What is the scheduled fee?

The scheduled fee is the fee set and recognised by the Commonwealth Department of Health and Ageing for the payment of Medicare benefits for a medical services.

While benefits are based on the scheduled fee, it's important to remember that medical providers are free to set their fees at any level.

How much does Medicare pay?

When admitted as a private patient of a hospital Medicare pays 75% of the Medicare Benefits Schedule Fee for medical services provided by your treating doctors, such as your surgeon, assistant surgeon and anesthetist and for radiology and pathology services. Police Health will pay up to 25% of the Medicare Benefits Schedule Fee.

Where services are billed higher than the Medicare Benefits Schedule Fee, Police Health's Access Gap Cover scheme will, in many cases, allow us to cover the fee in full or at least to pay a higher benefit  and thus reducing your out-of-pocket cost. It is up to the doctor or service provider to participate in Access Gap Cover. Where a doctor or service provider chooses not to participate in the Access Gap Cover scheme, Police Health is only permitted to pay up to 25% of the Medicare Benefits Schedule Fee, after the Medicare benefit.

Enrolled for Medicare Benefits?

For Police Health to pay you up to 25% of the Medicare Benefits Schedule Fee and to pay you benefits under the Access Gap Cover scheme for medical services, you will need to be enrolled with Medicare and hold (or appear on) a valid "green" or "blue" Medicare card. If you are a holder of a "yellow" Medicare card, you are not covered under Medicare for treatment as a private patient in a public or private hospital and Police Health will not pay you benefits for medical services.

Note: Police Health does not pay benefits for medical services where Medicare does not pay a benefit, including services provided to persons who are not enrolled with Medicare or who hold a "yellow" Medicare card.

When not admitted as a patient in a hospital

Medicare pays up to 85% of the Medicare Benefits Schedule Fee and no further benefit is available through health insurance. Please note that charges for medical services provided in a private hospital Accident and Emergency fall in this category.

Do I have a choice of doctor or health care provider?

Yes. Police Health does not direct you to a particular doctor or any other health care provider. Our aim is to give you the freedom to make true choices about who treats you and where.

If your doctor refers you to a specialist you can make your own inquiries about their fees and whether they have an agreement with Police Health. Remember, if you choose a doctor who uses our Access Gap Cover scheme it is likely that you will have no out-of-pocket expenses, or if there is an uninsured gap to pay, you will be advised of this prior to treatment.

Use the Facilities & Providers Search to find participating doctors in the Access Gap Cover doctor search.

What if I need a prosthesis?

There are many brands and types of prosthesis available for a particular use, all designed to achieve the same result – but they can vary in cost and comparative benefits.

The Federal Government together with a panel of health specialists issues a listing for prostheses detailing the benefit that health insurers must pay. While the surgeon or hospital providing the prosthesis can determine what they will charge for them, it is intended that the government required benefit should fully cover the cost of at least one of the items available that meet your surgical requirements.

To make an informed decision ask your doctor the following questions:

  • Which prosthesis will be the best one for you and is there a gap to pay for it?
  • If a gap is payable, is there a gap free option available?
  • What are the costs of the surgery, including the prosthesis?

Request a written cost estimate and contact Police Health to confirm what is covered and if there are any gaps to pay.

Who can be covered by my Police Health membership?

If you take out single policy, it will cover you only. Our family policy covers you, your spouse or partner, and your children until they are 21 years of age.

Children who are full-time students are covered until they are 25, while non-student children can be covered until they are 25 under Platinum Plus, as long as they are not married or in a defacto relationship.

The same level of cover for children applies under our single parent family policy.

See who is covered for more information.

When do my child dependents cease to be covered by Police Health?

Your children cease to be covered by Police Health when they reach the age limit for cover under your policy. When this happens they can take out their own Police Health policy without any waiting period provided they:

  • join from their 21st birthday (25th birthday for Platinum Plus)
  • join a table of the same or lower level than yours (if they join a cover higher than what was previously held, waiting periods will apply to the higher level of cover)
  • If they have been covered as a student dependent, they can join from March 1 following a completed study year or from the date they left full-time studies

In all these circumstances, your children have two months in which to join with their premiums being calculated from the date they ceased to be an eligible dependent.

