Private Insurance

In this part of the Reality Check website, the moderators have saved discussion threads out of the rest of the forum which have addressed a popular issue containing terrific information, or threads that have generated a lot of discussion and which we feel people may well find useful to refer to in future.

Private Insurance

Postby Bluey » Mon Jan 15, 2007 3:26 pm

I need to investigate getting Private Health Insurance and every Insurance company I have called have given me different Hospital cover that I need to be eligable for a pump in a years time.

Does anyone know what the code is I need to provide and does it fall under basic hospital cover?

Thanks,
Nicole
Bluey
 
Posts: 14
Joined: Fri Jun 30, 2006 3:51 pm
Location: Brisbane

Postby Tash » Mon Jan 15, 2007 6:00 pm

When I signed up for mine I told them I was going to claim for a pump in a year...and needed to be sure that I was covered.... they were cool... I was told to get Top Hospital cover...and that would cover it....

As for claim numbers for pumps.... they wont tell you much till your one year wait is over... and then its more up to the hospital how much is covered... rather than the insurance company... least thats what I was told today (im in the middle of claiming for new pump)...

Im with MediBank Private... they just said that all I do now is apply for hospital appointment and stuff thru my Endo... and the hospital will proccess it all and they let me know what my 'excess' will be *excited bout new pump*
How many carbs in a donut? Image ...mmmh donuts!
Tash
Moderator
 
Posts: 1605
Joined: Wed Oct 06, 2004 11:14 pm
Location: Brisbane

Postby Catapult » Mon Jan 15, 2007 6:47 pm

basic hospital cover is meant to cover insulin pumps but some insurance companies have been pains about their obligations. as it stands, they still have to fork out for the whole value of the pump.

most basic hospital covers have an excess or co-payment - this would apply for the time you are in hospital for your pump education. you must be an inpatient (even if it's just a few hours) for the pump to be covered by the insurance company.

with top hospital cover i would expect there to be no excess or very little to pay out of pocket. you also need to check that the hospital is on the insurance company's list of approved hospitals otherwise there will be a big gap to pay.

Cat.
Catapult
admin
 
Posts: 5012
Joined: Fri Oct 08, 2004 8:50 pm

Postby Inga » Mon Jan 15, 2007 8:42 pm

Hi Nicole,
If you are in WA, I would definately go with HBF. Thats what everyone has told me. Very smooth to deal with and they dont have any problems.
Inga
 
Posts: 662
Joined: Tue Feb 07, 2006 3:03 pm
Location: Perth WA

Postby artemis » Tue Jan 16, 2007 10:03 am

I have an excess with my insurance, but the public hospital I went to for my pump ed (John Hunter in Newcastle) waived the excess. Apparently it's better for a public hospital if you go in as a private patient, and they still get more money even if you don't pay the excess - does that make sense? Actually when I got my pump I was only covered for basic hospital because I'd only switched to top cover a few months previously.
Jane
Infundo ergo sum.
artemis
Moderator
 
Posts: 3949
Joined: Sun Jan 29, 2006 10:32 am
Location: Port Stephens, NSW

Postby bruce » Tue Jan 16, 2007 11:28 am

You have to be admitted to hospital as a private patient because the hospital buys the pump and claims the cost back from your private health insurance co.
You can ask your PHI company for a pre-determination of your claim, this is when you will need a letter from your endo, the hospital required this before they would order my pump.
I have a hospital cover excess and received an account for the accomodation component. (It was less than $200.)
bruce
 
Posts: 258
Joined: Mon Oct 11, 2004 7:29 pm
Location: Tasmania AUSTRALIA

Postby Catapult » Tue Jan 16, 2007 1:05 pm

artemis wrote:Apparently it's better for a public hospital if you go in as a private patient, and they still get more money even if you don't pay the excess - does that make sense?


It makes a lot of sense because public hospitals receive their funding from their state government at the start of the year. If 1000 extra patients come in, that is too bad. If private patients come in, that's a whole lot of unexpected funding for them.

Cat.
Catapult
admin
 
Posts: 5012
Joined: Fri Oct 08, 2004 8:50 pm

Postby Bluey » Tue Jan 16, 2007 3:39 pm

So does everyone have "Basic Hospital" coverage?
Bluey
 
Posts: 14
Joined: Fri Jun 30, 2006 3:51 pm
Location: Brisbane

Postby Catapult » Tue Jan 16, 2007 4:15 pm

I have the highest hospital and extras cover, and i am glad i do as i have been hospitalised many times (not just because of D but for other conditions).

