Access Gap Cover

What is Access Gap Cover?

Access Gap Cover (AGC) is a billing scheme that aims to reduce or eliminate out-of-pocket expenses to members for doctor and specialist services received in hospital. Doctors may choose to participate in AGC on a patient by patient basis, so you should discuss this with your doctor.
Why won't my doctor or specialist participate in Access Gap Cover?

It is up to your doctor or specialist to decide whether to charge you under the Access Gap Cover scheme. Even if the doctor has participated in this scheme before it does not automatically guarantee that the doctor has participated in Access Gap for your treatment. Doctors and specialists are free to choose whether they will participate on a patient-by-patient basis. This decision remains solely with the doctor or specialist.

Benefits / Claiming

Benefit limits are per calendar year. What does this mean?

A calendar year is from 1 January to 31 December. Overall benefit limits are available between this yearly period. Once a benefit limit is reached over the course of a calendar year it will not be refreshed until 1 January of the following calendar year.
How many Extras services can I receive benefits for in one day?

Benefits are limited to one service per patient, per provider, per day.

If a provider performs more than one consultation, the treatment that attracts the higher benefit will be paid.

Where multiple visits/services are performed on the same day at different times by the same provider, then the visit/service that attracts the higher benefit will be paid.
Am I covered for medical procedures in my doctors’ room rather than a hospital?

If you receive services in your doctors' room rather than a day surgery or hospital you are only entitled to benefits from Medicare. We will not pay a benefit for services outside of a hospital for non admitted patients.

Medicare will pay 85% of the Medicare Benefits Schedule (MBS) fee, and you will be required to pay the remainder of the account.
Can I claim benefits back for doctor/specialist appointments?

Your private Hospital cover takes effect when you are admitted to hospital. Any out-of-hospital medical expenses incurred (scans, blood tests, appointments) will not be covered by your private health insurance. They may be covered to some extent by Medicare.
How can I claim for Healthy Lifestyle benefits such as gym membership?

To be eligible to claim for Healthy Lifestyle benefits the program or service must be approved by Teachers Health Fund and received as part of a health management program intended to prevent or help a specific health condition. To comply with legislation, we require your health professional (e.g. GP, medical specialist or Allied Health provider) to sign the Healthy Lifestyle supporting documentation form.

Benefits are not payable for meal replacement products or prepared food.
The benefit limit says 75%, how does this work?

Healthy lifestyle offers a benefit of 75%. This means that you will receive a benefit of 75% of the cost up to the maximum limit available on your level of Extras cover. For example, if you have Top Extras cover and purchase a 10 pack of Pilates classes you are entitled to 75% of the cost of the Pilates classes up to $200 per person. Essential Extras has an overall limit of $150 per person and StarterPak has an overall limit of $150 per person and $300 per family.




Eg:CostBenefit available for Top Extras coverBenefit received
10 pack pilates class$25075% up to $200 per person$187.50
What pharmaceuticals am I covered for?

Benefits are payable for drugs prescribed by a doctor that are not covered by the Pharmaceutical Benefit Scheme (PBS) but are approved by the Therapeutic Goods Administration (TGA). You can claim a benefit for the difference between the actual cost of the item and the PBS co-payment amount up to a maximum amount of $60.
What out-of-pocket expenses can I expect for extras services?

The out-of-pocket expense will be the difference between what the provider charges and the benefit we pay. For example if you see a physiotherapist (second visit) and are charged $70 for a standard consultation you will receive a $40 benefit from Teachers Health Fund. This will leave you with a $30 out-of-pocket charge.
What is an increasing limit and how does it work?

Increasing limits are calculated based on years of continuous membership of Teachers Health Fund Top Extras cover. This means that the longer you hold Top Extras cover with us the higher the overall benefit will be for major dental and hearing aids. Loyalty limits accrued at other health funds are not transferable.

Increasing limits also applies to Orthodontia. Loyalty limits accrued for Orthodontia at other health funds can be transferred to your Teachers Health Fund membership when you change funds, this is only applicable to new memberships effective from 1 January 2012 and where evidence of continuous unbroken cover is provided by the member.
My child has been admitted to a public hospital and I am required to stay with him/her in the hospital overnight

If you have Top Extras cover, a benefit of $30 a day up to a maximum of $200 per person per calendar year is payable.
I need to travel more than 200km (return trip) to receive treatment for a serious medical condition.