What happens if I transfer to Police Health from another fund?

If you are still covered by another fund at the time you join, you and your dependents will receive continuity of cover.

We'll even give you credit for waiting periods you've already served with your previous fund on a new policy with Police Health.

When transferring from a lower level of cover you are required to serve a waiting period only for the areas of higher cover. Waiting periods also apply when other people transfer from another cover to your existing Police Health policy.

The waiting periods may be reduced or waived in the case of special offers by Police Health.

See Changing to Police Health for more information.

Why do you need waiting periods?

All private health insurers have waiting periods to protect the interests of existing policy holders and to prevent people from jumping in and out of cover.

Waiting periods do not apply if they have already been served on your current policy. (Subject to it being the same level of cover as your new Police Health policy). See waiting periods for more information or call us on Adelaide local 8112 7000 or other areas 1800 603 603.

What is a pre-existing condition?

A pre-existing condition is one where signs or symptoms of your ailment, illness or condition existed at anytime during the six months preceding the day on which you became insured under a particular health insurance policy. This is in the opinion of a medical practitioner appointed by Police Health (not your own doctor).

Please note, if you change your level of cover, you will be considered to be insured under a new health insurance policy, but assessment regarding a pre-existing condition will be made only if you have not served the required waiting period with the previous cover or it relates to the payment of a benefit that was not available with the previous cover (this includes any excesses, co-payments, excluded services and restrictions applicable to the previous cover).

Am I covered interstate?

Yes, all our hospital and extras policies cover you anywhere in Australia, where benefits are paid in accordance with the state of registration of the membership, not the treatment location.

Am I covered overseas?

No, your policy does not cover you overseas or on cruise ships. Please read our information on travel insurance. We strongly recommend that you take out travel insurance when you travel overseas.

What happens if I am travelling overseas for an extended period?

You can apply to have your Police Health membership suspended, provided the application is made prior to your departure date and your time spent overseas is less than 2 years. Please note that you cannot claim benefits while your membership is suspended and periods of suspension may be subject to the Medicare Levy Surcharge depending on your level of income. Please see our Suspension Application Form.

Is there assistance for people in remote areas?

A government sponsored scheme operating in, provides assistance to patients living in regional or remote areas who have to travel long distances to access specialist medical/surgical services.

In addition to the benefits available under, under certain circumstances Police Health also offers travel and daily accommodation benefits to members who need to travel more than 200 kilometres from their home to receive in-patient hospital treatment. Please contact Police Health prior to your admission date for further information.

For details of what is and not covered please refer to you state based product brochure.

Is there a limit to the number of days I can claim for hospital treatment?

No. Hospital benefits are payable 365 days a year, however if your hospital stay exceeds 35 days, you must obtain an acute care certificate to continue receiving full benefits. In our experience, it is rare to continue a hospital stay with out an acute care certificate.

For details on what is and not covered please refer to your state based product brochure.

Who are recognised providers?

Police Health will only pay benefits for goods and services provided by a provider recognised by Police Health for benefit purposes. There are a number of ways that a provider of services may become recognised by Police Health and this includes meeting criteria recognised by Police Health.

The complementary therapy providers criteria is assessed by the Australian Regional Health Group (ARHG) and can cover areas such as training, membership to a professional association or registration board, length of work experience, education and appropriate professional indemnity and public liability insurance. 

Use our Facilities & Provider Search to find a recognised provider or call us on 8112 7000 (Adelaide local) or 1800 603 603 (all other areas).

How do I change my contact details?

The policy holder can make these changes by calling us or sending a written request.

I recently changed my name, what should I do?

Email, fax or post your new details to Police Health together with a copy (not the original) of either your marriage certificate, Medicare Card or drivers license.

How do I change my level of cover?

You can change your level of cover by downloading and completing an application form, then send it to us with the relevant changes and we will inform you of your new premium.