Cat.
Catapult
admin
 
Posts: 5012
Joined: Fri Oct 08, 2004 8:50 pm

Postby Kate » Tue Jan 16, 2007 4:55 pm

No, not EVERYONE has private insurance. I have zip, nulla, nada, none. And never have - 23 years of D. Though am looking into it now. I used to say proudly that if you knew the system you could do fine without private insurance even if you did have a chronic condition like diabetes, and all the best docs were in the public system anyway, but things have changed and the private patient in a public hospital seems like most people's preference as required. OK am officially getting off my butt to get it at long last. Owch.
Kate
 
Posts: 5249
Joined: Tue Sep 07, 2004 4:08 pm
Location: Melbourne

Postby artemis » Wed Jan 17, 2007 12:03 pm

I only took ouot phi so I could get a pump. But when I had to have my hand and wrist operated on last year, there was no wait because I had phi. (Mind you, the time before that when I was in Armidale before I had phi, I only had to wait 2 weeks for an op in the public hospital- and that was only because I had to go to the pre-admission clinic.)
Jane
Infundo ergo sum.
artemis
Moderator
 
Posts: 3949
Joined: Sun Jan 29, 2006 10:32 am
Location: Port Stephens, NSW

Postby Bluey » Wed Jan 17, 2007 2:04 pm

I was told that even when you have PHI it doesn't cover the cost of seeing a private Endo. Is everyone else experiencing this? I'm paying $150 each time I sese my endo and thought that PHI would cover it.....
Bluey
 
Posts: 14
Joined: Fri Jun 30, 2006 3:51 pm
Location: Brisbane

Postby Catapult » Wed Jan 17, 2007 5:24 pm

Bluey wrote:I was told that even when you have PHI it doesn't cover the cost of seeing a private Endo. Is everyone else experiencing this? I'm paying $150 each time I sese my endo and thought that PHI would cover it.....


Seeing an Endo at their clinic won't be covered by PHI but you will get some of it back from Medicare. Most of us here end up paying around $35 gap.

Seeing the Endo in hospital as an inpatient, Medicare covers some of it and PHI usually picks up the rest, so you shouldn't have any gaps to pay.

Cat.
Catapult
admin
 
Posts: 5012
Joined: Fri Oct 08, 2004 8:50 pm

Postby Jelli » Wed Jan 17, 2007 10:59 pm

I need your help here! Im only a little tiker compared to a lot of you with regards to all this PHI stuff. I did a term at school on Medicare and health insurances etc but am still learning here! Ok, so my mum and I have PHI and im pretty sure our PHI is called Family First, MBF. I am going down to brissy in a few weeks to get sized up for the pump but found out today that apparently our PHI only cover $500 of the pump and we have to pay the excess (is that called the 'gap') Obvously I wont be getting the pump if only $500 of it is covered but it sounds like a lot of you guys out there are on a similar cover to us but you got your pump covered? We pay $187.50 per month if that is any help? Does this type of cover mean we have the basic hospital cover of what? Do you think im eligable to be covered for the pump?
Jelli
 
Posts: 306
Joined: Wed Jul 05, 2006 7:39 pm

Postby artemis » Thu Jan 18, 2007 9:07 am

Jelli, check again with you8r fund. It sounds as though they are telling you that it is covered under extras, when a pump is covered under hospital insurance. If they won't play ball, you and your mum might think about changing to another phi. Good luck. When you ring them, tell them it is a schedule 5 item (prosthesis) and that you have to be admitted to hospital to have it fitted.
Jane
Infundo ergo sum.
artemis
Moderator
 
Posts: 3949
Joined: Sun Jan 29, 2006 10:32 am
Location: Port Stephens, NSW

Postby Kate » Thu Jan 18, 2007 9:36 am

Re Pumps and Private Health Insurance

All private health funds MUST fully refund an insulin pump, and the cover that you require is "basic hospital cover". This is mandated by law.

Regarding approaching private health funds to enquire about coverage for insulin pumps, as has been discussed here many times, this is a nightmare if done directly by you. If at all possible leave the discussion/negotiation/arguments to the medical staff arranging your pump.

