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Insure? Not Sure?

Topics in this Section

Introduction

Contents

General Information

Surcharges and Incentives

About Private Health Insurance

Types of Cover

Questions You Should Ask

Common Terms

Insurer Contact Details

Common Terms Used by Private Health Insurers

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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.