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Premium Increase
FAQ Answer
Each year the Minister for Health reviews and approves new private health insurance premiums across the industry, to take effect from 1 April.
If you're an Emergency Services Health member, you'll receive personalised information from us about how you're affected.
For general questions about the premium changes, we have developed this list of FAQs. However, if you have any additional questions, or want to discuss changes to your policy specifically, please just contact us on 1300 703 703 or email us. We’re here to help.
Why do premiums go up?
Annual Private Health Insurance premium changes are necessary to ensure health funds have adequate capital and income to pay for what they will be expected to fund in the next 12 months. In general the amount needed to cover costs continues to climb due to a number of factors, including;
- The increased cost of an episode of hospital treatment
- The increasing cost of a service provided by health professionals which may be reflected as higher benefits paid for services
- Increases in the number of services claimed against an insurer relative to the number of policies
- Introduction of new medical technology and equipment
- Consumer expectations (e.g. seeking better quality care, more thorough testing etc.)
- Aging population
Other factors that may impact your premium include changes to the Australian Government Rebate on private health insurance and the application of the Lifetime Health Cover Loading (LHC).
How will changes to the Australian Government Rebate on private health insurance (Rebate) affect the cost of my health insurance?
If eligible, the Rebate is a contribution the Government makes towards the cost of your private health insurance to make it more affordable and accessible.
The Government adjusts the Rebate on 1 April each year based on a calculation referred to as the ‘Rebate Adjustment Factor’ (RAF) which incorporates any changes to the industry weighted average increase in premiums and the Consumer Price Index. The RAF is set out in the Private Health Insurance (Incentives) Rules 2012 (No.2).
To find out how the change in Rebate will affect you personally, refer to your personalised premium increase information from by Emergency Services Health, or visit health.gov.au to view the updated Rebate tiers.
Why is the premium change more than the increase in the Consumer Price Index (CPI)?
It’s a common misconception that CPI is related to health insurance costs. Health insurance increases are not directly correlated with increases in CPI because the two figures are indicative of different things:
- CPI is reflective of price increases for a wide range of goods (with healthcare being a subset), and the CPI does not take into account frequency of use;
- while changes in health insurance premiums usually reflect the increased cost of healthcare (which traditionally runs above the rate of CPI), as well as any increased frequency of use.
What was Emergency Services Health’s average premium change this year and should it match the change to my premium?
Premium changes differ between policies based on the type of cover, how many people are insured on a policy and in what state or territory a policy is purchased. The average premium % changes quoted by the Department of Health are averages across all policies, and so it is almost always different to the exact change applied to individual situations. This year, in anticipation of our amalgamation with our sister fund Police Health, the 3.14% average published by the Minister under Police Health’s name was a combined average across both Police Health and Emergency Services Health.
Who authorises a change in premiums?
Our Board considers and applies for proposed changes to premiums. Then, under the Private Health Insurance Act 2007, private health insurers must obtain approval from the Commonwealth Minister for Health before applying a premium change.
If the private health insurer does not provide sufficient information to the Minister to demonstrate that a premium change is necessary, then approval is not given. Likewise, the Minister has the power to change premiums beyond what is requested if it is believed that the private health insurer does not have enough funds in reserve to pay the required amount of member benefits.
In the submissions to the Minister, private health insurers must provide detailed financial information and cost and benefit projections to justify any changes. An independent review of this information must also be undertaken by an Appointed Actuary prior to submission.
The proposed increases are examined by the Department of Health and by the Australian Prudential Regulation Authority (APRA).
I haven’t received my premium change notification. How do I get it?
A copy of your premium change notification will be sent to you by email or post (depending on your preference) as soon as possible - usually late February/ early March. If you have any issues you can give us a call on 1300 703 703 or email us at enquiries@eshealth.com.au and we’ll be happy to help.
About Tax Statements
FAQ Answer
At the end of each financial year private health insurers, including Emergency Services Health, previously issued a Private Health Insurance (Tax) Statements to members (Contributors and partners/spouses) who held cover or paid contributions during that financial year. While no longer required to issue the Tax Statements at the end of a financial year, Emergency Services Health has decided to do so this year. These Tax Statements contains important information to help you complete your tax return. Click here for a quick guide on how to read your Emergency Services Health Tax Statement.
Q. When will I get my Private Health Insurance (Tax) Statement?
Tax Statements are emailed or mailed out to members (depending on the member's set preference) during the first two weeks of July. Additionally, the Contributor (the policyholder) can access the Tax Statements by registering and accessing Online Member Services (OMS) on our website.
Q. What do I have to do to get a Private Health Insurance (Tax) Statement?
You do not need to do anything. If you are an existing member or have held private health insurance with Emergency Services Health during the last financial year, we will automatically issue you a Tax Statement. If you misplace the version sent out to you, Contributors (the policyholder) are able to access a copy via our Online Member Services portal.
Q. Why do I need my Private Health Insurance (Tax) Statement?
You may need it to complete your tax return.
Your Tax Statement will include details of the number of days you have been covered by an appropriate level of Private Hospital Cover during the last financial year with Emergency Services Health. The ATO uses this information when assessing if you will be subject to the Medicare Levy Surcharge.
Your Tax Statement will also outline your allocation (if any) of the Australian Government Rebate on private health insurance, if you have received this as a reduction in your premiums, and will be used to assess any liability or offset.
If you have any questions about the Australian Government Rebate on private health insurance, please call the Australian Tax Office helpline on 132 861.
Q. Why do I have two lines of information on my Private Health Insurance (Tax) Statement?
The Australian Government determines the way the Rebate is calculated and applied to premiums. Rebate percentages are adjusted on 1 April each year. If you paid premiums for your policy before and on or after 1 April, your Tax Statement will contain at least two lines of information. Where more than one line of information has been provided, the information from each line must be entered separately at the corresponding labels on the income tax return at Private Health insurance policy details.
Q. What is the Medicare Levy Surcharge (MLS)?
The MLS is a government incentive to encourage individuals to take out private hospital cover and is an additional payment incurred on top of the Medicare Levy that most Australians have to pay. You will only be impacted by the MLS if your income (as assessed by the ATO for this purpose) is over $90,000 for singles or $180,000 for families or couples and you don’t have an appropriate level of private hospital cover. Depending on your income, the MLS ranges between 1 to 1.5% of your income, on top of the 2% Medicare Levy. For more information view our help guide on the Medicare Levy Surcharge.
Q. Last year there was a Lifetime Health Cover Loading (LHC) Statement with the Private Health Insurance (Tax) Statement. How do I get a copy of that?
You don’t need an updated LHC Statement to complete your annual tax return, but we’re happy to provide this information on request. Please email enquiries@eshealth.com.au or call 1300 703 703.
Q. Will my child covered on my policy receive a Private Health Insurance (Tax) Statement?
Dependent children do not receive their own Private Health Insurance (Tax) Statement because they are not entitled to a private health insurance rebate.
However, if your child is completing a tax return they may need to complete the private health insurance policy detail section of their return, so the ATO can verify their private health insurance coverage and ensure that they are not charged the Medicare Levy Surcharge (if their income is above the threshold).
To complete the Private Health Insurance Section of their tax return they will need to obtain a Tax Statement from one of the adults covered on the policy and follow the below steps.
Using the Private Health Insurance Statement of an adult on the policy (using the Health Find ID –SPE and the Membership Number), complete your individual tax return as per the ATO instructions.
Type or write Tax claim code F.
Q. Where can I find out more?
If you want further information, you can call Emergency Services Health on 1300 703 703 however we are unable to provide specific tax advice.
Additionally, you can contact the Australian Tax Office on 132 861, visit their website at ato.gov.au, or speak to your tax advisor.
Access Gap Cover (when admitted to hospital)
FAQ Answer
Under our Access Gap Cover you may never have to pay a doctor’s bill. Your doctor can forward all accounts to us and we pay them on your behalf.
Top Tip
Before you’re admitted to hospital check with your doctor if they are one of 25,000 doctors Australia wide who has an arrangement with us under the Access Gap Cover scheme.
When doctors bill under this arrangement we can pay higher benefits to eliminate or at least reduce your out of pocket costs.
While all doctors can be involved in Access Gap Cover, it is up to individual doctors to participate on a case by case basis.
Please speak with your doctor or specialist to see if they will participate in Access Gap Cover for any planned private hospital treatment. For a list of providers eligible to participate and who have agreed for their details to be published, please call us or use our online provider search.
Am I covered for ambulance?
FAQ Answer
Emergency Services Health - Unlimited Ambulance Cover Australia-wide
Did you know that to call an ambulance can cost around $900 depending on your state or territory?
In a medical emergency, the cost of calling an ambulance is not at the top of your mind, but the bill after can be quite a shock if you do not have an ambulance cover. Good news when you are insured with Emergency Services Health all policies include ambulance cover- Australia Wide no matter if you’re in your home state or visiting another part of Australia.
