What does Accuro SmartCare+ cover?

Pharmac vs non-Pharmac drug cover

Standard prescription drugs (under the GP+ module) must be listed under sections A to I of the Pharmac Schedule, Pharmac-approved, medically necessary, and prescribed by a registered medical practitioner; the member must meet Pharmac's funding criteria. As part of the Hospital and Surgical+ base plan, the Non-Pharmac subsidised drugs benefit covers all drugs registered by Medsafe for use in New Zealand where: the treatment is prescribed by a registered medical specialist as the appropriate medical treatment for the condition; the treatment or condition is not excluded elsewhere in the Health Plan document; and the drug is prescribed within the guidelines set by Medsafe. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac drugs benefit are included in the maximum limit of the surgical or non-surgical benefit (whichever applies) under the Hospital and Surgical+ base plan, and the non-Pharmac drugs benefit cannot be used with any benefit on an additional module. No specific Keytruda example is mentioned.

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ACC interaction

SmartCare+ is designed to complement ACC and will not cover claims related to accidents that ACC covers. If ACC does not cover the full amount for treatment, the policy may pay the difference if the treatment is covered under the policy. The full payment option (where ACC contracts a provider and pays the total cost) should be the member's first choice. Under the ACC partial payment option, SmartCare+ covers the difference in cost up to Reasonable charges or the benefit limit, whichever is less. If ACC declines cover, UniMed may ask for a review or appeal, requiring the member to provide the ACC decline letter within 3 months. If ACC refuses or stops cover due to non-compliance by the member, the member cannot claim under the policy. Any ACC reimbursement is deducted from the total before assessing the amount under the policy benefit. The ACC top-up benefit covers any shortfall between what ACC pays and the actual costs of the surgical procedure or medical treatment in an approved private hospital or facility, subject to the excess and benefit maximums.

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Mental health cover

Annual sublimit: $1,000

The mental health benefit under the Hospital and Surgical+ base plan covers $1,000 per person per policy year for consultations with a psychiatrist, psychologist, psychotherapist, or counsellor (no excess applies). Practitioners must be registered under the psychiatry scope with the Medical Council of New Zealand, as a psychologist with the New Zealand Psychologists Board, as a psychotherapist with the Psychotherapists Board of Aotearoa New Zealand, or as a counsellor with the New Zealand Association of Counsellors or other relevant association. Psychiatric, psychological, and neurodevelopmental disorders are generally excluded from cover (including ADHD, autism spectrum disorder, dementia, etc.). There is no specific inpatient mental health admission benefit described; the exclusion of psychiatric/psychological disorders applies broadly.

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Pre-existing conditions

A pre-existing condition is any health or medical condition that the member is aware of, or was experiencing signs or symptoms of, before the start of the policy, or a medical event that occurred before the start of the policy. All pre-existing conditions must be disclosed at application. The underwriters assess each condition and may place personal exclusions on the policy certificate, which last for varying periods (from 1 year to life) depending on the medical condition. Claims may be declined for undisclosed pre-existing conditions that the member knew about or should have known about, and any such exclusion may be backdated to the policy start date. For example, a hernia present at policy start would result in a 5-year personal exclusion. Medical reports are required for claims within the first 5 years of the Hospital & Surgical+ base plan or Specialist+ module where the member has not previously claimed for that condition.

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IVF and assisted reproduction

Treatment, investigation, and diagnosis of infertility and assisted reproduction are explicitly excluded. However, after 3 years of continuous cover under the Specialist+ module, a loyalty benefit of $2,000 per person per policy year covers obstetric care during pregnancy and infertility diagnosis and treatment by a registered medical specialist (this benefit does not cover antenatal ultrasounds).

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Oncology and high-cost cancer drugs

Non-Pharmac subsidised drugs benefit under the Hospital and Surgical+ base plan covers the costs of Reasonable charges associated with accessing the most effective treatment available, including drugs not subsidised by Pharmac/government, provided they are registered by Medsafe for use in New Zealand, prescribed by a registered medical specialist as appropriate medical treatment, not excluded elsewhere in the Health Plan, and prescribed within Medsafe guidelines. If the drug qualifies for a government or other subsidy, only the remaining cost is reimbursed. All costs under the non-Pharmac drugs benefit are included in the maximum limit of the relevant surgical or non-surgical benefit (up to $500,000 for general surgery or $300,000 for private hospital medical admission). Chemotherapy drugs administered orally at home, prescribed by a registered medical specialist and used during an approved cycle of chemotherapy, are also covered under the private hospital medical admission benefit ($300,000 per person per policy year). A personal accessories benefit of $2,000 per person per policy year is available for items such as wigs, hats, scarves, or mastectomy bras needed during or within 6 months after a cancer procedure or medical treatment.

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Gap payment rules

UniMed pays up to the Reasonable charges for a procedure or medical treatment, up to the specified benefit limit. If the cost for a procedure or medical treatment is above what UniMed judges to be a Reasonable charge, the member may be asked for further information or recommended an alternative. If the member chooses to proceed with a provider charging above the Reasonable charge, the member must pay the difference between the amount approved and the actual cost, regardless of the benefit's maximum limit. This extra amount must be paid directly to the healthcare provider. If a procedure cost exceeds the benefit maximum limit, the exceeded amount cannot be paid and is the member's responsibility. UniMed does not cover excess applicable under another insurance plan. Members must also claim any other refunds, subsidies, or entitlements (e.g. ACC, another insurer, government-funded agency) first, and UniMed deducts any such reimbursement from the total before assessing the claim.

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