based discounts − it’s not mandatory for funds to make this discount available.

Read more about age-based discounts and see what you’re eligible for.

Australian Government Rebate

The Australian Government Rebate on private health insurance (Rebate) is a means-tested Rebate which you may be eligible for. The percentage of Rebate is determined depending on your age and income. Most people choose to claim this Rebate as a reduction in their premiums. You can also choose to claim it as a tax offset when you lodge your annual tax return.

See if you’re eligible for the Rebate. 

We get that one of the most important questions you have about your cover is “When can I start using it?” Waiting periods are designed to make health insurance fair for all.

I’m new to health insurance

Waiting periods apply to all those who are new to private health insurance. These are set out in the table bellow.

I’m transferring from another fund or upgrading my CBHS cover

If you already have cover with another fund, and choose to switch to CBHS, you won’t need to re-start your waiting periods.

If you served part of your waiting periods within one health fund, you can complete these with CBHS.

If you upgrade your level of cover, waiting periods will apply to benefits not previously included within your original cover.

Learn more about waiting periods.

* If you have a pre-existing condition, a waiting period of 12 months will apply before we will pay hospital or medical benefits towards any treatment for that condition.

**Once you have served the two-month waiting period, you can choose to upgrade your cover (once in a lifetime) and access the higher benefits for hospital psychiatric treatment associated with that cover, without serving an additional waiting period. For more details, contact us on 1300 654 123 or email help@cbhs.com.au.

***Accident means an unexpected or unforeseen event caused by an external force or object resulting in an injury to the body which requires treatment by a medical practitioner, hospital or dentist (as the context requires) but excludes pregnancy.

What can I claim for?

If your chosen Extras cover includes them, you can claim for the following services. Check our product sheets to see the details on what each cover includes.

• Chiropractic
• Dental
• Dietary services
• Health care aids
• Occupational therapy
• Optical
• Osteopathy services
• Pharmaceuticals
• Physiotherapy
• Podiatry
• Psychology
• Speech therapy
• Wellness benefits for a variety of health checks and programs designed to assist you in better managing your health and wellbeing e.g gym membership, skin cancer screening, bone density screening and breast examinations.

If you’re planning to claim for a treatment or service under Extras, make sure you’re using a recognised provider.  We can only pay benefits if you use a recognised provider.

How is my claims benefit calculated?

We automatically calculate your claims benefit for you when you lodge a claim at your provider’s practice or when you lodge a claim online. If you claim through your provider, you’ll receive the benefit as a deduction in the cost of the service. Your benefit will be based on the percentage you’re entitled to under your chosen Extras cover, as well as the per service limit (see the product sheet) as well as much of your limit entitlement you have left available to use.

You can also find out your benefit using the Online Benefit Quote tool in the Member Centre.

How long does it take CBHS to pay Extras claims?

If your service provider has HICAPS or iSOFT facilities, all you need to do is give them your membership card and the benefit will be automatically deducted from the total service fee. If you’re visiting one of our Choice Network providers, you may not have any out-of-pocket expenses to pay.

Members who claim online typically receive their benefits within 1 – 2 business days. Once you have lodged your eClaim, you will receive an email confirmation. Once your claim has been assessed, you will receive a benefit remittance confirming your claim benefit.  

What is the CBHS Choice Network?

This is a group of over 9,000 providers who are committed to reducing or removing the gap for Extras services on selected preventative dental and optical frames, lenses and contact lenses.

Find a CBHS Choice Network provider near you.

When do my benefits renew?

Most benefits for services are based on per person per calendar year, unless otherwise stated in the product sheet. They will renew on 1 January.

For services with a ‘three year’ or ‘five year’ period attached, the benefit will renew on the same date which you received the service in three or five years respectively.

For services which attract a ‘lifetime’ benefit period, the benefit limits only useable once only.

What do I need to claim for health management services?

If you’re claiming for health management services such as gym memberships and personal training, you’ll need to have your GP, specialist, or allied health service provider complete a Health Management Program (HMP) Authorisation Form. The, simply provide this to us when submitting your claim. 

What types of services do I need a referral for?

We need a referral from your medical practitioner for artificial aids, health care appliances, contraceptives and some pharmacy items in certain circumstances.

How can I claim on travel and accommodation?

Under Top Extras cover, we pay benefits towards travel and accommodation if you need essential medical or dental treatment that is not available within a 160km round trip from your home. We only pay benefits for the member receiving treatment.

Essential medical treatment means:

• Your registered medical practitioner has referred you for the treatment; and
• You have a medical certificate from the registered medical practitioner, which states that the treatment is essential.

We also require the following:

• A medical certificate from the treatment location you travelled to e.g. the medical practitioner/a copy of the doctor’s invoice
• A copy of the receipt from the hotel, motel, etc. (for accommodation only)
• A completed and signed CBHS claim form.

Do I need to send the original receipts?