Comprehensive 100% Ambulance cover for emergency transport, clinically required non-emergency transport and treatment not requiring transport.*
What's not covered?
Benefits are not payable:
For elective ambulance transport or other non-eligible ambulance service, for example when you pre-book transport between locations such as going from a hospital to a nursing home.
When you’re covered by a third party arrangement**. For example where you are covered by an ambulance subscription or if you have access to a State/Territory ambulance transportation scheme.
If you are still serving waiting periods.
*May be subject to waiting periods and other conditions.
**Third Party Arrangements: Please note Queensland and Tasmanian residents have third-party arrangement ambulance services provided by state government schemes. In some other states, Department of Veterans Affairs Gold Card, pension and healthcare card holders may be exempt from paying for ambulance services. Under those arrangements, the relevant scheme is responsible for the cost and Emergency Services Health does not pay a benefit. If the benefit for any eligible ambulance treatment costs are not fully covered by an arrangement or scheme, Emergency Services Health will pay a benefit.
Annual Maximum
FAQ Answer
The Annual Maximum benefit payable for services received during the calendar year for particular service or group of services per person unless stated otherwise. The Annual Maximums start new on the 1st January each year (orthodontics maximum is determined by length of membership based on anniversary year). Emergency Services Health also provides a Rollover Benefit to most Extras.
Are there any Benefit limitation periods?
FAQ Answer
Other funds may apply benefit limitations which pay reduced benefits on one or more services for a set period of time that is no longer than normal waiting periods, then pay full benefits after this period.
At Emergency Services Health our hospital cover has no benefit limitation periods.
At Emergency Services Health our hospital cover has no benefit limitation periods.
Benefit limitation
FAQ Answer
At Emergency Services Health our hospital cover has no benefit limitation periods.
Other funds may apply benefit limitations which pay reduced benefits on one or more services for a set period of time that is no longer than normal waiting periods, then pay full benefits after this period.
Benefit limits for Extras
FAQ Answer
Emergency Services Health pays 80% back on most Extras services up to the benefit limits and subject to waiting periods, Annual Maximums and Rollover Benefits available.
To see examples of benefits paid please download a copy of our State Premiums & Benefits Guide.
Benefit Statements
FAQ Answer
Just received a benefit statement from us and want to know more? Take a look at these frequently asked questions.
Q. Is this a bill?
No. This statement is for your records only and outlines benefits paid on behalf of your membership with Emergency Services Health. If there are any additional out of pocket expenses your provider should have already advised you and may bill you separately.
Q. Why am I receiving this statement?
Statements are a good way for you to receive regular information about your cover and give you visibility of the claims paid on your behalf during the period. If a Hospital or Medical provider has made a claim on your behalf, you will receive a statement by email or post each month (depending on how you’ve asked us to communicate this type of message with you and in line with our Privacy Policy).
Q. Can I opt out of receiving a statement?
Since your statement is important for transparency of claims paid on your behalf, members are unable to opt out. Where no Hospital or Medical claims have been paid during the month, you will not receive a statement.
Q. I received medical or hospital treatment on the date stated, but I don’t recognise this provider. Who are they?
Some services may be performed by an assistant surgeon or an anaesthetist. Your treatment may have also included x-ray or pathology services. The name displayed would likely be for the provider who performed those services. If you are still concerned the provider is incorrect, please contact us and we can investigate the claim further.
Q. I do not remember engaging a provider to perform a service on the date stated. What is this claim for?
Please contact us with the date of service, provider and amount shown so we can investigate this for you.
Q. Can I have a statement for my Ancillary claims?
Yes, if you would like an Ancillary claim benefit statement at any time, please contact us. You will continue to receive a remittance advice when your Ancillary claims are paid.
Q. Why does my statement show a negative number?
Negative numbers normally reflect a claim adjustment for a previous period. If you would like further information about the adjustment, please contact us and we can investigate the claim further.
Q. Why does the Date of Service fall outside the statement date range?
There can be a delay between the date a service is provided and the date the claim is paid. The statement lists all claims paid during the period. Since you would already be aware of the date you received the service, the date of service is shown as a point of reference.
Q. Why is there a delay between the Date of Service and the date my claim was paid?
Hospital and Medical providers raise their accounts at various time frames from the Date of Service. This means we can receive these bills a considerable time after discharge. Once we receive a bill, we endeavour to pay the claims received as quickly as possible.
Q. What are “Medical claims”?
Medical claims are for inpatient (admitted to hospital) services only and reflect your private health insurance component of the benefit paid (does not include Medicare benefits where applicable). They do not cover services performed by a GP or Specialist not relating to an in-patient episode of hospital treatment.
Q. My statement includes all people within my membership. Can I have a statement showing only my own?
Yes. To request an ad hoc statement for only your claims, please contact us. Our monthly statements will continue to show all claims during the period.
Q. I am a dependant (child or partner) on the policy. Can I stop my claims displaying on their statement?
As per our Privacy Policy, a person over the age of 14 years may request to have their sensitive information kept private from other persons insured on the policy. Emergency Services Health will endeavour to keep the information private, but will be obliged to disclose information on request by the Contributor of the insurance policy, or a parent or guardian of the person. If any insured person aged 18 years or older wants to guarantee that their personal information (in particular sensitive information) is not disclosed to other persons on the health insurance policy, they will need to purchase their own health insurance policy.
To request your sensitive information be kept private from other persons insured on the policy, please contact us. Please refer to our Privacy Policy for further information.
Q. Why are other insured persons not showing on my statement?
There are a few reasons why a claim is not displaying on your statement. The claim may not have been paid during the statement period, or we may not have received the bill from your provider yet. Alternatively, as per our privacy policy, Emergency Services Health people have the ability for their information to be kept private. Please refer to our Privacy Policy for further information.
Q. A person is showing on my statement who was removed from my membership a few weeks ago. Why can I see their claims?
There can be a delay between the date a service is provided and the date the claim is paid. It is likely the claim was paid after the person left your membership. Since all claims paid during the period are displayed, this claim was included.
If you believe this may not be the case, please contact us and we can investigate the claim for you.
Q. My membership is currently suspended or closed – why am I receiving this statement?
There can be a delay between the date a service is provided and the date the claim is paid. It is likely the claim was paid after you suspended or closed your membership. Since all claims paid during the period are included in a statement, a statement has been generated for you.
If you believe this claim was not for you, please contact us and we can investigate the claim for you.
Q. I thought my Medical and Hospital claims were covered 100%. Why is the Total Benefit Amount different from the Provider Fee?
If you transferred to Emergency Services Health from another health fund, an excess may have still applied to your cover until the end of your waiting period. Gaps may also apply for theatre fees or some prosthetics. Any such discrepancies should have been brought to your attention prior to your service.
If the benefits paid do not match what you were expecting, please contact us so we can investigate the claim for you.
Q. Can I receive my statement by post instead of email (or vice versa)?
Please contact us to arrange this. Once you have answered some security questions we can change your preferences for general correspondence.
Q. How do I change my contact details, level of cover or the people included in my membership?
In line with our Privacy Policy, there are restrictions on who can update particular details within a membership. Please contact us to discuss which details you would like to change, any documentation required and who has authority on your membership to make the required change.
Can I buy glasses online from overseas and claim them on my extras cover?
Can I suspend my membership?
FAQ Answer
You can apply to have your membership suspended under certain circumstances:
Full suspension or partial suspension when you’re overseas, provided the application is made prior to the date of departure.
Full suspension while you continue to receive short-term income maintenance through Centrelink and are eligible for and/or have a Health Care Card for a minimum of 14 days.
To be eligible you must be covered by a health insurance policy with Emergency Services Health for a minimum of one month. The minimum period of suspension is 14 days, the maximum period of suspension is two years and the minimum period between suspensions is four months unless we agree otherwise.
For further information on our suspension policy simply call us on 1300 703 703.
Complaints & Dispute Resolution
FAQ Answer
At Emergency Services Health, we're constantly trying to improve the quality of our products, processes and services. Your feedback, good or bad, is an important part of this process.
If for some reason you are not satisfied, please let us know and we will work to resolve the problem. We can be reached in various ways:
- call a Customer Services Officer on 1300 703 703.
- email enquiries@eshealth.com.au
- send a fax to 1300 151 152.
- write to our postal address (Emergency Services Health, Reply Paid 84966, Halifax St SA 5000).
Our customer service officers can address a wide range of issues on the spot. If necessary, their supervisor will be on hand to discuss your concerns and, if you are still not happy, your complaint will be elevated to the senior manager responsible.
Private Health Insurance Ombudsman
If you are still not satisfied, you can contact the Commonwealth Ombudsman who provides an independent service for consumers with health insurance problems and enquiries.
