Understanding your Extras cover

Understanding Extras Cover

Not everything that keeps you healthy is covered by Medicare. That’s why Extras cover can be a big help. Extras cover is all about covering some of the costs that aren’t hospital related. Some of the most common services and treatments that people make Extras claims for include:

• Dental check-ups and cleans
• Optical products, such as glasses and contact lenses
• Physiotherapy, chiropractic, occupational therapy, podiatry
• Health aids and appliances, such as asthma pumps/nebulisers, blood glucose monitors and hearing aids.

Providers of Extras services have to be recognised by Bupa in order for us to pay towards the cost of your treatment. The following information is important for you to understand what is required for a claim, and how your choice of provider can affect what we will pay.

What is not covered?

Extras benefits will not be payable:

• during a waiting period
• where a third party, including Medicare, a Government body, or an insurance company provided a benefit (except for hearing aids and breast prosthesis items)
• for different services within the same service type from the same provider on the same day. For example, if you went to see an acupuncturist and then received a massage from the same provider on the same day, you cannot claim for both services.
• when a prescribed treatment for orthotics or surgical shoes is not custom made
• when a provider is not recognised by us for benefit purposes
• for any treatment or service rendered outside Australia
• when you have reached the limits on your product including yearly, lifetime or service limits for the service you are claiming.

Waiting periods

When you first take out or upgrade health cover there’s a period of time before you can make a claim on your new level of cover. This is common across the health insurance industry.

You can’t claim for services that you receive during this period at your new level of cover, even if you wait to submit the claim once the period is over. Note that you will still be able to claim for services that were covered under your previous product.

Different waiting periods apply to different Extras services:

Service/Treatment	Waiting Period
Initial waiting period	2 months
Hire and repair of health aids and appliances	6 months
Health management	6 months
Major dental	12 months
Orthodontics	12 months
Purchase of health aids and appliances	12 months
Laser Eye Correction Surgery (applies to Gold Ultimate Health Cover and Corporate Ultimate Health Cover)	3 years

Choosing your provider

We all have different priorities when it comes to choosing a provider for a medical service or other health treatment. Your choice could be based on location, recommendations, cost, or other factors that are important to you.

The amount you'll pay for treatment can depend on:

1. How much the provider charges for the service.
2. The type of service, and if it’s included in your cover.
3. Any agreements between the provider and Bupa.
4. The amount you can claim back, determined by your level of cover and benefit claiming restrictions.

We understand that factors other than cost can be important to you, like familiarity or location. That’s why we’ve built networks of providers to try and keep your costs down. We call them our 'Members First' providers.

There are great advantages of using a Members First provider:

• You'll usually get more back than you would if you visit another provider. You'll know exactly what we’ll pay, and what will be left over for you to pay.
• Depending on your cover, you could get 50% or more back on most dental, physiotherapy, chiropractic and podiatry consultations at Members First providers, up to yearly limits.
• For some services, depending on the service and the provider, you'll pay nothing at all.
• In most cases you'll be able to claim on-the-spot by using your Bupa membership card. You’ll know instantly how much is covered by Bupa, and what amount you need to pay out-of-pocket.

If your dental practitioner, chiropractor, or podiatrist, physiotherapist isn’t in our Members First network, you can still make a claim if the service is included in your cover, and you’ve served your waiting periods. However, you may have a larger out-of-pocket expense when you get the bill.

How our Extras networks give you more Find a Members First provider

Claiming for Extras

You can make a claim for a treatment or service provided in Australia if it’s covered by your policy and the provider is recognised by Bupa. For example, you might purchase a pair of glasses, but we might not recognise the provider, so you’ll not be able to make a claim. Extras providers must meet certain requirements to be recognised by Bupa.providing our members with a quality product.

Before you book a treatment or buy a health appliance, it’s a good idea to check with us. We can confirm that we recognise the provider and what your cover includes.

Knowing your claim limits

Claim limits are a maximum dollar amount that we’ll pay for specific treatments and services. This is common for most types of insurance. Other health insurers might set the same or different limits to us.

If you move between health funds, your use of limits usually moves with you. For example, most funds have a lifetime limit on orthodontics, so if you have claimed your lifetime limit at your old fund, Bupa would recognise this and you wouldn’t be able to make a further claim.

Here are some of the most common limits that might apply to your policy:

Yearly limit

This is the maximum amount you can claim for a service from 1 January to 31 December. If you haven’t claimed up to your yearly limit, this doesn’t ‘roll over’ to the next year – it resets on 1 January.

Sub limit

This is like a limit within a limit. It applies to a very specific service, per person, per year. For example, if you have Your Choice Extras, there’s a yearly limit of $500 for natural therapies. A sub limit applies to massages of $100 per person, so once you have reached that limit for massages, you can no longer claim that year. However, you could make further claims for other natural therapies, such as acupuncture.

Person limit

This is the maximum amount that each person covered by your Bupa membership can claim in a calendar year. If you’re on a policy with a family member, then you’ll have your own individual limits.

Membership limit

This is the maximum amount that can be claimed collectively by everyone covered by your membership within the calendar year. Remember that these apply in addition to your individual per person limits. Also, the membership limit might not be high enough for all your family members to claim their individual limits. For example, you may have a person limit of $500 for chiropractic services, but a membership limit of $1,000. This could be used by two family members even if you have four people listed on your policy.

Lifetime limit

Health insurers usually have a lifetime limit for orthodontics. This applies to an individual. If you have reached this limit, you can’t make any further claims for this at Bupa again. It doesn’t reset, even if you leave Bupa and start your cover again with us.

You can find information about limits in your policy information, available at myBupa.

Restrictions on making claims

You need to have finished any waiting periods that apply. If you’re new to Bupa and Extras cover, it’s good to be on top of what waiting periods apply to you and when they will end.

1. You can’t claim twice

   If you’ve made a claim with Medicare or another insurance policy, such as Work Cover or travel insurance, then you can’t claim the cost under your Extras cover. There are some exceptions, such as hearing aids and breast prosthesis, so check with us if you’re not sure.

2. You can’t claim for multiple services from the same provider on the same day

   For example, if you went to see an acupuncturist and then received a massage from the same provider on the same day, you can’t claim for both services. They are both ‘natural therapy’ treatments. However, if we recognised that provider as both an acupuncturist and a chiropractor and they provided you with acupuncture and a chiropractic treatment on the same day, then we would recognise both treatments, as they are different types of services.

   Some specific services have their own limits. For example, we generally only pay for one dental check-up claim every six months, so if you have special dental needs outside this you should contact us.

3. You have up to two years to submit a claim

   We allow customers two years from the date of service to submit any claims for benefits to be paid.

   The two-year claim rule is in place as it is consistent with Medicare's claim rules.

See Start using your cover for easy ways to claim plus more information about your Bupa cover.

You can download the Important Information Guide to find out more about your Extras cover.