Policy changes

The following healthcare services were added:

• Anti-reflux mucosal ablation (ARMA)
• Transcoronary ethanol septal ablation (TESA)

The following healthcare services were removed:

• Anti-reflux mucosal ablation (ARMA)
• Cerebral angiograms completed in a cath lab setting
• Transcoronary ethanol septal ablation (TESA)

The following healthcare service was amended to include coverage under exception provisions:

• Cryoablation of central or peripheral nerve (except when used in the treatment of cancer-related pain)

The following healthcare service was added:

• Temporary implantable nitinol device (TIND) for benign prostatic hyperplasia (BPH) (e.g. iTind)

Eligibility criteria for radiotherapy for cancer care changed:

View eligibility criteria for radiotherapy for cancer care before 30 May 2025.

Eligibility criteria for eustachian tube balloon dilation changed:

View eligibility criteria for eustachian tube balloon dilation before 01 April 2025.

Eligibility criteria for basivertebral nerve ablation changed:

View eligibility criteria for basivertebral nerve ablation before 31 March 2025.

The following healthcare service was added:

• Robot-assisted primary knee replacement
  • CORIN: OMNIBotics procedures for total and partial knee arthroplasty

The following healthcare service was updated by removing the word 'knee' after 'total':

• Robot-assisted primary knee replacement
  • Stryker: MAKO procedures for total and partial knee arthroplasty

The following healthcare service was removed:

• Endovascular aneurysm repair (EVAR)

The following healthcare service was amended to specify cover:

• Primary cochlear implant surgery and initial internal receiver/stimulator only

The following healthcare services were amended to include coverage under exception provisions:

• Cochlear implant and surgeries (except for Cochlear implant primary cochlear implant surgery and initial internal receiver/stimulator only)
• Sleep apnoea surgery (except for tonsillectomy, adenoidectomy, and adenotonsillectomy)

The following healthcare services were added:

• Endovascular aneurysm repair (EVAR)
• Endoscopic Carolyn’s window

The following healthcare services were removed:

• Transcoronary ethanol septal ablation (TESA)
• Liposuction for secondary lymphedema following an oncological intervention
• Basivertebral nerve ablation (BVNA)
• Thoracic endovascular aortic repair (TEVAR)

The following variations were added:

Robot-assisted surgery 

Robot-assisted ventral hernia repair is removed from the list of exceptions to the robot-assisted surgery exclusion on the following policies.

• Wellbeing One and Two  
• KiwiCare and RegularCare  
• Wellbeing Starter  
• First Cover Plans  
• Westpac First Cover plan  
• SureCare concessionary.  

The following healthcare services were added:

• Transcoronary ethanol septal ablation (TESA)
• Complex abdominal doppler ultrasound with CT angiography scan (e.g. Scholbach Protocol) for abdominal compression syndromes
• Magtrace lymphatic tracer
• TRODAT scans
• Basivertebral nerve ablation (BVNA)
• Robot-assisted orthopaedic surgery (except for Robot-assisted primary total hip replacement and Robot-assisted primary knee replacement; see Affiliated provider-only healthcare services for details of the robot-assisted orthopaedic surgery we cover)
• Thoracic endovascular aortic repair (TEVAR)

The following healthcare services were amended to include coverage under exception provisions:

• Botulinum toxin injections (e.g. Botox, Dysport) (except when used in the treatment of anal fissures and laryngeal dystonia, or into the bladder, urethra, or pelvic floor in conjunction with a pudendal nerve block)
• Brow lift, except as part of a major facial lesion removal
• Liposuction (except when used for an eligible breast reconstruction or revision surgery)
• CT calcium scoring, except as part of CT coronary angiography (CTCA)

The following healthcare services were removed:

• Radiofrequency ablation of Morton's neuroma
• Gastrointestinal ultrasound (GIUS)
• Contrast-enhanced mammography

The following healthcare services were added:

• Laparoscopic fundoplication
• Robot-assisted primary knee replacement
  • Johnson & Johnson: VELYS procedures for total knee arthroplasty
  • Zimmer Biomet: ROSA procedures for total and partial knee arthroplasty
  • Smith + Nephew: CORI procedures for total and partial knee arthroplasty
  • Stryker: MAKO procedures for total knee, and partial knee arthroplasty
• Robot-assisted primary total hip replacement
  • Stryker: MAKO procedures for total hip arthroplasty
  • Smith + Nephew: CORI procedures for total hip arthroplasty

The following healthcare services description were amended to correct spelling errors:

• Removal of exostoses
• Endoscopic ultrasound
• Single fibre electromyogram (SFE)

The following healthcare service was amended to include drug cover:

• Intravitreal injection: Only $100 is available towards the cost of the drug used for each injection, regardless of the type of drug used

Eligibility criteria for cochlear implant internal device changed:

View eligibility criteria for cochlear implant internal device before 12 November 2024.

As New Zealand’s largest health insurer, we believe health insurance plays an important role in empowering people to live well for longer. We are committed to ensure that our plans stay relevant to our members.

Policy Review is a regular review of the benefits offered by our health insurance policies.

Product simplification for improved understanding, member experience and accelerated product delivery. This includes changes such as removing excesses from some benefits, and plain language policy wording. There is also provision for internal process simplification and clarification of existing cover so that members understand what they already have cover for.