If you have Top Extras cover, a benefit of 15 cents per kilometre up to a maximum of $400 per person per calendar year is payable for a serious medical condition requiring treatment that is not available closer to your home and confirmed by a doctor or specialist. A benefit is not payable for ambulance transportation or where the distance is less than 200km return from your home.
Where fund benefits are not payable

There are certain circumstances that will prevent the payment of a claim including:

  • Lodgement of claim two years or more after the date of service

  • When you or someone on your membership have the right to recover costs for a third party or authority, either by law or by statute, or from any insurance or employment benefits scheme

  • When no charge has been raised (services received is free of charge)

  • For any period during which your membership is unfinancial or suspended

  • Waiting periods have not been served

  • Provider is not recognised by Teachers Health Fund at the time the service is received

  • The official receipt is not provided

  • A member has been treated by a provider related to them

  • For services not provided face-to-face (with the exception of telepsychology services provided by a registered psychologist)

  • For hospital and general treatment received, or goods purchased overseas
What constitutes an official receipt?

A receipt must be on official letterhead or stamped with a provider stamp containing the:

  • name of the practitioner providing the service

  • address where the service was provided

  • contact number for the provider

  • provider number (where available or practical) and/or registration number of provider with professional associations

  • If an account or receipt is produced electronically it should be signed at the time of issue either by the provider or their representative


The receipt should be itemised with the following details:

  • the name of the patient receiving the service

  • the date of each individual service provided

  • the type of each individual service provided

  • the cost of each individual service provided

  • a body part identifier, prescription/script number or tooth identification where required
    whether the account has been paid or not

  • handwritten provider details and alterations to accounts will not be accepted

Excess

What is an excess?

An excess is an amount you pay each calendar year when admitted to hospital. Choosing a product with an excess reduces your premium and is only payable if you are admitted to hospital.

The excess you pay will depend on the level of your cover and excess you choose.
When do I pay the excess?

If you have Top Hospital 300/500, Mid Hospital 300/500 or Basic Hospital 300 you will be required to pay an excess towards your hospital admission. This excess is paid directly to the hospital. Be sure to ask the hospital how and when they would like to receive this payment.
HOSPITAL COVER EXCESS
Top Hospital 300 $300 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for family, couple or single parent memberships. Excess is waived for dependants under the age of 21. Only payable when admitted to a private hospital or day surgery.
Top Hospital 500 $500 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for family, couple or single parent memberships. Excess is waived for dependants under the age of 21. Only payable when admitted to a private hospital or day surgery.
Mid Hospital 300 $300 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for family, couple or single parent memberships. Excess is waived for dependants under the age of 21. Payable when admitted to a private or public hospital or day surgery.
Mid Hospital 500 $500 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for family, couple or single parent memberships. Excess is waived for dependants under the age of 21. Payable when admitted to a private or public hospital or day surgery.
Basic Hospital 300 $300 per person, per calendar year. This excess is paid once per person, per calendar year to a maximum of twice per membership for family, couple or single parent memberships. Payable when admitted to a private or public hospital or day surgery.

Fraud prevention

As a not-for-profit organisation, Teachers Health Fund exists for our members and we work hard to improve efficiencies, reduce operating costs and keep contribution rates as low as financially sustainable.

An area that is increasingly impacting on our operating expense is false claims, or more accurately – fraud. Each year we find that the volume of fraudulent claims increase despite our monitoring and audit processes.

Private Healthcare Australia estimates that millions of dollars are lost every year in private healthcare through fraud and inappropriate claiming. Every dollar of this ultimately affects the contribution rates of those holding private health insurance, with fraud causing resources to be diverted away from the payment of necessary services and legitimate claims.
What is fraud?

Fraud can occur through a healthcare provider or health fund member providing misleading or false information or withholding information. Examples include:
- Charging for treatment(s) that have not been provided
- Creating false documents
- Altering accounts to increase financial benefits
What is Teachers Health Fund doing to detect and prevent fraud?

At Teachers Health Fund we have a dedicated investigations team that engages in a variety of activities designed to either prevent such losses, or detect and recover these losses on behalf of our members.
What can you do?

To help ensure that your membership is protected from fraud or misuse and help us keep premiums as low as possible, don’t forget to:
- Report any stolen or lost membership cards within 24 hours
- Never leave your membership card with service providers
- Check your limits online
- Keep your online member services password safe and change it regularly
- Always check your receipts including signing for services claimed electronically

Teachers Health Fund and the investigations team will always treat any concerns raised with the utmost confidentiality and protect your identity or respect your right to remain anonymous.