The Commonwealth Ombudsman's contact details are:
Complaints Hotline: 1300 362 072
Website: www.ombudsman.gov.au and www.privatehealth.gov.au
View Emergency Services Health's Complaints Policy
Complementary Therapies
FAQ Answer
Emergency Services Health provides benefits for a range of recognised Complementary Therapies within extras cover.
In an area where the qualifications and skills of service providers can vary considerably, we employ the services of the Australian Regional Health Group (ARHG), an organisation providing expertise in the recognition of health service providers who assist 24 health funds around Australia. The ARHG applies a rigorous and well-considered criteria to the acceptance of the individual therapies and service providers, giving confidence to health funds and their members.
Please note from the 1 April 2019, the Australian Government has made changes to therapies eligible for cover.
|
THERAPIES COVERED |
THERAPIES NOT COVERED |
|
Myotherapy |
Apitherapy |
Note: Not a complete list.
Recognised service providers
While the vast majority of private service providers registered and practicing in Australia within an accredited therapy will be recognised by us for benefits, not all providers are recognised. Individual therapists are required to meet certain criteria in education, continuing work experience, professional education, hold appropriate professional indemnity and public liability insurance and have completed a prescribed number of hours of work experience.
So when you’re treated by one of the 25,000 Complementary Therapy providers around Australia that we cover, you’ll rest assured they’ve met these well-considered standards.
If you wish to ensure your provider is recognised by Emergency Services Health, please contact us prior to treatment.
Benefits paid
To provide for a fair distribution of Complementary Therapy benefits to all members we’ve established the following requirements:
The amount paid for a Complementary Therapy consultation is a set benefit of $30.
Waiting periods apply for new members or a member upgrading their cover.
One benefit is payable per day per person insured under a policy. If an insured person receives a consultation from two different providers under Complementary Therapies on the same day, then a benefit will be paid for only one of the consults.
If a service provider is recognised for more than one modality, say Remedial Massage Therapy and Acupuncture, and provides both services to you on the same day, then a benefit will only be paid for one service.
Benefit limits
Benefits for Complementary Therapies are subject to the combined annual maximum applying to chiropractic, osteopathy, acupuncture and complementary therapies.
Rollover
Complementary Therapies are subject to the combined rollover limit applying to chiropractic, osteopathy, acupuncture and complementary therapies.
Eligibility
FAQ Answer
Emergency Services Health cover is for people who are or were employed (including volunteering) in the provision of emergency services, and their family.
Eligible family members include a dependent child, an adult child, an adult child's partner/spouse, an adult child's dependent child, a sibling, a sibling's partner/spouse, a sibling's dependent child, a parent, or a grandchild. The primary sectors are;
Fire Response & Recovery Sector
- Currently or previously employed/volunteering for a Not-for-profit, Commercial, or a National, State or Territory Government Fire Department/Service or Association/Union.
- Currently or previously employed/volunteering for a registered training organisation and/or specialist emergency service equipment suppliers in the Fire Response & Recovery Sector.
Ambulance & Medical Response & Recovery Sector
- Currently or previously employed/volunteering for a Not-for-profit, Commercial, or a National, State or Territory Government Ambulance Department/Service or Association/Union.
- Currently or previously employed/volunteering for a Not-for-profit, Commercial, or a National, State or Territory Government Hospital Service or Association/Union.
- Currently or previously employed/volunteering in a medical, nursing or allied health capacity and are registered with the Australian Health Practitioners Regulation Agency (AHPRA), or currently or previously employed by such a person or related organisation.
- Currently or previously employed/volunteering for a registered training organisation and/or specialist emergency service equipment supplier in the Ambulance & Medical Response & Recovery Sector.
- This sector includes all practitioners registered with the Australian Health Practitioners Regulation Agency (AHPRA)
Water Response & Recovery Sector
- Currently or previously employed/volunteering for a Not-for profit, Commercial, or a National, State or Territory Government Life Saving (or Sea Rescue) Department/Service or Association/Union.
- Currently or previously employed/volunteering for a registered training organisation and/or specialist emergency service equipment supplier in the Water Response & Recovery Sector.
State Emergency Response & Recovery Sector
- Currently or previously employed/volunteering for a Not-for profit, Commercial, or a National, State or Territory Government Emergency Services Department/ Service or Association/Union.
- Currently or previously employed/volunteering for a registered training organisation and/or specialist emergency service equipment supplier in the State Emergency Response & Recovery Sector.
If you’re not sure call us on 1300 703 703.
Extras - What's covered?
FAQ Answer
For the majority of services provided by recognised providers, Emergency Services Health pays a generous 80% of the cost.
The waiting periods outlined in the above table may not apply if they have been served with another insurer prior to joining. Further waiting periods may apply for pre-existing conditions. For a list of example benefits please download our State Premiums & Benefits Guide.
Extras -What is not covered (non-exhaustive list*)
FAQ Answer
- Claims for a service that has exceeded the Annual Maximum and Rollover Maximum.
- A second and subsequent consult with the same professional on the same day.
- Where the service charge exceeds the fee recognised by Emergency Services Health, the benefit you receive may be less than 80% of your cost.
- Where the service provider is a partner, child or parent of the person being treated. Business partners within the practice are also excluded.
- Services incurred before a waiting period has been served.
- Services where a Medicare benefit is payable.
- Services that are provided outside of the Commonwealth of Australia.
- Services where an entitlement exists or may exist under any compensation, sports club or third party insurance.
- A claim for a service that is submitted more than two years after the date of service.
- Services provided by practitioners not recognised by the fund.
- Cancellation fees, for missed appointments, as set by the provider.
- Benefits for ambulance services covered by a third party arrangement such as a State/Territory transportation scheme.
* This provides a general description of what is not covered. Should you require information about a particular treatment or benefit please call us on 1300 703 703.
Fund Rules
FAQ Answer
Fund Rules are rules that set out your rights and responsibilities as a member of the Fund, including establishing the rules for payment of benefits.
All persons covered by a health insurance policy with Emergency Services Health are subject to the Fund Rules, which are subject to change.
Emergency Services Health will send a copy of the Fund Rules to an adult covered by a health insurance policy with Emergency Services Health, if it receives a written request from the person to do so.
Hospital - What isn't covered?
FAQ Answer
What is not covered (non-exhaustive list*)
- Services incurred before waiting periods have been served.
- Treatment for which Medicare does not pay a benefit, including cosmetic surgery. (Some benefits may be payable for hospital treatment following this surgery. Please call us for more details.)
- Services that are provided outside of the Commonwealth of Australia.
- Services where an entitlement exists or may exist under any compensation, sports club or third party insurance.
- A claim for a service that is submitted more than two years after the date of service.
- Outpatient services, unless there is an agreement between Emergency Services Health and the hospital.
- Pharmaceuticals not related to the reason for hospitalisation or not covered under the agreement with the hospital or provided on discharge.
- Exceptional high cost drugs where no or limited benefits are paid.
- Prostheses items that are not included on the Federal Government approved list.
- Charges greater than the benefit defined in the Federal Government’s Prostheses List.
- Personal and take-home items, e.g. newspapers, toiletries, television, hairdressing, manicure, etc.
- Treatment provided to a person in a private hospital emergency department.
- Aged care and accommodation in an aged care facility.
- If you’re in hospital for more than 35 consecutive days and not classified as an acute care patient, your benefits will significantly reduce.
- Benefits for ambulance services covered by a third party arrangement such as a State/Territory transportation scheme.
* This provides a general description of what is not covered. These are not “excluded or restricted” hospital treatments or services. Should you require information about a particular treatment or benefit please call us on 1300 703 703.
Hospital - What's covered?
FAQ Answer
These days many policies are paring back cover, not paying benefits for certain treatments (exclusions) or paying only limited benefits (restrictions). Not at Emergency Services Health. Our Gold Hospital cover is comprehensive and covers all treatments and procedures where Medicare pays a benefit.
Hospital 35-day rule
FAQ Answer
Hospital benefits are payable 365 days a year. However, if your hospital stay exceeds 35 consecutive days you must obtain and send us an Acute Care Certificate to continue receiving comprehensive benefits. Benefits will be reduced and out of pocket expenses apply where an Acute Care Certificate is not obtained.
The hospital is aware of this and will usually arrange a certificate on your behalf.
The hospital is aware of this and will usually arrange a certificate on your behalf.
How can I pay my premiums?
How health insurance works in Australia
FAQ Answer
The Australian Government provides certain incentives to encourage all Australians to take out private health insurance.
The Australian Government Rebate on private health insurance (Rebate)
The Australian Government Rebate on private health insurance (Rebate) is an incentive whereby you’re offered a Rebate on your private health insurance premiums. The level of Rebate on private health insurance is based on your household income and the age of the oldest person covered by the policy.