When you are booked in, the hospital you are going to will ask for your private health insurance fund number and your Medcicare number and order the pump through their hospital supplies department who will then chase your company for the refund. If it doesn't work this way (for exampel you are asked to pay full price and then you personally be reimbursed for the pump a year later) there is a problem. And you should get your doctor/nurse/hospital to deal with the insurance fund to sort it out before you go in. Alternatively, the company who make your pump can deal with them to sort it out.

It is normally a huge waste of time and energy trying to deal direct with private health funds over this as the general customer service people who we are allowed to access will likely never have dealt with it before and know very little about pumps etc.

I hope that helps. Kate
Kate
 
Posts: 5249
Joined: Tue Sep 07, 2004 4:08 pm
Location: Melbourne

Postby abs » Thu Jan 18, 2007 11:36 am

Maybe Jelli has to cover the first $500 of the hospital stay (ie the excess) and the PHI covers the rest
abs
 
Posts: 2936
Joined: Thu Oct 07, 2004 5:44 pm
Location: Sydney, Australia

Postby Jelli » Thu Jan 18, 2007 5:56 pm

Thanks for your help everyone. Kate, when you say "basic hospital cover" I assume that this one of the most basic forms of PHI? I assume mum and I have that covered in our "family first" PHI? Because, as you said, I learnt the hard way yesterday when I rang MBF and the dead beat on the other end just said "we would cover $500 of the pump" - This didnt tell me wether they ment $500 of the actualy pump, or the hopsital stay or what. So, I think when I go down to Brissy in the next few weeks I will sus it out with the Endo I am seeing down there. Either way, am I covered for the pump if I have basic hopsital cover, which I assume I do?
Jelli
 
Posts: 306
Joined: Wed Jul 05, 2006 7:39 pm

Postby d's wife » Thu Jan 18, 2007 7:21 pm

we have been vaguely investigating a pump for hubby for a little while. My mum works at a phi fund, and has been researching for us what cover we were entitled to. She found it very difficult to find any info., as most staff didn't really know what a pump is, and therefore couldn't decide whether it was a prosthesis or whatever and therefore didn't know what schedule it was under. This is probably the problem you have come up against Jelli.
Our endo was very definate, and told us the same info Kate has. phi are required by law to fully refund the entire cost of the pump. There was discussion by the endo and mum about some brands not being covered, so it might be worth while checking that out before you go ahead. The endo said a lot of phi try to get out of paying by various devious means (it is an awful lot of money), but it is up to the medical facility to chase the money, not the patient.
and here is the interesting bit. Mum found out that there are moves afoot to change the law requiring funds to fully cover pumps. She didn't know how true it was, but a couple of different sources advised her that if we were going to get a pump, it would be better to do it sooner rather than later.
mik
d's wife
 
Posts: 39
Joined: Sun Jul 09, 2006 2:47 pm
Location: Brisbane

Postby Catapult » Fri Jan 19, 2007 2:09 pm

d's wife wrote: Mum found out that there are moves afoot to change the law requiring funds to fully cover pumps. She didn't know how true it was, but a couple of different sources advised her that if we were going to get a pump, it would be better to do it sooner rather than later.
mik


Coverage of various prostheses does vary. All PHI have to cover at least the basic model of prosthesis. Some categories of prosthesis have different models and prices, and PHI only cover the lower model/price. If you want a higher model, you have to pay the gap between the two models. At this stage insulin pumps are not in this category. All pumps have to be fully covered by PHI (there is no basic/lower model vs higher model). Gradually the rules will change until all prostheses fit into categories where there will be a gap for higher models.

Cat.
Catapult
admin
 
Posts: 5012
Joined: Fri Oct 08, 2004 8:50 pm

Postby abs » Fri Jan 19, 2007 4:13 pm

and the problem with doing "sooner rather than later" is that when it comes to renew, if those moves afoot actually become steps and happen - bad luck in a few years time when it comes time to replace etc etc

Will you go back to syringe/pens or somehow find that then $15K or whatever the price is in a few years time
abs
 
Posts: 2936
Joined: Thu Oct 07, 2004 5:44 pm
Location: Sydney, Australia


Return to Solid Gold - Some of our Favourites!

cron