Members can assist us reduce fraud by reporting any suspicious activity to:
Fraud Hotline: (02) 8346 2207
Email: investigations@teachershealth.com.au

Going to hospital

I need to go to hospital for surgery or treatment. What should I do?

Have a read of the Hospital Guide so you can get a better understanding about what you should know before going to hospital. We strongly encourage you to contact Teachers Health Fund before scheduling your surgery or treatment to ensure that you are covered and to check if the hospital of choice is an 'Agreement Private Hospital'. We can also help you understand what your out-of-pocket expenses may be.
What may I have to pay for during my hospital stay?

There are some services that you may receive in hospital that are not covered by us. These include:

- Telephone charges
- TV hire, internet access or other items of a non-medical nature
- Pharmaceuticals that are not covered in the agreement with the hospital or that are listed under the Pharmaceuticals Benefits - Scheme (PBS).
- X-rays, scans and other tests
Am I classified as an inpatient (admitted in a hospital) when having chemotherapy or dialysis on a daily basis?

You will be covered for chemotherapy or dialysis received on a daily basis as long as the hospital you are receiving the treatment from has an agreement with Teachers Health Fund and admits you as a day patient.
What happens if I get taken to hospital in an emergency?

In an emergency situation, you will be taken by an ambulance to the nearest accident and emergency department of a public hospital. In this situation you have the right to choose to be treated as a public patient at NO charge, by a doctor appointed by the hospital. You are fully covered for the emergency ambulance transportation provided by a State Government Service (including State Government air ambulance) under Teachers Health Fund Hospital and Extras cover.

If you are taken to an accident and emergency department at a private hospital you will be charged for treatment as an out-patient and there will be no benefits available from Teachers Health Fund for medical charges raised by doctors or facility fees raised by the hospital’s accident and emergency department.

Joining Teachers Health Fund

How can I join?

Joining Teachers Health Fund is fast, easy and hassle free. You can join:

- Online;
- Over the phone, by calling 1300 727 538;
- Or, by completing a printed application form.
Am I eligible to join?

As a restricted membership health fund, you must meet the eligibility criteria in order to join Teachers Health Fund. Eligible members include:

Teachers and academics:
If you are a full-time, part-time or student member of any of the following education unions, you are eligible to join:

- New South Wales Teachers Federation
- Australian Education Union (AEU) and affiliated unions
- Independent Education Union (IEU) and affiliated unions
- National Tertiary Education Union
- State School Teachers Union of Western Australia
- Institute of Senior Education Administrators

Administration and support staff:
If any of the following criteria describe you, then you are also eligible to join:

- A member of the Institute of Senior Education Administrators NSW (SEANSW)
- A current or former staff member employed by the NSW Department of Education and Training, The Office of the NSW Board of - Studies, the Institute of Teachers or in the TAFE Commission, who is (or was) a member of an appropriate union, where one exists.
- A current or former employee of the NSW Teachers Federation or Teachers Mutual Bank (formerly known as Teachers Credit Union) who is (or was) a member of an appropriate union, where one exists.

Family members:
The family of existing Teachers Health Fund members are also eligible to join. Eligible family members include:

- A partner or former partner, including same-sex and de facto partners
- Dependant and adult children, including their partner and children
- Siblings, including their partners and children
- Grandchildren
- Parents
Do you have a 'cooling off' period?

Our cooling-off period means that if you change your mind within 30 days from the date your health insurance policy started, we will cancel your membership and provide a full refund, providing no claims have been paid during this period.
Transferring to Teachers Health Fund

If you are already with another fund and would like to switch to Teachers Health Fund you just need to join online or complete an application form ensuring you fill out the clearance certificate section. This gives us permission to organise the transfer for you and also understand your level of cover and waiting periods already served.
What is a Standard Information Sheet (SIS)?

A Standard Information Statement gives a summary of the key product features. Health funds are required by law to provide these Statements so you can review your existing policy or compare it to other products. It allows you to see if your broad needs are covered by a product by displaying benefit entitlements, restrictions, and eligibility requirements to join a fund, if any. If you would like a copy of an SIS for any of our products, they are available at privatehealth.gov.au. Further information about our policies and services, please contact Teachers Health Fund on 1300 727 538.

Lifetime Health Cover

What is Lifetime Health Cover and how can I avoid the loading?