If you’re eligible for a Rebate you can choose to receive it either as a reduced premium or in a lump sum at tax time. Most people choose to take advantage of the lower premiums. See your State Premiums & Benefits Guide to help you work out which Rebate Tier may be applicable to you.
For more information on how to claim at tax time, visit ato.gov.au
Lifetime Health Cover (LHC) Loading
The Lifetime Health Cover (LHC) Loading is a legislated requirement that encourages you to take out private hospital cover early on in your life. You’re rewarded with lower premiums for taking out cover and maintaining it. This is how it works: if you wait until you’re aged 31 and take out private hospital cover in the following financial year, premiums will be 2% more expensive. This increases by 2% for each subsequent year you delay taking out private hospital cover. This additional percentage is called the LHC Loading.
For example, if you wait until you’re 40, you end up paying 20% more on your private hospital cover. Similarly, if you wait until you’re aged 50, you end up paying 40% more.
The LHC Loading is capped at 70% at age 65, and removed after 10 continuous years of appropriate private hospital cover.
In other words, the earlier you take out private hospital cover, the better, as deferring your decision can be costly.
Medicare Levy Surcharge (MLS)
Medicare Levy Surcharge (MLS) is a levy you should be aware of. Most Australian taxpayers are charged a 2% Medicare Levy. However, those who do not have appropriate private hospital cover may have to pay an additional levy called the Medicare Levy Surcharge (MLS).
A 1% MLS applies to couples or families without hospital cover who have a combined annual income greater than $180,000*, and singles earning more than $90,000*. This increases aligned to the income tiers as shown in your State Premiums & Benefits Guide. Family thresholds are increased by $1,500 for the second and subsequent dependent child.
Both partners must have hospital cover; otherwise, both have to pay the levy. If you have dependent children they also need to be covered by a policy or you may have to pay the levy, even if you’re separated. If you’re unsure how this might affect you, we recommend you seek further advice from your tax advisor or the Australian Taxation Office. For details on what income is included in the assessment please contact the ATO or refer to their website.
*Effective for 2019/20 and 2020/21 income years.
How to make a claim
FAQ Answer
Lodging claims with Emergency Services Health is easy. Depending on the service and provider, there are a number of ways to claim which have been listed below.
Extras Claims
On the spot claims on extras services
With the majority of extras claims such as dental and optical, health providers can process your claim on the spot using eftpos-style claiming facilities provided by HICAPS and iSOFT HealthPoint.
These are often referred to as "On the spot" claiming. On the spot claiming has become the preferred option for most policyholders, with more than 85 percent of eligible claims being processed this way.
All you have to do is swipe your membership card and sign to validate the service. Your claim will be automatically lodged with Emergency Services Health and we pay the provider directly.
There is no need to pay the full consultation fee up-front and then wait for reimbursement of your benefit. Just present your Emergency Services Health membership card, pay any out of pocket gap and you're done.
Who offers on the spot claiming?
To find out if your health provider offers on the spot claiming simply look for the HICAPS & iSOFT logo or contact your health provider.
You can also search online for health providers that offer HICAPS.
While Emergency Services Health accepts most claims on the spot, the service is not available for orthodontic, pharmacy, health appliances (including hearing aids), counselling and eye therapy. By handling these claims manually, we are able to deliver better and fairer benefits to our members for these services.
There may also be situations where benefits cannot be processed on the spot, or where there is no benefit entitlement. In these situations, you will be asked to contact Emergency Services Health.
Other extras services claims
Not all extras claims can be lodged on the spot. For extras claims that cannot be lodged on the spot simply fill out an Emergency Services Health claim form and send it with the relevant accounts and receipts to any of the three options:
Email: myclaim@eshealth.com.au (Include your membership number in the email subject line)
Mail: Emergency Services Health, Reply Paid 84966, Halifax St SA 5000
Free Fax: 1300 151 152.
Alternatively, if you are happy for the money to be paid into your nominated contributor account you can download the Emergency Services Health Mobile Claiming App.
To make your claim simply:
- Download the free App to your smartphone.
- Register your details in the App.
- Photograph your account items.
- Submit your claim, no claim form required!
Hospital Claims
Hospital claims generally come directly to us from the hospital and we send the claim payment back to the hospital. This means you don't have to make a claim.
Medical Claims
Access Gap Cover
Doctors billing under our Access Gap Cover will normally forward their account directly to Emergency Services Health. We then claim your Medicare entitlements and pay that, together with your Emergency Services Health benefit, directly to the doctor.
Payments
Cheques covering medical or extras services are made payable to you if you've paid the account or, if you haven't, to the provider of the service. In both instances, the cheques are sent to you (naturally if the payment is in your favour you can elect to have the payment direct credited to your financial institute).
If the account has not been paid, forward the cheque to the provider together with your portion of the payment.
How to fast-track your claims payments
If you have already paid the invoice from your medical or extras provider, Emergency Services Health offers PromptPay to ensure fast payment of your claim. With PromptPay your benefit is paid directly to your financial institution account as a direct credit.
Download our claim form, simply write "YES" in the box `Please Pay To My Bank Account Yes/No' and then fill in your nominated financial account details.
Lodgement of Claims
Claims must be lodged with Emergency Services Health within two years of the date of service. Claims older than two years will not be accepted.
I lost my membership card, what can I do?
I need to travel long distances to access specialist medical services, am I covered?
FAQ Answer
Each state has a government-sponsored travel and accommodation assistance scheme which provides assistance to a patient who, because of their locality, must travel long distances to access specialist medical services.
In addition, under certain circumstances, we offer travel and accommodation benefits to members who need to travel more than 200 kilometers from their home to receive inpatient hospital treatment. Please call us prior to admission.
IVF and other Assisted Reproductive Services
FAQ Answer
Emergency Services Health's Gold Hospital and Gold Combined includes cover for in-hospital services relating to In vitro fertilisation (IVF) and other assisted reproductive services that treat infertility. Normal waiting periods apply including the 12 month waiting period for pre-existing conditions.
It’s important to be aware that IVF treatment has several stages and only the components which involve admission to hospital as an ‘in-patient’, as well as those services that have a valid Medicare item number, are eligible for benefits.
Usually, the harvesting of eggs is the main surgical procedure in an IVF cycle and as this procedure is carried out in an operating theatre you’ll be admitted as an in-patient to hospital.
In this instance, Emergency Services Health’s hospital cover will provide a benefit toward the theatre fees, hospital accommodation, anesthetist and treating doctors’ fees. It is important to be aware that you may need to pay a gap if medical fees are more than the Medicare Benefits Schedule fee.
Some patients are also admitted as an in-patient for the embryo transfer procedure if so, the same benefit as described above applies.
IVF Services which occur outside of hospital admission (as an ‘out-patient’) cannot be covered by private hospital cover but may be claimable on Medicare or paid out of your own pocket.
There may also be additional costs associated with egg transportation, testing, and freezing that will need to be covered at your own expense.
Some pharmaceutical items such as IVF Nasal Sprays and Pessaries may also be partly covered under an Extras cover with Emergency Services Health.
Ask for an IVF quote.
To help determine what you will be covered for, we strongly recommend you ask your IVF clinic for a detailed quote of your expected treatment plan, including all medical item numbers.
Providing this quote to Emergency Services Health before undertaking treatment will assist us in being able to provide advice that is as accurate as possible based on the information provided in regard to what you are covered for and what costs you are likely to incur.
This help guide is intended as a brief summary and outline of benefits. For more information contact Emergency Services Health on 1300 703 703 or you can view additional resources on IVF on the Ombudsman’s website.
Lifetime Health Cover (LHC) Loading
FAQ Answer
The Lifetime Health Cover LHC Loading is a legislated Australian Government requirement that encourages you to take out private hospital cover early on in your life. You’re rewarded with lower premiums for taking out cover and maintaining it.
Once you turn 31, a 2% loading is added to your hospital cover premium for every year you’re without hospital cover. This is called the Lifetime Health Cover (LHC) loading.
How it Works
If you wait until you’re aged 31 and take out private hospital cover in the following financial year, premiums will be 2% more expensive. This increases by 2% for each subsequent year you delay taking out private hospital cover. This additional percentage is called the LHC Loading.
For example, if you wait until you’re 40, you end up paying 20% more on your private hospital cover. Similarly, if you wait until you’re aged 50, you end up paying 40% more.
The LHC Loading is capped at 70% at age 65, and removed after 10 continuous years of appropriate private hospital cover. The loading may be reapplied if you drop your hospital cover and then take up the cover again.
In other words, the earlier you take out private hospital cover, the better, as deferring your decision can be costly.
Family & Couples
What happens if you have had continuous cover but your partner/spouse on your policy has not?
