Phoenix Health Fund’s Silver Plus Essentials Hospital 500 and Mid Extras offers Members all the same great comprehensive benefits as our Top Hospital cover, but removes coverage for Pregnancy services, Assisted reproductive services, Gastric Banding and Psychiatric is restricted to help you save money.  Additionally, with this combination you get a great Mid Extras package for services such as dental, optical and physiotherapy and much more.

What’s Included in Hospital Cover

Treatments Covered
Assisted reproductive services No
Back neck and spine Yes
Blood Yes
Bone, joint and muscle Yes
Brain and nervous system Yes
Breast surgery (medically necessary) Yes
Cataracts Yes
Chemotherapy, radiotherapy and immunotherapy for cancer Yes
Dental surgery Yes
Diabetes management (excluding insulin pumps) Yes
Dialysis for chronic kidney failure Yes
Digestive system Yes
Ear, nose and throat Yes
Eye (not cataracts) Yes
Gastrointestinal endoscopy Yes
Gynaecology Yes
Heart and vascular system Yes
Hernia and appendix Yes
Hospital psychiatric services Restricted
Implantation of hearing devices Yes
Insulin pumps Yes
Joint reconstructions Yes
Joint replacements Yes
Kidney and bladder Yes
Lung and chest Yes
Male reproductive system Yes
Miscarriage and termination of pregnancy Yes
Pain management Yes
Pain management with device Yes
Palliative care Yes
Plastic and reconstructive surgery (medically necessary) Yes
Podiatric surgery (provided by a registered podiatric surgeon – limited benefits) Yes
Pregnancy and birth No
Rehabilitation Yes
Skin Yes
Sleep studies Yes
Tonsils, adenoids and grommets Yes
Weight loss surgery No

What’s Included in Extras Cover

Unless otherwise stated, benefit limits apply per person per calendar year.

Please also note that this page does not include the full detail of all services covered, and that sublimits apply for some services.  It is recommended that you either check your Online Member Services or contact us before your treatment to check exactly what you are covered for.ly what you are covered for.

 

Treatments Benefit (for commonly claimed items) Waiting Period
General Dental 011 – Periodic oral examination – $32.00
114 – Scale & clean – $55.20
121 – Fluoride treatment – $19.20
$500
Optical
(Excluded: Sunglasses, where no sight correction is needed)
Single vision lenses & frames – $150.00
Multi-focal lenses & frames – $150.00
Frame – $80.00
Single Vision Lenses – $96.00
Multifocal Lenses – $150.00
$150
Non PBS Pharmaceuticals (Excluded: contraceptives and items purchased over the counter) Per eligible prescription – $30.00  (Paid after General PBS copayment has been paid) $200
Chiropractic/Osteopathic Chiro/Osteo Initial visit – $32.00
Chiro/Osteo Subsequent visit – $24.00
Chiropractic X-rays – $80.00
$250
Physiotherapy Physiotherapy Initial visit – $40.00
Physiotherapy Subsequent visit – $29.60
$250

Important Hospital Information

For hospital services to which Phoenix Health Fund provides coverage, Silver Plus Essentials Hospital 500 & Basic Extras provides coverage for:

  • Private and public hospital services nationwide (after the up-front excess has been paid) with access to an extensive range of quality services and approved programs in private hospitals which have an agreement with Phoenix Health Fund.
  • Public or Private Hospital bed – shared or private room (if available)
  • Same day patient fees
  • Theatre fees
  • Intensive care
  • Labour ward
  • In hospital pharmacy
  • Prosthesis (Commonwealth Government approved)
  • All other in-patient services where a Medicare benefit is payable (not listed as an exclusion in the hospital table above)

Additional costs you may incur are:

  • The amount the doctor charges above the Medicare schedule fee or “Access Gap” cover amount
  • some drugs, pharmacy items and non-PBS drugs for personal use or on discharge; and possibly
  • a co-payment for prostheses devices above the minimum benefit.
  • There are a small number of public hospitals that do not have agreements with us. In these cases a personal payment may apply.

Ambulance Coverage

Phoenix Health Fund covers all medically necessary transport from a State Emergency Ambulance service. This also includes when an Ambulance is called to attend to you, but you do not subsequently need to be taken to hospital. Coverage is not offered when it is not medically necessary for you to be transported by an Ambulance.

Excluded services

If you are to be admitted into a public or private hospital as an in-patient for an excluded service on your policy, the fund will not pay a benefit.

Restricted Services

If you are to be admitted into a public or private hospital as an in-patient for a restricted service, you will need to be aware of how your fund will pay your benefits.
Be aware that if you are admitted with a restricted service, significant out of pocket expenses can apply.

Service Category Benefit Rules
Psychiatric
  • If you are admitted in a Public Hospital as a private patient, services will only be paid at the Public Hospital Shared Ward Accommodation rate
  • If you are admitted in a Private Hospital, accommodation benefits payable are in accordance with the relevant default benefits as determined by the Commonwealth Government, resulting in the member having a large out-of-pocket expense.
  • If you are admitted into a Private Hospital, no benefit for private hospital theatre fees, facility fees or labour ward apply.
  • If you are admitted into hospital, only Commonwealth Government approved prostheses will be covered.

Excess

If you are admitted to a hospital, you will pay an up-front excess of hospital costs until you have reached your excess maximum of $500 per person within a calendar year (1st January through to 31st December).

The excess is applied as follows:

  • An excess of $500 per adult applies to day or overnight admissions in a private or public hospital
  • The maximum excess per family membership is $1000
  • The excess is waived for all dependant children/adult on family/sole parent policies

Medical Gap cover

 

Phoenix Health Fund, as a member of the Australian Health Service Alliance, has “Access Gap” arrangements with more than 15,000 doctors Australia-wide. These arrangements minimise or eliminate Members’ out-of-pocket expenses when our Members are treated as admitted hospital patients.

If your doctor participates in the “Access Gap” scheme, you will either have no out-of-pocket expenses to pay or will know exactly how much you will have to pay before treatment begins. Your doctor can bill Phoenix Health Fund direct, so in most cases you will not be required to lodge a claim with us, making it easier for you.

To check whether your doctor participates in “Access Gap”, use our Doctor Search facility, or ask your doctor.

Silver Plus Essentials Hospital 500 & Basic Extras waiting periods

Hospital

  • 12 month waiting periods for pre-existing conditions
  • 2 month waiting periods for all other hospital items

Extras

  • 2 month waits for general dental and endodontic claims
  • 6 month waits for optical claims
  • Nil waiting periods for emergency ambulance
  • 2 month waits for all other extras item claims

Fund Rules

For the complete description of the Fund rules, relating this product, please refer to the General Information section on our website.

Please ensure you have read and retained the information relating to your policy of choice before applying for membership.