The Lifetime Health Cover initiative rewards those who take out Hospital cover earlier in life, allowing them to pay a lower contribution compared to others who take out Hospital cover when they're older. If you delay taking out Hospital cover, you will pay a 2% loading on top of the base contribution amount for every year you are over the age of 30 until you first take out Hospital cover.

Medicare

What is the Medicare Safety Net?

The Medicare Safety Net is there to help you. It provides families and individuals with financial assistance towards high out-of-pocket expenses associated with medical services provided as an out-patient. Once you meet a Medicare Safety Net threshold, you may be eligible for additional Medicare benefits for out-of-hospital Medicare Benefits Schedule (MBS) services for the rest of the calendar year.

Register for the Medicare Safety Net for free at medicareaustralia.gov.au. This allows Medicare to track your out-of-hospital, out-of-pocket expenses and advise you when you are nearing the threshold.

Medicare Levy Surcharge

What is the Medicare levy surcharge?

The Medicare levy surcharge is an additional 1 – 1.5% surcharge of taxable income imposed on higher income earners who are eligible for Medicare but do not have private Hospital cover. If the surcharge applies to you, your Medicare levy increases from 2.0%, that is paid by most Australian tax payers, to 3.0 – 3.5% of your taxable income.

The Medicare levy surcharge is means tested based on income.
How to avoid the Medicare levy surcharge?

If you are single and earn more than $90,000 a year or a couple/family earning more than $180,000 per year, you can avoid paying the Medicare levy surcharge by taking out any of our Hospital or Combined cover products.
Medicare levy surcharge Percentage
Singles less than $90,000 0.0%
Couples/families less than $180,000 0.0%
Singles $90,001 - 105,000 1.0%
Couples/families $180,001 - 210,000 1.0%
Singles $105,001 – 140,000 1.25%
Couples/families $210,001 – 280,000 1.25%
Singles more than $140,001 1.5%
Couples/families more than $280,001 1.5%

Members Area

What should I do if I have forgotten my password?

Go to online member services and then click on 'Forgotten password' from the right hand side. Enter the details required and your password will be emailed to you.
What is online member services?

Online member services provides you with access to your health insurance policy details 24 hours a day, 7 days a week. It is a convenient way of tracking your health cover, obtaining information and making changes to your policy and those covered at a time when it suits you.
How do I register for online member services?

Enter the online member services area, select 'Register' on the right hand side, enter your details and submit.
I want to receive my mail electronically - how do I change my mail preference?

To change your mail preference to receive correspondence electronically, follow these simple steps:
- Log in to online member services
- Select Contact details from the My membership main menu
- Select Edit
- Scroll down to Contact preferences
From the drop down menu select either of the following:
- Via Member Services area (with email notification)
- Via Member Services area (with SMS notification)
- Select Next to confirm the change
- Tick the declaration and select Submit to finish transaction

My membership

Can my partner manage my membership also?

Yes. If you would like your partner (who is on your membership) to have authority to operate your membership, ensure that you tick the box for partner authority on the membership application form when you are joining. Otherwise, you can let us know via email or post.
I am going overseas for a holiday, what should I do?

We strongly advise you to take out adequate travel insurance as Teachers Health Fund benefits do not cover the costs of hospital treatment or extras services outside of Australia. If you are travelling overseas for a period of more than 2 calendar months but less than 36 calendar months you may suspend your health cover while you are away. Check out Teachers Health Fund Travel Insurance.
When can I suspend my policy?

You can suspend your policy if you have been a financial member for a minimum of 12 months and are:

- Travelling overseas for more than 2 months but less than 36 months
- Experiencing financial hardship
- Taking leave without pay

It is important to note that during a suspension period you will not be able to make any claims and if you develop a condition or illness during the suspension period, you may not be immediately covered. Please contact us to discuss. Downgrading your level of cover might be a better option for you.
How can I upgrade or downgrade my cover?

You can upgrade or downgrade your level of cover at any time. Upgrading your cover can done via our online member services area or by calling or emailing us. When upgrading your cover, waiting periods will apply for services that were not previously covered. If you wish to downgrade your cover you will need to do this in writing. When downgrading your cover, it is important to understand what you may no longer be covered for.
What does emergency ambulance transport cover?

If you have Hospital or Extras cover, you will be covered for emergency ambulance transport. This covers you for the costs of transporting a seriously ill person to the nearest hospital by a State Government Ambulance Service or by a private ambulance service recognised by Teachers Health Fund in order to receive urgently needed treatment. This includes transportation from the scene of an accident or the scene of a medical event such as a heart attack or stroke, but does not include transportation to hospital for the routine management of an ongoing medical condition or transportation between Hospitals.