The loading is calculated by taking an average of the loadings applied to the adults on the hospital cover. So, if one person has 20% loading and their partner has no loading, or 0%, the loading applied is 10% overall.
Permitted Days without Cover
If you have taken up hospital cover on or after your Lifetime Health Cover base day, then you can access the following 'permitted days without hospital cover' during which you do not have an active hospital policy, but your loading does not increase. For most people, your base day is the later of 1 July 2000 or the 1 July after your 31st birthday.
If you have hospital cover on or after your base day, you are entitled to 1,094 days without hospital cover that won’t affect your LHC loading status, see privatehealth.gov.au for more details.
Switching Health Funds
When you move funds, your LHC loading goes with you. When transferring cover, we will contact your previous insurer to obtain a Transfer Certificate. It’s a good idea to maintain your hospital cover up until the date that you transfer, to avoid using up any of your permitted days without cover unnecessarily.
Can I get my LHC Waived?
Private Health Insurers are legally required to apply LHC loadings to any new policyholders who were not privately insured under an appropriate cover by their LHC base day, which for most Australians is 1 July following their 31st birthday. New migrants to Australia can avoid incurring LHC loadings by commencing appropriate private hospital cover within 12 months of being registered as eligible for full Medicare benefits.
There is no function or clause in the legislation which regulates LHC which allows the Minister for Health, or their delegate, to waive a correctly calculated LHC loading under any circumstance.
New migrants to Australia
If you are a new migrant to Australia, then you have until the later of 1 July following your 31st birthday or the first anniversary of your full Medicare registration to take out private hospital cover without incurring a Lifetime Health Cover loading.
If the latter applies to you, your Lifetime Health Cover base day is the 12 month anniversary of your registration for full Medicare benefits (i.e. when you are eligible for a blue or green Medicare card).
Important Note
LHC loadings apply only to private patient hospital cover – they do not apply to general treatment cover (also known as ancillary or extras cover). The government does not pay the private health insurance rebate on LHC loading applied to the costs of a policy.
For more information around LHC
Medicare Levy Surcharge (MLS)
FAQ Answer
Medicare Levy Surcharge (MLS) is a levy you should be aware of. Most Australian taxpayers are charged a 2% Medicare Levy. However, those who do not have appropriate private hospital cover may have to pay an additional levy called the Medicare Levy Surcharge (MLS).
A 1% MLS applies to couples or families without hospital cover who have a combined annual income greater than $180,000*, and singles earning more than $90,000*. This increases aligned to the income tiers as shown in your State Premiums & Benefits Guide. Family thresholds are increased by $1,500 for the second and subsequent dependent child.
Both partners must have hospital cover; otherwise, both have to pay the levy. If you have dependent children they also need to be covered by a policy or you may have to pay the levy, even if you’re separated. If you’re unsure how this might affect you, we recommend you seek further advice from your tax advisor or the Australian Taxation Office.
For details on what income is included in the assessment please contact the ATO or refer to their website.
*Effective for 2019/20 and 2020/21 income years
Membership Conditions
FAQ Answer
This website does not contain all Emergency Services Health benefit details or conditions of membership.
These conditions are contained in the Fund Rules. In the event of any inconsistency between anything on the website and the Fund Rules, it is the Fund Rules which apply in all cases.
You can obtain a copy of the Fund Rules (excluding schedules) by contacting Emergency Services Health.
Non-recognised hospitals
FAQ Answer
Regrettably following negotiations, Emergency Services Health (Police Health Limited ABN 86 135 221 519) through the AHSA have been unable to reach agreement with Toowong Private Hospital on what we believe are fair fees.
Reaching agreement on the level of fees they charge and we cover is important as it avoids unnecessary pressure being placed on your health fund premiums.
Toowong Private Hospital have now terminated our agreement effective midnight 24 August 2017. From this date, new and increased fees may be charged by them for the hospital services they provide. These fees are likely to be higher than what Emergency Services Health recognise for benefit payment purposes, resulting in a portion of their fees not being covered by us and being borne directly by you.
Transitional arrangements are in place to provide protection for our members at this hospital if before 25 August 2017:
- Treatment has commenced.
- Treatment has been pre-booked and will be performed prior to 24 February 2018.
- A course of treatment has commenced (includes treatments for up to 6 months).
In these circumstances the hospital will bill patients in line with the existing agreement and Emergency Services Health will pay its benefits.
A list of possible alternate hospital facilities offering mental health programs and care nearby can be found below. These are all hospitals with whom we have agreements over the fees they charge which will generally be covered by Emergency Services Health.
- Brisbane Private - Brisbane
- Belmont Private – Carina
- New Farm Clinic – New Farm
- North West Private Hospital – Everton Park
- Pine Rivers Private Hospital – Strathpine
If you require or are planning treatment at Toowong Private Hospital please contact us to discuss how this could affect you. Likewise if you have any questions regarding your hospital cover, please contact us on 1300 703 703.
Pharmaceutical benefits
FAQ Answer
Under extras cover you’re eligible to receive pharmaceutical benefits towards prescription items that are not eligible for subsidy under the Government’s Pharmaceutical Benefits Scheme (PBS).
Emergency Services Health’s pharmaceutical benefits cover a wide range of items that require a prescription when dispensed from private recognised pharmacies, Australia-wide.
Emergency Services Health doesn’t restrict you to a limited list of prescribed items or direct you to particular pharmacies before you can claim pharmaceutical benefits. You can go to any private pharmacy to have your prescription dispensed and still be able to claim pharmaceutical benefits on eligible prescription items.
All you need to do when you receive your prescription items is ask the pharmacist for a detailed receipt or tax invoice that also describes the prescription items supplied to you and then submit a claim to Emergency Services Health along with the receipt or invoice.
Emergency Services Health will refund your cost over and above the first $23, up to a maximum pharmaceutical benefit of $60 per prescription item supplied. Some simple conditions apply.
Which prescriptions are covered?
There are a multitude of rules which cover the dispensing of prescriptions. However, for simplicity, we’ll divide them into two categories, Group 1 (PBS) and Group 2 (Non-PBS).
Group 1 (PBS)
PBS items are those listed for a Government subsidy towards their cost. This subsidy is paid directly to the pharmacy by the Government. Health Funds are not permitted to pay benefits towards government subsidised items.
Group 2 (Non-PBS)
Non-PBS items cover virtually all prescription items other than those listed in the PBS. Some common Non-PBS items include some asthma medications, antibiotics and contraceptive pills. Non-PBS items attract Emergency Services Health Pharmaceutical benefits.
Conditions
To provide for a fair distribution of Pharmaceutical benefits to all members we’ve established the following requirements:
You must pay the first $23 towards each prescription item supplied.
The maximum Pharmaceutical benefit paid by Emergency Services Health per prescription item supplied is $60.
The maximum Pharmaceutical benefits paid per person per calendar year is $600, but may be higher (up to $1200) where members are eligible for Emergency Services Health’s unique Rollover Benefit.
For prescriptions dispensed in quantities greater than the minimum standard packaged quantity (as determined by Emergency Services Health), the initial member cost of $23 may increase.
Waiting periods (2 months) may apply to Pharmaceutical benefits for new members or members upgrading cover.
Pharmaceutical benefits will only be paid for items that require a prescription for their supply and, for almost all items, they must be supplied through a pharmacy.
Excludes medication ordinarily available without a prescription, including where the medication is recommended, ordered, prescribed or supplied by a doctor.
Once the government lists a prescription item for subsidy on the PBS, Emergency Services Health will be unable to pay a Pharmaceutical benefit, and this includes restricted and authority required prescription items.*
*For a prescription item appearing on the PBS list with a restriction or authority requirement for subsidy on the PBS, Emergency Services Health may pay a Pharmaceutical benefit for the supply of the prescription item where the person does not meet the restriction or authority requirements.
Please note, changes within the PBS list occur frequently, where items previously covered and not covered change. This may affect Emergency Services Health Pharmaceutical benefits where items you may claim now may not be eligible for claims in the future and vice versa. For the most up to date PBS list visit http://www.pbs.gov.au/pbs/home or ask your pharmacist when filling your script.
This help guide is only intended as a brief outline of our Pharmaceutical benefits.
If you have any questions do not hesitate to contact Emergency Services Health on 1300 703 703
Pre-existing conditions
FAQ Answer
If a new member has a pre-existing condition before joining Emergency Services Health, they may need to serve a 12-month waiting period under the terms of our policy before benefits are payable for the particular condition. This does not apply for psychiatric care, rehabilitation or palliative care.
A pre-existing condition is one where signs or symptoms of your ailment, illness or condition existed at any time during the six months preceding the day on which you purchased your insurance or upgraded to a higher level of cover.
A medical practitioner appointed by Emergency Services Health (not your own doctor) is the only person authorised to decide that a condition is pre-existing. The practitioner must, however, consider any information regarding signs and symptoms provided by your own treating doctor or specialist.