Strategic initiatives

• Excesses have been removed from 12 benefits with excesses now only applying to surgical procedures, chemotherapy for cancer including Cancer Cover Plus and radiotherapy.
• Increased cover for breast procedures.
• Consider the best way to provide necessary mental health support for members

Select a plan below to see the changes that took effect from 22 October 2024:

• HealthEssentials
• KiwiCare
• RegularCare
• Wellbeing One
• Wellbeing Two
• UltraCare
• First Cover
• SureCare Concessionary
• Wellbeing Starter
• Westpac First Cover

The following healthcare services were added:

• 3D low-dose, weight-bearing X-ray (e.g. EOS imaging)
• Abbreviated breast MRI
• Botulinum toxin for laryngeal dystonia
• Periurethral for urinary incontinence
• Drug-eluting balloon angioplasty for in-stent restenosis
• Image-guided percutaneous carpal tunnel release
• Image-guided percutaneous trigger finger release
• Implantation of prosthetic iris device (including custom-made artificial iris)
• Implantation of microstents/microshunts for the treatment of glaucoma - Glaukos iStent or Glaukos PreserFlo or Allergan XEN Gel Stent.
• Intravascular lithotripsy for coronary artery disease
• Liposuction for secondary lymphedema following an oncological intervention
• MicroPulse Transscleral Cyclophotocoagulation (MP-TSCPC)
• Peripheral sensory nerve ablation for cancer-related pain
• Per Oral Endoscopic Myotomy & Zenker's peroral endoscopic myotomy (POEM and ZPOEM)
• Robot-assisted knee replacement
• Robot-assisted total hip replacement
• Single fibre electromyogram (SFE)
• Thyroid nodule ablation
• Total temporomandibular joint (TMJ) replacement
• Transcoronary ethanol septal ablation (TESA) also known as Transcatheter ethanol septal ablation

The following variations were made:

Travel and accommodation allowance

Under the travel and accommodation allowance terms and conditions, cover is also available for the following:

• Travel costs include ride sharing services such as Uber and companion driving services.
• Accommodation costs include rental accommodation through recognised accommodation providers, for example hospital flats, or hosting platforms such as Airbnb or Bookabach.

Prognostic gene testing for breast cancer

This variation provides cover for specified prognostic gene testing for breast cancer performed by an Affiliated Provider. UltraCare members do not need to see an Affiliated Provider. You must be referred by a specialist in private practice.

For prognostic gene tests, eligibility criteria need to be met before we’ll cover them. We’ll cover the actual costs incurred for the following prognostic gene tests for breast cancer:

• Prosigna
• Oncotype DX
• Mammaprint.

No excess or co-payment applies to this cover. Policy limits do not apply.

This cover is not available under the HealthEssentials policy.

Cosmetic procedures and treatment under the surgical procedures benefit

The exclusion for cosmetic procedures and treatment does not apply to the following procedures under the surgical procedures benefit:

• Reconstructive procedures following resection or removal of a tumour
• Blepharoplasty and ptosis surgery to correct droopy eyelids that impair vision
• Open septoplasty (septorhinoplasty) for nasal obstruction 
• Sclerotherapy or embolisation of simple vascular malformation.   

Healthcare services related to mental health

The exclusion for healthcare services related to mental health does not apply to the following benefits:

• general practitioner services
• nurse services
• prescriptions. 

Diagnostic imaging benefit

The exclusion for health screening and maintenance services does not apply to the ‘Diagnostic imaging’ benefit for breast screening ultrasounds where a mammogram is unsuitable due to confirmed dense breast tissue. Dense breast tissue must be confirmed by a mammogram or MRI.

The description of the following healthcare service was updated:

• Cochlear implant replacement receiver/stimulator appliance

The following healthcare services were amended to include coverage under exception provisions:

• Botulinum toxin injections (e.g. Botox, Dysport) (except when used in the treatment of anal fissures or into the bladder, urethra, pudendal nerve, or pelvic floor in conjunction with a pudendal nerve block)
• Liposuction (except when used for an eligible breast reconstruction or revision surgery and secondary lymphedema following an oncological intervention)
• Microstents and microshunts for the treatment of glaucoma / Minimally invasive glaucoma surgery (MIGS) (except for devices specified on the list of prosthesis and specialised equipment)

The following items were added: 

• Periurethral bulking agent (Bulkamid) with prosthesis maximum of $3,000
• Prosthetic iris device with prosthesis maximum of $10,250
• MIGS specialised equipment, category 3 (XEN gel Stent, iStent Trabecular Micro-Bypass Stent, PreserFlo MicroShunt) with prosthesis maximum of $2,500
• MIGS specialised equipment, category 2 (iTrack canaloplasty microcatheter, MicroPulse
• P3 Delivery Device) with prosthesis maximum of $1,500
• MIGS specialised equipment, category 1 (Kahook Dual Blade) with prosthesis maximum of $1,000
• MicroPulse Transscleral Cyclophotocoagulation (MP-TSCPC) with prosthesis maximum of $1,500 for a MicroPulse P3 Delivery Device
• Pacemaker (initial appliance) Except for Lead-less pacemaker (Medtronic Micra)
  • Prosthesis maximum of $2,760 for a single chamber pacemaker
  • Prosthesis maximum of $4,485 for a dual chamber pacemaker
  • Prosthesis maximum of $10,260 for a Biventricular/complex pacemaker
• Temporomandibular joint with prosthesis maximum $26,000 for unilateral
• Temporomandibular joint with prosthesis $45,000 for bilateral

Eligibility criteria for bilateral breast reduction allowance changed:

View eligibility criteria for bilateral breast reduction allowance before 9 October 2024.

Eligibility criteria for fat grafting following an eligible mastectomy changed:

View eligibility criteria for fat grafting following an eligible mastectomy before 25 September 2024.

Eligibility criteria for prophylactic treatment allowance changed:

View eligibility criteria for prophylactic treatment allowance before 25 September 2024.