Emergency Ambulance cover can be taken out on its own if you do not have Hospital or Extras cover.










ServicesEmergency Ambulance cover
Transport from the scene to a hospital
Treatment at the scene by a qualified ambulance officer
Air ambulance services*
Transfers from a medical facility to a hospital and vice versa
Transport from the hospital to home
Transport to a hospital for routine management of an ongoing illness
Australia-wide coverage
Waiting period1 day


*Air Ambulance services administered by state owned ambulance services are covered by Teachers Health Fund. Services administered by non-state based ambulance services, Royal Flying Doctors Service, Care Flight Helicopter and Private Air Ambulance will not attract a benefit. Queensland and Tasmanian residents are covered by State funded ambulance services.
What is a Standard Information Sheet (SIS)?

A Standard Information Statement gives a summary of the key product features. Health funds are required by law to provide these Statements so you can review your existing policy or compare it to other products. It allows you to see if your broad needs are covered by a product by displaying benefit entitlements, restrictions, and eligibility requirements to join a fund, if any. If you would like a copy of an SIS for any of our products, they are available at privatehealth.gov.au. Further information about our policies and services, please contact Teachers Health Fund on 1300 727 538.
How can I make a payment?

Here are three easy ways to make a payment if you need to:

1. BPAY - Contact your financial institution and quote our BPAY reference number (54072) and your BPAY member reference number. If you are unsure of your BPAY member reference number please contact us.
2. Phone - Payments can be made using our secure pay-by-phone service by calling 1300 728 588 or (02) 9255 9539 if calling from a mobile phone or from overseas. Accepted credit cards are MasterCard and Visa.
3. Credit Card - via our Online member services

You may pay your contribution through our secure online member services centre. Accepted credit cards are MasterCard and Visa.

Planning a family

What happens if I am considering getting pregnant but my Hospital cover excludes pregnancy?

It is important you have Hospital cover that includes pregnancy benefits, such as Top Hospital, as a nine month waiting period applies for all services relating to pregnancy and childbirth. This means, you will need to have held Top Hospital well in advance of your pregnancy.

Please read the Pregnancy Guide.
When do I need to add my baby to my policy?

When you are settled in and have a few moments to spare, give us a call on or log on to the online member services to add your baby to your cover. You will need to advise us of the name, date of birth and sex of your baby. All waiting periods will be waived for your baby if you add him/her to your membership from the date he/she was born, within two months of the birth.

Please note: If you are on a single membership, you will need to upgrade to a family or single parent membership to add your baby to your cover.
When is my baby an admitted patient?

Babies born without complications are generally not admitted to hospital, but treated as an out patient. A newborn baby is classified as an inpatient when one of more of the following criteria are met:

- the baby is admitted to an approved neo-natal intensive care facility
- the baby is the second or subsequent born in a multiple birth situation (i.e. twins or triplets)
- the baby is more than 10 days old and still in hospital.

Private Health Insurance Rebate

What is the Private Health Insurance Rebate?

The Private Health Insurance Rebate reduces your contribution amount, making health insurance more affordable and accessible for you. The rebate is income tested against the income tier thresholds in the table below. Your rebate percentage entitlement will be reduced as your income tier rises.

View the Private Health Insurance Rebate levels here.
Who is eligible to claim the Private Health Insurance Rebate?

The Private Health Insurance Rebate is available to everyone who is eligible for Medicare and has private health insurance and whose taxable income falls within tiers 2 and below.
How can I claim the Private Health Insurance Rebate?

You can claim the Private Health Insurance Rebate as:
- As a reduction on your contribution amount
- Through your annual tax return

More information about the Private Health Insurance Rebate.
Do I need to tell Teachers Health Fund my income?

Members will be encouraged but not required to nominate a tier with Teachers Health Fund.
What happens if I select the wrong tier?

There is no limit to the number of times you can change the tier nomination and no penalties are applied for not making a nomination or making an incorrect nomination.
What happens if I over claim or under claim the rebate?

Adjustments will be made through the tax system. Teachers Health Fund will not be informed or involved.
Can Teachers Health Fund provide advice to me regarding which tier I should nominate?

Teachers Health Fund is unable to provide financial advice to its members. We encourage you to discuss with your tax agent, financial planner or with the Australian Taxation Office.
Where can I find more information?