A government leaflet containing further information is available by clicking here
Pregnancy and private health insurance
FAQ Answer
If you’re thinking of starting a family, now’s a great time to review your health insurance to make sure you’re happy with and understand your cover.
Everyone’s journey through family planning, pregnancy and beyond is unique. To help support you along your path, we’ve put together this resource as a general guide.
For more information please call us on 1300 703 703.
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IMPORTANT A 12 month waiting period applies to all private health insurance benefits for Obstetrics treatment (pregnancy and childbirth). This is an industry-standard enforced by most health insurers including Emergency Services Health so you need to think ahead to make sure you’re adequately covered. If you’re considering switching insurers and have already served relevant waiting periods on your current policy, we provide continuity of cover. For more information call us on 1300 703 703 |
Private Health Information Statement (PHIS)
FAQ Answer
All Australian health funds are required by law to provide Private Health Information Statement (PHIS) for each product they offer. PHIS's are important tools to aid the consumers of health insurance to review their existing policy or compare private health insurance products when making a purchasing decision.
There are three types of Private Health Information Statements:
- Hospital - describes the features and limitations of hospital cover, including the type of accommodation, which medical services are covered in full, part or not covered, waiting periods and additional payments (excesses, co-payments, and gaps),
- General Treatment - describes the features and limitations of general treatment cover, including which services are covered, waiting periods, benefit limits and example benefits for each type of service, and
- Combined - describes the features and limitations of a combined hospital and general treatment cover, with details as above.
A Private Health Information Statement gives a summary of the key product features only, it is a description of your cover.
You should not fully rely on the dollar amounts of premiums on the Statement as they are there for comparison purposes only, but are indicative. The actual premium may vary depending on your circumstances, for example, your age and your age when you first got health insurance. Benefits will vary depending on the details of your policy, the treatments you are having, the health service provider and the payment option you choose.
A government leaflet containing further information is available by clicking on the below pdf downloads
Government Brochures
Reasons to join
FAQ Answer
We believe we’re the best health insurer for emergency services employees, volunteers and their families because;
- We’re designed specifically for the emergency services community.
- We’re a not-for-profit health insurer with straightforward products, ensuring our members receive the best health cover at the best possible price.
- We keep it simple. You only have to choose between our comprehensive extras, hospital or both.
- We offer you freedom to choose your preferred hospital, doctor and any other service provider, such as your physiotherapist and dentist, as long as the provider is recognised by us.
- We’re part of Police Health, started in 1935 and looks after over 60,000 members of the policing community.
At Emergency Services Health, we make your private health insurance choices as simple as possible to ensure maximum value. We don’t cut corners, we don’t overload you with options, or opt-ins or opt-outs. Our products are simple and designed for life.
Recognised health providers
FAQ Answer
Recognised health providers are those who are in private practice in Australia and recognised by us. We only pay benefits for services by these providers. If you wish to ensure that your provider is covered please refer to our online provider search (for a non-exhaustive list) or speak to us prior to treatment.
Rollover Benefit
FAQ Answer
Most benefits for extra services, like your major dental, chiropractic and optical have Annual Maximums, which are renewed each calendar year.
To provide extra protection to our members we have developed our Rollover Benefit to give you greater assurance if something were to happen.
The Emergency Services Health Rollover Benefit allows members to carry over any unused Annual Maximum benefit that is not claimed during the previous calendar year into the following year. The Rollover Benefit covers most extras services, such as major dental and physiotherapy, and gives members more flexibility in using their limits.
Claims are always paid from the current year’s Annual Maximum before your Rollover Benefit is accessed.
New members are eligible for Rollover Benefit after just 12 months (2 years for major dental). The combined Rollover Benefit and the Annual Maximum are shown as the “Rollover Maximum”.
The Australian Government Rebate
FAQ Answer
The Australian Government Rebate on private health insurance (Rebate) is an incentive whereby you’re offered a Rebate on your private health insurance premiums. The level of Rebate on private health insurance is based on your household income and the age of the oldest person covered by the policy.
If you’re eligible for a Rebate you can choose to receive it either as a reduced premium or in a lump sum at tax time. Most people choose to take advantage of the lower premiums. See your State Premiums & Benefits Guide to help you work out which Rebate Tier may be applicable to you.
If you would like to register for the Rebate as reduced premiums on your policy contributions, simply fill out the Application for Australian Government Rebate on private health insurance form. Once registered you can choose to change your selected rebate tier anytime by emailing us at enquiries@eshealth.com.au.
For more information on how to claim at tax time, visit ato.gov.au
Thinking about having a baby?
FAQ Answer
Then it’s a good time for you to review your health insurance and make sure you understand what your policy does and doesn’t cover.
Waiting periods of up to 12 months can apply for pregnancy, birth and newborn related health services, so if you’re unsure whether you are on the right cover for your growing family, please give us a call on 1300 703 703.
Ensure your newborn is covered!
If you are an expecting adult* on a Family, Couple or Single Parent Family policy that includes hospital cover:
- Your baby will be immediately covered for treatment provided the policy contributor has served the appropriate waiting periods.
- You need to officially add your baby to your policy within six months of birth for the baby to be eligible for cover as it applies to the contributor of the policy (i.e. any waiting periods served by the contributor covered by the same policy will also be taken as served by the new baby). The baby's cover will be backdated to the date of the birth, provided they are registered within those first six months. This will not affect your premiums.
- If the baby is not registered within six months of birth, the child will be treated as a new member and all waiting periods will apply.
* The term 'adult' refers only to the adults defined in the policy, therefore excluding child dependents on the policy regardless of their age.
If you are the expecting adult on a Single policy that includes hospital cover:
- Your baby will not be covered for treatment.
- To add your new baby to your policy, you will need to contact Emergency Services Health within 2 months of birth and update your policy to either Family cover or Single Parent Family cover in order for the baby to be eligible for cover as it applies to the Contributor (i.e. any waiting periods served by the Contributor covered by the same policy will also be taken as served by the new baby). Cover will be backdated to the date of birth, and any additional premiums will be payable from the date of birth.
- If the baby is not registered within two months of birth, the child will be treated as a new member and all waiting periods will apply.
Call us on 1300 703 703 for more information.
Understanding Medicare
FAQ Answer
How much does Medicare cover for out hospital services?
Certain out-of-hospital medical services are paid by Medicare and are therefore not covered by private health insurance. These include visits to or by your doctor plus medical services (including pathology and radiology) when provided to you as an outpatient or in a hospital emergency department (as the patient is not admitted). A hospital visit by a paediatrician to a newborn also falls into this category if the baby has not been admitted to the hospital as a patient in their own right.
In all these cases, claims should be lodged with Medicare for payment.
Medicare pays 85% of its Scheduled Fee for medical services provided to people who have not been admitted to hospital.
How much does Medicare pay for in medical services?
Medicare pays 75% of the Scheduled Fee for medical services provided to people who have been admitted (in-patient).
Who pays the difference?
For medical services provided to you as a hospital in-patient, Emergency Services Health pays the gap between the Medicare benefit and the Scheduled Fee.
In the vast majority of cases where medical services are billed under our Access Gap Cover scheme, we can also cover the difference between the Scheduled Fee and actual fee charged. Where the fee exceeds that covered by Access Gap Cover, the service provider should advise you of any gaps that exist and what you will need to pay.
What about out-of-pocket costs?
We strive to minimise treatment costs to members. While we have succeeded in covering most situations, there are some occasions when members will incur a charge from the service provider:
Charges greater than the Scheduled Fee that do not fall within the Access Gap Cover.
Charges greater than those recognised for Access Gap Cover.
Non-in-patient medical services, including those medical services provided while treated in the emergency department of a hospital.
Visits by a paediatrician to a newborn who has not been admitted to hospital as a patient in their own right.
For more information on what Medicare covers visit this website.
Waiting periods
FAQ Answer
Like all private health funds, Emergency Services Health has waiting periods for new members, including people transferring from another insurer when taking out a higher level of cover. Waiting periods also apply to current members upgrading their cover.
Waiting periods are designed to protect the interest of our members. Without them, it would be easy for people to join only at the times when they need cover and to receive benefits. This would lead to higher premiums for all fund members.
At Emergency Services Health the waiting periods are:
Hospital benefits of Gold Hospital and Gold Combined:
- 2 months membership for all benefits, excluding accidents
- 12 months membership for obstetric treatment
- 12 months membership for pre-existing conditions, excluding psychiatric care, rehabilitation or palliative care.
- 12 months membership for continuous positive air pressure (CPAP) machines, and goods and services under Non-surgically Implanted Prosthesis and Appliances and other aids and appliances.
