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Common Terms used by Private Health Insurers

A | B | C | D | E | F | G | I | L | M | P | R | S | T

Accommodation

Accommodation covers meals and a bed in hospital, and includes all hospital-provided services including nursing care. It does not include treatment by doctors or other health professionals.

Ancillary services

See General treatment services

Benefit limitation period

Limited benefits are paid for certain conditions for a specified period of time. This is not the same as a waiting period during which no benefits are paid for a period of time after you purchase a policy.

Broader Health Cover

Health insurers may now offer cover under their hospital policies, for treatment in settings other than hospitals – for example in your own home – as well as programs to manage chronic disease.

Co-payment

A co-payment is where you agree to pay an agreed amount each time a service is provided. For example, a private health insurance policy may have a co-payment clause that requires you to pay the first $50 for each day’s hospital accommodation.

Dependent child

‘Dependent child' is defined as a person:
(a) who is:

I. aged under 18, or

II. a dependent child under the rules of the private health insurer that insures the person; and

(b) who is not aged over 25 or over; and

(c) who does not have a partner.

‘Dependent child non-student' means a person who:

(a) is aged between 18 and 24 (inclusive) and was born before 1991; and

(b) is a dependent child under the rules of the private health insurer that insures the person as referred to in subparagraph (a) (ii) of the definition of ‘dependent child’ in the Private Health Insurance Act 2007, whether or not the person is wholly or substantially dependent on an adult insured under the same health insurance policy; and

(c) does not have a partner; and

(d) is not receiving full-time education at a school, college or university.

Note: A ‘dependent child non-student' is therefore a ‘dependent child’ as defined in the Private Health Insurance Act 2007.

Diagnostic tests

Diagnostic tests can include such things as x-rays and blood tests.

Drugs, dressings other consumables

Drugs, dressings and other consumables are additional services to support hospital treatment. They include medications, bandages and crutches, prostheses (surgically implanted items such as hip replacements, artificial lenses and heart valves).

Elective surgery

Elective surgery is treatment of a condition your doctor considers does not require immediate attention.

Excess

An excess is an amount that you agree to pay towards the cost of hospital treatment in exchange for lower premium costs. You may be required to pay an excess every time you go to hospital, or only the first time, depending on the private health insurance policy you take out. An excess is also known as a front-end deductible.

Extras

See General treatment services

Federal Government Rebate

For every dollar that you contribute to your private health insurance premium, the Australian Government will give you back 30 cents. For health insurance members aged between 65 and 69 years, this amount increases to 35 cents, and for members aged over 70 years it is 40 cents.

Front end deductible

See Excess.

Gap

The term 'gap' generally means the difference in the amount that your doctor charges and the amount that is covered by Medicare and your health insurer, i.e. the amount that you must pay for your medical services received in hospital.

It can also refer to the difference between what your hospital charges and the amount that is covered by your health insurer.

General treatment services (previously known as ancillary or extras)

General treatment services are services, such as physiotherapy, speech pathology and podiatry, which are provided by health professionals.

Intensive care

Intensive care is treatment for actual or potential life-threatening illnesses, injuries or complications.

Labour ward fees

Labour ward fees include costs for delivery of babies in a birthing suite.

Lifetime Health Cover

Lifetime Health Cover was introduced on 1 July 2000. Under Lifetime Health Cover, health insurers are required to charge members different premiums based on the age they are when they first take out hospital cover. If a person does not have hospital cover on 1 July following their 31st birthday and decides to take out hospital cover later in life, they will pay a 2% loading on top of their premium for every year they are aged over 30. The loading will cease if the person has had hospital cover for a continuous period of 10 years.

Low Front End Deductible

Your front end deductible (also known as excess) must be equal to or less than $500 per annum for single policies or $1,000 per annum for families/couples to be considered a low front end deductible.

MBS Fee (Medicare Benefits Schedule Fee)

The Government sets a schedule of medical fees – called the Medicare Benefits Schedule. You can claim a rebate for medical fees whether you are a member of a health insurer or not. The rebate is currently 75% of the MBS fee for in-hospital medical fees and 85% of the MBS fee for medical fees incurred out of hospital.

Medical expenses/charges

Medical expenses are charges for medical procedures performed during a hospital stay. This covers items such as surgeons' fees, obstetricians' fees, radiology, pathology and anaesthetists. Medicare pays 75% of the MBS fee for these services.

Medicare Levy Surcharge (MLS)

Higher income individuals and families who do not have private hospital insurance cover will pay an extra 1% of their taxable income for the Medicare Levy Surcharge. This is in addition to the normal 1.5% Medicare Levy.

Palliative care

Palliative care is provided when a patient's condition is terminal. Such care provides relief of suffering and any enhancement to quality of life that can be achieved.

Pre-existing ailment

A pre-existing condition is an ailment, illness or condition, the signs or symptoms of which, in the opinion of a medical practitioner appointed by the health insurer, existed at any time during the 6 months prior to the member becoming insured under the policy.

Private Health Insurance Rebate

For every dollar that you contribute to your private health insurance premium, the Australian Government will give you back 30 cents. For health insurance members aged between 65 and 69 years, this amount increases to 35 cents, and for members aged over 70 years it is 40 cents.

Private patient in a public hospital

You are a private patient in a public hospital if you choose to be treated in a public hospital but retain the right to choose your own doctor. If you do so, you will be charged for hospital accommodation costs and doctors’ fees. Medicare will cover 75% of the MBS fee for your doctors' charges. If you have private health insurance, your health insurer will pay at least the remaining 25% of the MBS fee for your doctor’s charges and can pay more if your doctor is participating in your health insurer’s gap cover arrangements. Your health insurer will also cover some or all of your hospital accommodation costs.

Private patient in a private hospital

You must be a private patient to be treated in a private hospital. As a private patient in a private hospital you have the right to choose your own doctor, and you are responsible for all hospital and doctors' services. Medicare will cover 75% of the MBS fee for these doctors' charges. If you have private health insurance, your health insurer will pay at least the remaining 25% of the MBS fee for your doctor’s charges and can pay more if your doctor is participating in the health insurer's gap cover arrangements. Your health insurer will also cover some or all of your hospital accommodation costs.

Prostheses (surgically implanted)

Prostheses include such things as hip replacements, artificial lenses and heart valves.

Psychiatric care

You are under psychiatric care if you have a disability and you are taking part in a program designed to improve your functions, retrain you in lost skills or help you to re-establish your place in society.

Public patient

You are a public patient if you choose to be treated in a public hospital under Medicare by a doctor appointed by the hospital.

Rehabilitation care

You are under rehabilitation care if you have a disability and you are taking part in a program designed to improve your physical functions, retrain you in lost skills or help you to re-establish your place in society.

Restricted benefits

Cost for treatment as a private patient in a public hospital will be covered but there will be out of pocket expenses for treatment in a private hospital.

Same-day patient

You are a same-day patient if you are admitted, treated and discharged on the same day.

Standard information statements (SIS)

A standard information statement is issued by your health insurer when you first take out a policy and at least once every 12 months. It contains details of what the policy covers and how benefits provided under it are worked out.

Theatre fees

Theatre fees are costs for procedures performed in an operating room including those performed in day surgery facilities.