More information can be found on the Australian Taxation Office website.

Online claiming

Mobile claiming app

For easy and convenient claiming, Teachers Health Fund now offers a mobile claiming app for both Apple and Android devices. Simply take a photo of your receipt to submit your claim! Please note, that you will need to keep your original receipts for two years.

For more information and to download the app, please click here.
What can I claim online?

You can claim the following range of services online (subject to your level of cover):

- Complementary Therapy consultations (eg acupuncture, remedial massage, naturopathy)
- Chiropractic consultations
- General Dental (item numbers)
- Optical (item numbers)
- Podiatry consultations
- Physiotherapy consultations
- Physiotherapy Group Therapy
- Exercise Physiology consultations
- Exercise Physiology Group Therapy
- Speech Therapy consultations
- Occupational Therapy consultations
- Psychology consultations
- Audiology consultations
- Dietician consultations
- Limited Major Dental – Endodontics (item numbers)
Why can't I find my provider from the list of providers or the search function?

Providers must be recognised by Teachers Health Fund for benefits to be payable.

You may have previously received a benefit from the Fund when a provider was recognised. Some providers, particularly those providing complementary therapies, are required to maintain professional indemnity insurance and membership of a recognised professional association to stay recognised with Teachers Health Fund. Where this does not occur the provider will no longer be recognised by Teachers Health Fund.
How much can I claim online?

Up to $500 per day worth of benefits can be paid online. This is the limit for the entire membership. This limit is not per person.

If claims lodged in a day exceed $500 in benefit you will be required to submit the receipts for the entire claim in order for the total benefit to be released.
Am I required to send in my receipts?

If the benefit payable is under $500 you will not be required to submit your receipts. However you are required to keep your receipts for two years from the date of lodging your claim as we may conduct a random audit. If you are not confident that you won’t misplace the receipts you can always submit the receipts at the time of claiming.

If the total benefit for your claim exceeds $500 your benefit will not be paid until all the receipts for the claim are submitted to the Fund.
How long do I have to keep my receipts for?

You are required to keep your receipts for two years from the date you lodge the claim online.
What happens if I don't send in my receipts or keep them and I am audited?

You may be required to repay the benefits and may also be blocked from further online claiming.
How can I send in my receipts?

There are two ways to submit your receipts if you want to continue to send them to Teachers Health Fund to have on file.
1. After finalising your claim, the details will be shown on screen. If you select the button 'Email Receipts' that appears on this page, an email message will be generated which includes your member number and claim number in the subject line. Attach scanned copies of your receipts to this email and press send.
2. You can email your receipts to info@teachershealth.com.au. Please ensure that your member number and claim number are included in the subject line. You can find your claim number in the Claims History section of the online member services area.
What types of audit will be conducted on online claims?

Teachers Health Fund will conduct random audits of online claims. This could involve a written request to you to forward in the receipts for your claim or we may contact the provider to check the service details.
The service listed on my receipt does not match the service description in the dropdown. Should I just select something else?

No. You should only claim for services online that match the description on your receipt. For example if your Podiatrist itemises a receipt for a Biomechanical Assessment and the only option is Podiatry Consultation, you should not select Podiatry Consultation. The Fund does not pay a benefit for Biomechanical Assessments and submitting your claim as a consultation may result in a request for refund of the payment.

If the service listed on your receipt is not in the dropdown please contact the Fund to see if benefit is payable. You may need to send in a claim form for this benefit to be paid.
Will I be required to repay benefits if I have entered the incorrect details?

If incorrect details are included, resulting in the payment of benefit that you would not otherwise be entitled to, you will be required to repay those benefits. You may be temporarily suspended from access to online claiming or blocked for all future claiming.

Examples of where incorrect details may occur include: date of service, incorrect patient, incorrect provider or incorrect item number is selected.
Is there a time limit on how long I have to lodge a claim?

Teachers Health Fund accepts claims up to two years after the date of service.
The service that I claimed for has not been approved for payment. A message "Service cannot be processed. Refer Health Fund." was returned. Why?

There are a variety of reasons that a benefit might not be payable. Some of the most common are listed below. These might explain the reason your claim was not approved. If not please contact the Fund and we will explain the reason.