Extras benefits for Rolling Extras and Gold Combined:
- 2 months membership for all benefits, excluding accidents
- 12 months membership for major dental (like crowns and dentures) and orthodontics, hearing aids, nebulisers, blood glucose & blood pressure monitors, blood coagulation monitor and for pre-existing conditions
- 12 month membership for Rollover Benefit (2 years Major Dental).
Gold Combined:
- 3 years membership for corrective laser eye surgery.
It is important to note that if you are transferring from another insurer, waiting periods only apply to the level of cover that is greater the previously held.
For instance, if you previously had a top hospital cover with the previous insurer but with an excess, the waiting period only applies to the excess when joining Emergency Services Health.
A government leaflet containing further information is available by clicking here.
Pre-existing conditions
If a new member has a pre-existing condition before joining Emergency Services Health, they may need to serve a 12-month waiting period under the terms of our policy before benefits are payable for the particular condition. This does not apply for psychiatric care, rehabilitation or palliative care.
A pre-existing condition is one where signs or symptoms of your ailment, illness or condition existed at any time during the six months preceding the day on which you purchased your insurance or upgraded to a higher level of cover.
A medical practitioner appointed by Emergency Services Health (not your own doctor) is the only person authorised to decide that a condition is pre-existing. The practitioner must, however, consider any information regarding signs and symptoms provided by your own treating doctor or specialist.
A government leaflet containing further information is available by clicking here
What benefits are there for counselling?
FAQ Answer
How do Emergency Services Health’s counselling benefits work?
As part of our commitment to supporting the mental health and wellbeing of our Members, Emergency Services Health offers counselling services in our Extras cover.
As the counselling profession is unregulated, benefits will only be claimable by recognised providers. In order to qualify as recognised providers, counsellor’s must be registered with either the Australian Counselling Association (ACA), or the Psychotherapy and Counselling Federation of Australia (PACFA) and be in private practice whilst meeting a set of practice and educational criteria. This ensures our members can have confidence in the counsellors we recognise.
With the new benefit in place, eligible members will be able to claim back 80% of the cost of a counselling session, up to $80. Benefits are payable for one-on-one sessions, couples/family sessions and group sessions.
Counselling benefits and Psychology benefits have a combined Annual Maximum of $850, with a combined Psychology and Counselling Rollover Benefit of up to $1700 per person. *
*Subject to waiting periods and other conditions.
What criteria do counsellors need to meet to become recognised?
Emergency Services Health have partnered with the Australian Counselling Association (ACA) and the Psychotherapy and Counselling Federation of Australia (PACFA) to ensure a counsellor meets our requirements to be registered for counselling benefits with Emergency Services Health.
Both ACA and PACFA have various levels of membership determined by the counsellor’s education, experience and training. Both organisations require their members have professional supervision each year and complete minimum amounts of ongoing professional development.
A counsellor must meet the following requirements for counselling benefits with Emergency Services Health:
1. Hold a level 2, 3, or 4 membership with the Australian Counselling Association, or hold membership as a Clinical Registrant of Mental Health Practitioner with Psychotherapy and Counselling Federation of Australia; and
2. Hold appropriate public liability & professional indemnity insurance and appropriate first aid certification; and
3. Be in a private practice (organisations that are government owned or receive government funding do not qualify as a private practice)
When a counsellor meets the above requirements they apply directly through the ACA or PACFA to be registered as a Emergency Services Health provider for payment of counselling benefits.
A counsellor may be registered with more than one counselling association.
How can my counsellor register as a Police Health recognised provider?
Your counsellor should contact the Australian Counselling Association (ACA) or the Psychotherapy and Counselling Federation of Australia (PACFA) directly to determine and make application to be recognised for benefits by Emergency Services Health.
How can I find a recognised counsellor near me?
To help you locate a recognised provider, we are developing an online search function which will enable you to search for a recognised provider. In the meantime, please call us on 1300 703 703.
As Emergency Services Health is leading the way in providing health insurance benefits for counselling, the number of registered providers is still growing. If you can’t find a recognised provider near you we encourage you to check back again in a few weeks as new providers continue to come on board.
For members who are consulting a counsellor not yet registered for benefits, please encourage them to enquire with the ACA or PACFA so that benefits may be paid by Emergency Services Health.
What do I need to know if my child needs braces?
FAQ Answer
Orthodontics can vary considerably in the period of treatment, cost and how you’re billed.
Before agreeing to commence orthodontic treatment determine your payment plan with the provider. This may involve an upfront payment followed by instalments during the expected treatment period. Ask the provider what options are available and for a written plan once it’s agreed to.
Should you choose to pay for the total treatment up front, please be aware Emergency Services Health benefits will be spread over the treatment period and are subject to Annual and Lifetime Maximum limits and waiting periods. For more information please call us.
Please note, that while orthodontic annual limits are per calendar year, the amount you’re eligible to claim in your first 4 years of membership is determined by your length of membership based on anniversary year.
Transferring from another fund? Give us a call to check what benefits you will receive in your anniversary year.
What does a Members Health Fund Alliance mean?
FAQ Answer
Members Health is the peak industry body for an alliance of health funds that are not-for-profit or part of a not-for-profit group, member owned, regional and community based, and who all share a common ethic of putting their members’ health before profit. We are the voice of an alliance of 27 health funds, representing the interests of more than 3 million Australians.
Australia’s health insurance is dominated by a listed company and an overseas-based multinational. Australians need to know there are still Australian health funds that are run to benefit their members. We believe passionately that health insurance is about protecting the health of members, not making profits for others.
What does no excess or co-payments mean?
FAQ Answer
Other funds may charge an excess (an excess is an amount you agree to pay towards the cost of hospital treatment).
For example, if you have an excess of $500, when you’re admitted to hospital you’ll have to pay the first $500 of the hospital costs on top of anything else not covered by your policy. Similarly, some insurers charge a co-payment, which is the agreed amount you’ll pay per day in the hospital. At Emergency Services Health our hospital cover has no excesses or co-payments (other than where a waiting period applies).
What does no exclusions and restrictions mean?
FAQ Answer
Other funds may apply exclusions (you agree not to be covered at all for certain treatments). For example, you may have hospital cover but it excludes joint replacement.
Other funds may also apply restrictions (you agree to receive very limited benefits for certain treatments). For example, you may be covered for joint replacement only at a public hospital, and if the joint replacement is undertaken in a private hospital, basic accommodation benefits and no theatre fee benefits are paid, leaving your benefit well short of the cost.
At Emergency Services Health our Gold Hospital cover has no exclusions and no restrictions.
It’s important to note that all health insurers are governed by the Private Health Insurance Act 2007. This legislation sets out what health insurers can and cannot pay benefits towards. Within the hospital as an inpatient, health insurers can only pay benefits towards treatment and procedures where Medicare pays a benefit. That means for some services, like elective cosmetic surgery, health insurers cannot pay a benefit towards this treatment, and this is not classed as a restriction or an exclusion on a policy.
Why don't you offer different levels of cover?
FAQ Answer
The nature of health insurance is that you never know what health service you might need or when you might need it.
We often hear stories of those who get caught out by having inadequate cover when an unexpected health crisis takes hold. For that reason, Emergency Services Health provides only top level (comprehensive) cover.
By offering only top-level cover you can be assured that you will be looked after when the need to use your cover arises. It’s really quite simple, just great cover giving total peace of mind to you and your family.
Will you pay benefits towards my Pilates treatment?
FAQ Answer
Emergency Services Health does not provide a benefit structure for Pilates, either as a separate category or under our Complimentary Therapy category. Therefore, Pilates becoming an excluded natural therapy treatment from 1 April 2019 under the Government’s Private Health Insurance Reforms has had no effect on our existing benefit structure.
However, it’s important to clarify that under our Extras cover we do, and will continue to, provide Physiotherapy benefits to members visiting a physio who uses exercises or techniques drawn from Pilates as part of treatment - as long as the exercises or techniques are within the accepted scope of clinical practice. Benefits do not extend to instances where a physio (or any other health professional) conducts a Pilates session (either advertised or promoted as such) where the only service provided is Pilates exercises.
This distinction is self-assessed by your physio, who will bill differently depending on the service provided. So if in any doubt, talk to your physio before your treatment.
Your choice of doctor
FAQ Answer
We give you the freedom to choose.
Choose your preferred hospital, doctor or any other service provider, such as your physiotherapist and dentist, as long as the provider is recognised with us.
What does this mean?
Emergency Services Health will only pay benefits for services from recognised providers.
Individual providers are required to meet certain criteria in education, continuing work experience, professional education, hold appropriate professional indemnity and public liability insurance and have completed a prescribed number of hours of work experience. This protects our members, to ensure they are getting reputable care.
Practitioners in the dental, chiropractic and physiotherapy fields can apply through Medicare to be accredited.
