Q.N:2 When can I start to claim?

Ans: As soon as you have served your waiting periods.

If you’re switching from another private health insurer, we’ll generally recognise any waiting periods you’ve already served for comparable benefits.

A waiting period is a set amount of time before you can claim any money back for a service included on your cover. Waiting periods apply when you first join (or re-join after not having had health insurance for some time) or if you change to a higher level of cover that has additional services or higher limits.

For more information on claiming and waiting periods see the Member Guide.

Q.N:3 Does ahm have any provider restrictions?

Ans: At ahm we pay the same benefits at all recognised providers (other than our no gap dental offering at select dentists). This means you don’t have to switch your physio or chiro just because you’ve switched health funds. Convenient right!

See if your regular providers are recognised by ahm.

Q.N:4 What will be my medical out-of-pocket expenses?

Ans: Your out-of-pocket expenses may vary depending on a range of factors, but significantly if the service is included, partially covered (restricted) or excluded.

For a list of what we pay for each service, view the product guide.

Included hospital services

When you go to hospital, there might be a gap between what we pay for your medical services, and what your doctor charges you. This is the referred to as a medical gap and is your out-of-pocket expense.

Medical gaps exist because some doctors may charge higher fees than what is set out in the Medicare Benefit Schedule (MBS).

Doctors can choose to participate in GapCover or not on a per claim, per treatment and per patient basis, so you should always check with them prior to agreeing to each claim as part of your treatment. If your doctor chooses to participate in GapCover for the claim forming part of your treatment, then we’ll provide benefits up to an agreed fee and the maximum gap that you’ll have to pay is $500 per claim per provider (i.e. per each doctor’s account).

GapCover doesn’t apply to diagnostic services such as blood tests, x-rays and ultrasounds, out-of-hospital medical services and services not included on your policy. GapCover doesn’t apply to things such as excess payments and co-payments. You may still have out of pocket costs.

You can search for doctors who’ve previously registered to participate in GapCover with our find a provider tool. This doesn’t mean they’ll do so for your claim forming part of your treatment. You should always check upfront with your doctor before agreeing to each claim forming part of your treatment.

For more information on GapCover refer to What is GapCover? or Member Guide.

Partially covered hospital services

In addition to any out-of-pocket costs as a result of a medical gap, partially covered services only pay limited benefits towards your accommodation and won’t cover the full cost of treatment.

If you choose to use a hospital service that is only partially covered, you may be left with additional out-of-pocket expenses related to your stay in hospital.

To reduce your out-of-pocket expenses, you may choose to be treated as a private patient in a public hospital, rather than a private hospital. However, this will not reduce your out-of-pocket expenses entirely.

Should you need to use a partially covered hospital service, give us a call on 1300 485 138 before you go into hospital for your treatment and we can confirm what you’re covered for.

Excluded hospital services

If you choose to use a hospital service that is not covered, and you use the private health care system, your out-of-pocket will be the entire cost of the treatment. ahm will pay no benefits towards the cost of your treatment.

Included extras

Your out-of-pocket expenses for your extras services will be the difference between what your provider charges and what we pay back on that particular service.

Q.N5: How do I switch from another insurer?

Ans: Switching to ahm is easy – just tell us the name of your current health insurer when you join, and we’ll organise it for you. Also, any waiting periods you’ve already served are generally carried over for comparable services, so you might not need to wait to claim.

During the switch you’ll still be insured with us. That’s because your cover with ahm starts from the date your cover ends with your current insurer.

Q.N:6 What’s a pre-existing condition?

Ans: A pre-existing condition is any kind of ailment, illness or condition where you had the signs or symptoms (in the opinion of one of our Medical Practitioners) 6 months before you joined private health insurance or changed your cover.

Our appointed Medical Practitioner is the only person authorised to decide if an ailment, illness or condition is pre-existing. They must consider any information that was provided by the medical practitioner who treated the ailment, illness or condition.

For more information on pre-existing conditions see the Member Guide