- You have already reached the calendar year limit for the service you are claiming
- You are claiming for two services on the same day from the same provider. This could be due to you selecting the wrong date. Or you may be entering a consultation and a group therapy service for the same day. Benefits are limited to one service, per patient, per provider, per day. If your provider has performed more than one consultation or service on the same day, the treatment that attracts the higher benefit should be entered. This will most likely be the consultation.
- The service has previously been paid for. You may have received a benefit on the date of service through an electronic claim when your provider swiped your membership card.
- A Dental Reasonability Rule may have been triggered. Reasonability Rules have been put in place at Teachers Health Fund to enable benefits to be paid in accordance with the Fund Rules and to make sure that providers are using the correct item numbers for the services they provide to our members.

Example 1 Dental item 012 Periodic Oral Examination
Reasonability Rule states a maximum of two services per calendar year. This is based on the traditional 6 monthly check-ups.

Example 2 Dental item 161 Fissure sealing – per tooth
Reasonability Rule states item 161 is not payable with dental items 531 to 572. This is because when you are filling a tooth using item 531 to 572 on the same tooth, the fissure sealing is included.
Can I add the delivery charge into the cost of service?

No. There is no benefit payable for the delivery charge or postage and handling. You may be charged this when purchasing contact lenses online. This charge should not be added to the cost of the contact lenses.

Orthodontia

About Orthodontia

In Australia, the fee for orthodontic treatment involving upper and lower braces can vary from $4000 to more than $8000. This fee usually covers the entire treatment including the fitting of braces, adjustments at regular intervals, the removal of braces and the retention and observation periods that follow. This fee does not usually cover the initial consultation, records, photographs, removal of any teeth or other steps to prepare for the fitting of the braces (these fees also attract a benefit under Top Extras Dental Cover). Your orthodontist should discuss the treatment options and the fee with you before your treatment is commenced.

At Teachers Health Fund, benefits are payable for orthodontic treatment if you hold Top Extras Cover and have served the 24 month waiting period. We will pay 100% of the cost up to the level of your benefit entitlement. Your benefit entitlement will increase dependant on the number of years that you have held continuous Top Extras Cover.

Increasing limits:
Year 3: $1500
Year 4: $2000
Year 5: $2500

You also have a lifetime limit of $2500 for orthodontic treatment. Once you reach this lifetime limit you are unable to make any further claims for orthodontia.


How to claim for your orthodontic treatment

1. If you are considering orthodontic treatment, please contact Teachers Health Fund so we can discuss your benefit entitlements with you.

2. Send us a copy of your treatment plan. We can use this to quote you an accurate benefit based on the payments you are required to make and the length of your treatment.

3. Send us your receipts with a completed claim form after the treatment commences. Don’t forget to send your treatment plan if you haven’t already done so.

4. Orthodontia cannot be claimed using your Teachers Health Fund membership card via HICAPS at your orthodontist.

5. Orthodontia cannot be claimed using online claiming through online member services.


Important points to remember:

- Orthodontic benefits are only payable for members on Top Extras Cover.
- No benefit will be paid for services received during the 24 month waiting period
- No benefit is payable before the treatment commences, even if you choose to pay for your orthodontic treatment in advance. The benefit can only be paid once the braces or aligners are in place.
- If you pay for your orthodontia up front, you can continue to claim for orthodontia in the following years as long as you are still undergoing active orthodontic treatment (that is, your braces are still on). We will continue to pay your orthodontic benefits up to your annual limit and the lifetime limits that are applicable to your policy.
- If you transfer from another health fund and have received orthodontic benefits during the last 5 years this will be deducted from your benefit entitlement with Teachers Health Fund. Orthodontic benefits paid in the previous 5 years of cover are recorded on your transfer or clearance certificate from the health fund you have left.

Restricted and excluded services

What is a restricted service?

A service that is restricted means that if you go to a private hospital for a restricted service you will only be covered for the rate of a shared room of a public hospital. If you choose to go to a private hospital for these services you will be significantly out-of-pocket. There are no benefits payable towards theatre and labour ward fees.

These services are covered in a shared room of a public hospital. Whilst you will be able to choose your own doctor, you will not be able to avoid public hospital waiting lists.

Mid Hospital, Basic Hospital and StarterPak have restricted services.


What is an excluded service?

An excluded service is a service where no benefits are payable - regardless if it is performed in a public or private hospital. If a service is not covered by Medicare (e.g. elective cosmetic surgery) there will be no benefit payable from your Hospital cover.