If swapping to a lower level of cover, you will be entitled to receive benefits immediately.

When swapping to a higher level of cover, you will be entitled only to the benefits at your lower level until any relevant waiting periods are served, after which you will be entitled to benefits under your higher level policy. Contact us if you need clarification.

Why doesn’t my dentist or health provider have a swipe card facility?

Health insurers have no influence over how health practitioners administer their accounts. While most practitioners now have a HICAPS or HealthPoint swiping machine, it is up to the health service provider to implement such services.

What fees are recognised by Police Health?

Police Health has agreements with most hospitals, recognising their fees for full rebate.

With extras services, generally each health fund calculates its own set of average fees based on the claims they have paid previously.

Police Health goes further and in the majority of cases recognises charges up to 15% higher than the calculated average cost of the relevant service. This means that when members make a claim for extras with Police Health, they tend to get more back – 80% in the majority of cases.

Alternatively, we may elect to use the surveyed fees published by an association representing a particular profession.

Our 80% benefit applies to the net amount payable on any account, inclusive of any discounts the provider might be offering. This may vary where, for the benefit of our members, Police Health has negotiated specific agreements with selected providers.

Is my baby covered?

We recommend that a single policy be upgraded to a family or single parent family policy as soon as pregnancy is confirmed to ensure that a premature baby is covered by the policy.

A single hospital policy for mothers covers the cost of the birth of the baby but doesn't cover any costs incurred by the baby.

For a baby to be eligible for benefits immediately upon birth, the mother must have held a family or a single parent family policy for at least two calendar months prior to the infant's birth, regardless of whether or not the infant is premature.

Please note that where it is known or suspected that your baby may have developed a congenital condition during the pregnancy, no benefits are payable unless you have held continuous family or single parent family cover for at least 12 months prior to the baby's birth.

We request that you add your newborn to your policy within 14 days of baby's birth.

What does Annual Maximum mean?

Annual Maximum refers to the maximum benefit allowable in any one calendar year per person. It applies per person unless otherwise stated.

Will my private health insurance cover a visit to my GP?

Police Health is not permitted to pay benefits on services provided by a GP or specialist unless you are a hospital in-patient.

The benefits you receive from Medicare are based on 85% of the scheduled fee set by the Australian Government, so unless the doctor accepts Medicare benefits as full payment and bulk bills, you will be responsible for the 15% gap.

If doctors charge more than the schedule fee patients must also pay this additional amount.

Visit the Medicare website for more information.

Why doesn’t private health insurance cover accident and emergency service fees at private hospitals?

Many private hospitals charge a facility fee if you use their emergency department. In this case you are not classified as an in-patient and private health insurers are not permitted to pay benefits on these services.

In addition to the facility fee, you will also be charged for any medical services for doctors, radiology or pathology. These fees can be claimed from Medicare where you will receive 85% of the scheduled fee. No further benefits can be claimed from private health insurance.

If, after emergency treatment, you require admission to the hospital, services from that point are covered according to the limits of your Police Health hospital cover.

Will private health insurance cover my x-ray or breast scan?

Private health insurance funds are not permitted to pay benefits for medical services provided by a GP or specialist unless you are a hospital in-patient; this includes x-rays and radiology imaging like breast scans and ultrasounds.

When a medical service is provided to you, the benefits you receive from Medicare are based on 85% of the Medicare Benefits Schedule fee set by the Australian Government. Where a service provider “bulk bills” they accept the Medicare rebate of 85% as full payment and you won’t receive a bill, but where it is not bulk billed, you will be responsible for paying any differences between the medical practitioner charges and the Medicare rebate.  Police Health is legally precluded from paying any benefits for these medical services unless you are a hospital in-patient.

This situation extends to patients who receive medical services, including medical imaging services, on a hospital out-patient basis or while receiving treatment in the accident and emergency department of a private hospital.  Until you are admitted as a patient of the hospital, medical services provided in the accident and emergency department of a hospital are treated as an out-patient service, similar to visiting a doctor imaging centre.