Providers in fields of complementary (alternative/natural) services can apply to police health is to be recognised. Police Health enlists the help of the Australian Regional Health Group (ARHG), who provides expertise in the recognition of health service providers.
We use the Australian Health Services Alliance (AHSA) for hospital contracting.
To find out if your provider is recognised by us, please call us on 1300 703 703.
Members
LESS PAPERWORK THIS TAX TIME If you’re registered to receive the Australian Government Rebate on private health insurance through us, you will not need to collect a Private Health Insurance Statement (tax statement) from us for FY 2019/20 as information will be forwarded directly to the Australian Taxation Office (ATO) on your behalf. If for some reason you still wish to attain a copy of this statement, you’ll be able to download one from our Online Member Services (OMS) portal today.
As a not-for-profit, everything we do is about giving back to you.
Get more value and benefits from your private health insurance, without the hassle.
Did you know lodging claims with Emergency Services Health is easy? Here's everything you need to know on how to claim with our Extras and Hospital cover.
Manage your policy 24/7
IMPORTANT NOTICE: Changes to Bpay biller code from 20 June 2020: Please use new Bpay Biller Code 556449
COVID-19 UPDATES
As Australia’s healthcare system fast returns to pre-pandemic capacity, we’ve been monitoring claiming behaviour and access to services closely in order to balance our commitment to providing COVID-19 relief, while still ensuring we can pay benefits towards the services you need.
To support you while Australia focuses on containment of COVID-19, we’re extending our 4% COVID-19 Premium Discount for a further month, to total $2 million in member discounts applied since April. The discount will be automatically applied to any premium payments made on or before 14 August 2020.
Stay up to date with the latest information about COVID-19 here.
Understanding our ambulance cover
Your private health insurance guide to hospital
Rollover Benefit Explained
Find a Doctor - Access Gap Cover Search
Access Gap Cover eliminates, or substantially reduces, the out-of-pocket expenses that are part of a hospital stay for people with private health insurance. We have arrangements with a majority of doctors around Australia where, in most cases, our members will be fully covered for in-hospital medical treatment, or will at least be advised prior to treatment of any gaps that might exist.
You can search for participating doctors by specialist group, doctor name, and locality. You can also call us on 1300 703 703 or your doctor to verify if you will be covered in the Access Gap Scheme before treatment.
Find a Contracted Hospital
We have agreements with most private hospitals that are likely to be be accessed by members. These agreements (as part of Police Health Limited) ensure that an agreed schedule of fees (including in-patient accommodation, thatre and special unit accommodation fees as appropriate) is charged by the hospital and paid by us on our member's behalf.
Please note that a member's benefit entitlements will be affected by factors such as their level and type of cover and the financial status of their membership. This will affect the amount we will reimburse to the hospital. We strongly recommend you contact us on 1300 703 703 to confirm your benefit entitlement prior to recieving hospital treatment. If you choose a non-agreement hospital you may incur out-of-pocket expenses for hospital related sevices irrespective of your level of cover.
Emergency Services Health Mobile Claiming App
As a member of Emergency Services Health, we’ve got your back. Our Emergency Services Health App lets you manage your health cover 24/7.
Use the app to:
Easily make a claim for you or your dependents
Access benefit limits and cover details
View your claims history
Update your contact details
Who can use the Emergency Services App?
Anyone can access general fund information via the app, but to use features relating to your membership, you must be an Emergency Services Health Member and have registered your online membership account.
Where can I claim on the spot using my member card?
We like to make claiming on your health insurance easy, and one of the easiest ways to make a claim is through HICAPS – the system that lets you swipe your Emergency Services Health membership card to make a claim on the spot. HICAPS claiming isn’t available for everything, but this handy search function will help you identify times when it likely is.
Before you begin your search it’s important to note that this search facility is provided by HICAPS and therefore may include some health providers not recognised by us for on the spot claims, but may still be claimable*. The search may also include health providers not recognised by us for any payment of benefits and therefore won’t be covered by us. These situations are rare however members may wish to confirm that their health provider is recognised for benefits prior to service by contacting us directly.
On the spot HICAPS claiming is not available for;
- orthodontic,
- pharmacy,
- health appliances (including hearing aids),
- eye therapy.
To learn more on how you can claim for the above items, click here
Bushfire Relief Options for Members
Emergency Services Health is committed to providing relief options for members who have been significantly impacted.
Nourish Baby
Your one stop shop for all things baby.
If you’re trying or expecting a baby, members can now gain access to the Nourish Learning Hub.
Complaints & Dispute Resolution
At Emergency Services Health, we're constantly trying to improve the quality of our products, processes, and services.
Your feedback, good or bad, is an important part of this process.
If for some reason you are not satisfied or you would like to pass on some feedback, please let us know and we will work to resolve the problem.
Our customer service officers can address a wide range of issues on the spot.
If necessary, their supervisor will be on hand to discuss your concerns and, if you are still not happy, your complaint will be elevated to the senior manager responsible.
Emergency Services Health is brought to you by Police Health Limited ABN 86 135 221 519.
View our Complaints Policy Here, or contact us via your preferred option below.
Call Us
1300 703 703
Email Us
enquiries@eshealth.com.au
Write To Us
Emergency Services Health
Reply Paid 84966 Halifax St SA 5000
Fax Us
1300 151 152
Private Health Insurance Ombudsman
If you are still not satisfied, you can contact the Commonwealth Ombudsman who provides an independent service for consumers with health insurance problems and enquiries.
The Commonwealth Ombudsman's contact details are:
Complaints Hotline: 1300362072
Website: www.ombudsman.gov.au and www.privatehealth.gov.au
Claiming made easy
Get more value and benefits from your private health insurance, without the hassle.
Lodging claims for Extras with Emergency Services Health is easy. Depending on the service and provider, there are a number of ways that you can claim.
Emergency Services Health Mobile Claiming App
As a member of Emergency Services Health, we’ve got your back. Our Emergency Services Health App lets you manage your health cover 24/7.
Use the app to:
-
Easily make a claim for you or your dependents
-
Access benefit limits and cover details
-
View your claims history
-
Update your contact details
Who can use the Emergency Services App?
Anyone can access general fund information via the app, but to use features relating to your membership, you must be an Emergency Services Health Member and have registered your online membership account.
Take the first step in having cover like no other - get a quote now!
On the spot claims on extras services
With the majority of extras claims such as dental and optical, health providers can process your claim on the spot using EFTPOS-style claiming facilities provided by HICAPS and iSOFT HealthPoint.
These are often referred to as "On the spot" claiming. On the spot claiming has become the preferred option for most policyholders, with more than 85 percent of eligible claims being processed this way.
All you have to do is swipe your membership card and sign to validate the service. Your claim will be automatically lodged with Emergency Services Health and we pay the provider directly.
There is no need to pay the full consultation fee up-front and then wait for reimbursement of your benefit. Just present your Emergency Services Health membership card, pay any out of pocket gap and you're done.
Who offers on the spot claiming?
To find out if your health provider offers on the spot claiming simply look for the HICAPS & iSOFT logo or contact your health provider.
You can also search online for health providers that offer HICAPS.
While Emergency Services Health accepts most claims on the spot, the service is not available for orthodontic, pharmacy, health appliances (including hearing aids), counselling and eye therapy. By handling these claims manually, we are able to deliver better and fairer benefits to our members for these services.
There may also be situations where benefits cannot be processed on the spot, or where there is no benefit entitlement. In these situations, you will be asked to contact Emergency Services Health.
Other extras services claims
Not all extras claims can be lodged on the spot. For extras claims that cannot be lodged on the spot simply fill out an Emergency Services Health claim form and send it with the relevant accounts and receipts to any of the three options:
-
Email: myclaim@eshealth.com.au (Include your membership number in the email subject line)
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Mail: Emergency Services Health, Reply Paid 84966, Halifax St SA 5000
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Free Fax: 1300 151 152.
Alternatively, if you are happy for the money to be paid into your nominated contributor account you can download the Emergency Services Health Mobile Claiming App.
How to receive your benefits faster!
Claim as soon as possible - provide us with your bank account details so your benefit is paid directly to your account. Claims for services older than two years will not be accepted.
More Information
Your Private Health Insurance Guide To Hospital
What’s different when you have private health insurance?
This guide explains your rights and responsibilities as a private patient entering hospital – what you should know and what you should ask, whether you have hospital cover or not.
Waiting periods for claiming on Hospital and Extras
Depending on your circumstances, you may have a period of time you need to be covered before you’re eligible to claim on certain procedures or services.
But if your switching from another fund and you have already served your waiting periods, they witch with you so you will not have to serve them again.
Frank & Kathy
June 2016
We were quite surprised to find Emergency Services health offered a really comprehensive package tailored just for us. The price is right for what you get too. All enquiries have been answered either by email or on the phone. Highly recommend this for all members seeking health insurance.
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