StarterPak has additional excluded services including:

  • Pregnancy & birth related services

  • Infertility investigations & treatments

  • Hip & knee replacements

  • Coronary care & cardiothoracic surgery

  • Dialysis procedures & treatments

  • Cataract & eye lens procedures


If you go to a private or public hospital as a private patient for any of these services you will not be covered.

Switching Funds

How do I switch to Teachers Health Fund?

Switching to Teachers Health Fund is easy. You can notify your current fund yourself or we can do it for you. Simply complete the Clearance Certificate details when you join and we will take care of the transfer. This gives us permission to contact your previous fund to obtain your cover details.


What is a Clearance Certificate?

A Clearance Certificate is a certificate issued by a health fund when a member terminates a policy or wishes to transfer to another fund.

It is a record of your private health insurance cover including details about:

- Type of cover
- Level of cover
- Join and cancellation dates
- Waiting periods served
- Certified Age of Entry (CAE)
- A history of recent claims


Will I have to re-serve any waiting periods?

If you are transferring to an equivalent level of cover with equivalent benefits, you will not have to re-serve your waiting periods with Teachers Health Fund. If your previous level of cover was lower than your Teachers Health Fund cover, waiting periods will apply to any services that were not covered by your previous fund. Waiting periods will also apply to services that are covered at a higher level.

For example: You switch to Teachers Health Fund to Top Extras cover. Your previous level of cover did not include benefits for remedial massage. Top Extras provides benefits for remedial massage under complementary therapy and has a 2 month waiting period. In this instance you will be required to serve the 2 month waiting period before you can make any claims for complementary therapies.

Tax statements

When will I get my tax statement?

Tax statements are mailed out to all members during the second week of July each year.


Can I get my tax statement earlier?

Tax statements must include details of all payments processed by Teachers Health Fund up to and including 30 June. This means that we cannot begin preparing the statements until after that date. A lot of work goes into preparing these tax statements and we endeavour to get them out to you as soon as we possibly can.

All members can download a copy of their statement through Online Member Services and we will update our website as soon as they are available.

Waiting periods

What is a waiting period?

A waiting period is a period of time you need to wait after taking out your cover before you can receive benefits for services or items covered. Benefits are not payable for services received over the course of a waiting period.
Who does a waiting period apply to?

Waiting periods apply to:
- New members to private health insurance.
- Existing Teachers Health Fund members who upgrade to a higher level of cover or reduce their level of excess – in this case you will need to serve the relevant waiting period for the higher benefit entitlement.
- Members who transfer from another health fund who have not already completed the required waiting periods, or who are transferring to a higher level of cover.
- All health funds have waiting periods.
How long is the waiting period?

The length of a waiting period will depend on the type of service.

Hospital waiting periods

Pre-existing conditions 12 months
Pregnancy & birth related services 9 months
Psychiatric, rehabilitation & palliative care 2 months
All other hospital services 2 months
Emergency Ambulance transport 1 day

Extras waiting periods

Orthodontia 24 months
Wheelchair purchase 24 months
Major dental 12 months
Medical appliances 12 months
Optical and Healthy Lifestyle 6 months
All other services 2 months
Emergency Ambulance transport 1 day

Pre-existing

What is a pre-existing condition?

A pre-existing condition is an illness, ailment or condition where the signs or symptoms existed at any time during the six months before taking out private health insurance or transferring to a higher level of cover.

Teachers Health Fund will appoint a medical practitioner to determine whether you have a pre-existing ailment, based on information provided by your treating doctor or specialist.
Who does the pre-existing condition rule apply to?

This rule applies to:
- New members
- Existing members who are upgrading their level of cover.

A 12 month waiting period applies to all pre-existing conditions except psychiatric, palliative care and rehabilitation, which are covered by the two month waiting period.
What if I have a pre-existing ailment?

If you are a new member to private health insurance you will have to wait 12 months before you can receive benefits for items or services related to a pre-existing condition. This means that if you receive treatment for a pre-existing condition within the 12 month waiting period, you will not be eligible for benefits.

If you change to a higher level of cover, you may have to wait 12 months to receive benefits, including benefits for services not previously covered.

Wisdom teeth

I need to have my wisdom teeth removed. Am I covered?

If you are planning to have your wisdom teeth removed by your dentist in a private practice, Top Extras, Essential Extras CoreElect and StarterPak will provide benefits.

If you are admitted to a hospital for the removal of your wisdom teeth, your Hospital cover will cover the hospital costs such as accommodation, theatre and anaesthetist fees but Extras Cover that offers major dental benefits will still provide benefits for the dentist to do the extraction.