Where a patient receives medical services, including x-rays and scans, when admitted as a patient of the hospital (in-patient), Medicare will pay 75 percent of the Medicare Benefits Schedule fee.  If you are covered for hospital treatment  (Top Hospital, Platinum Health & Platinum Plus), Police Health will pay at least up to 25 percent of the Medicare Benefits Schedule  fee.  Higher benefits are payable if the service is claimed under the Police Health GapCover arrangements*.

Police Health does not pay benefits for medical services that do not attract a Medicare rebate.

While mammograms undertaken as screening services are not covered by Medicare, free mammograms for eligible women are available through the BreastScreen Australia Program.  This Program targets women between 50 and 69 years of age, but is available to any woman over the age of 40 years.  

Please note that Police Health does pay benefits towards certain radiography procedures when ordered and conducted by a dentist or chiropractor in their facilities , benefits may be payable under an appropriate health insurance product that covers “extras” treatments.

* Subject to waiting periods being served.



Are anaesthetists covered on my hospital cover?

You need to check with your doctor to see if you are fully covered by Medicare and your Police Health policy. Like all health professionals, anaesthetists set their own charges.

While this is often more than the scheduled fee, many patients are covered by Police Health's Access Gap Cover. Additional gap payments may occur if this is not the case.

When admitted as a patient in a hospital (in-patient)

Medicare pays 75% of the Medicare Scheduled Fee for medical services such as your specialist, surgeon, assistant surgeon, anaesthetist, radiology and pathology. Police Health will pay 25% of the Medical Schedule Fee.

Where services are billed higher than the Medicare Schedule Fee, Police Health's Access Gap Cover scheme will in many cases allow us to cover the fee in full or at least to pay a higher benefit reducing your out-of-pocket cost. It is up to the doctor or service provider to participate in Access Gap Cover, where they chose not to participate in the scheme Police Health is only permitted to pay up to the Medicare Schedule Fee.

When you are not admitted as a patient in a hospital, and you see an anaesthetist in their consulting room, Medicare pays 85% of the Medicare Schedule Fee and no further benefit is available through health insurance. Please note that charges for medical services provided in a private hospital Accident and Emergency fall in this category.

Note: Police Health does not pay benefits for medical services where Medicare does not pay a benefit. 

How do I find out about the costs?

Whether you are treated in a private hospital or as a private patient in a public hospital, it is your right to be provided with information about the costs before you agree to the treatment.

If it’s an emergency you should be told about any charges as soon as practical after the treatment.

In all cases, you are only given an estimate as there can be extra charges if there are complications and additional treatment is required. Once you know the expected fee and the level of cover under your Police Health policy, you can decide whether to go ahead as planned or see another doctor.

Can you send me updates on what I've claimed?

You can check your benefits available and items you have claimed on our secure member login-in site, alternatively you can contact one of our friendly staff by phone or email.

What happens to extras benefits that I don't use during the year?

Many unused Annual Maximums not claimed during one calendar year can be rolled over by Police Health to the following year to give you greater cover. We call this our Rollover Benefit.

Claims are always paid from the service 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).

Can I swap cover for services we don’t use and increase it for things we do?

Our extras cover is designed to provide equity among all policy holders. Allowing policy holders to select greater cover in a particular area would result in increased claims and  premiums.

As Police Health only offers top of the range products, our policy holders are never caught out with an inappropriate level of cover. Policy holder feedback has consistently shown that the policing community prefers to have a broad ranging comprehensive policy that better looks after them and their family through all stages of their lives.

How can I provide feedback to Police Health?

Police Health continues to seek areas where we can make improvements in the cover and the services we provide. Police Health commissions regular member research to remain abreast of members' issues, and we also encourage and welcome your feedback at anytime.

Please email, feedback@policehealth.com.au, with your feedback/suggestions on our services, cover, communication material and internet functionality.

Your feedback will help us to maintain our services and cover, to ensure our members remain satisfied.

If however you have a general enquiry about Police Health, our services or cover and would like a response, please email enquiries@policehealth.com.au