Glossary

A 'gap' is the amount you pay out of your own pocket for treatment in hospital, either for medical or hospital charges over and above what you get back from Medicare or your private health insurer. Some health insurers have gap cover arrangements to insure against some or all of these additional payments.

Gap cover arrangements

Gap cover arrangements minimise any gaps between the MBS fee and what doctors actually charge. Some gap cover arrangements provide partial cover for the gap between the MBS fee and actual doctor's fee. Other gap cover arrangements provide full cover. Doctors can decide to use the gap cover arrangements on a case-by-case basis, so full cover cannot usually be guaranteed by the insurer.

General treatment cover

Health insurance to cover non-hospital medical services that are not covered by Medicare, such as dental, optical, physiotherapy, other therapies and ambulance.

General dental

Minor dental services, such as annual checkups, cleaning and fluoride treatment.

Health fund top of page

See Insurer

HICAPS

Health Industry Claims And Payment Service. Allows you to make your claim at the point of service via an EFTPOS style transaction using your Health Fund membership card.

Hospital cover

Health insurance to cover your costs as a private patient in hospital, including hospital accommodation, medical treatment and ambulance (in some states).

Informed financial consent top of page

The provision of cost information to patients; including notification of likely out-of-pocket expenses (gap), by all relevant service providers, preferably in writing, prior to admission to hospital.

In-patient

A patient who has been formally admitted to a hospital or day facility.

Insurer

Private health insurance organisation.

Intensive care

Hospital treatment for actual or potential life-threatening illnesses, injuries or complications.

Item

Specific medical service for which a benefit might be paid, identified by MBS code or an insurer's own code. Specific sample items are listed on the SIS.

Jurisdiction top of page

See State

Labour ward fees top of page

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

Lifetime Health Cover (LHC)

Lifetime Health Cover is a Government initiative introduced from 1 July 2000. It was designed to encourage people to take out hospital insurance earlier in life, and to maintain their cover. People aged 30 or under who take out (and keep) hospital cover pay lower premiums throughout their lifetime than people who join later. If you join after age 30, you pay 2% more on basic private hospital insurance than someone who joined at age 30. If you join at 35, you pay 10% more and if you join at 50, you'll pay 40% more. There are no age penalties or incentives for general treatment cover.

Major dental top of page

Significant dental services, such as tooth extractions, crowns and bridges.

MBS payable item

Services listed under the Medicare Benefits Schedule, which includes medical services necessary to maintain your health. Some services are not covered by MBS, such as elective cosmetic surgery.

Medicare Benefits Schedule (MBS)

The schedule of fees set by the government for standard medical services, based on a fair price and how much Australia can afford to pay for the total health system. Whether you have private health insurance or are a private patient paying for all your own costs, the government provides a rebate on nearly all medical fees. This rebate is currently 75% of the MBS fee for in-hospital medical fees and 85% of the MBS fee for specialist medical fees incurred out of hospital. You can purchase health insurance to cover the remaining 25% of the MBS fee and gap cover for any potential additional fees.

Medical expenses

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.

Medical gap

See Gap.

Medicare Levy Surcharge (MLS)

The Medicare Levy Surcharge is levied on Australian taxpayers who earn above a certain income and do not have private health insurance (hospital treatment cover). The surcharge aims to encourage individuals to take out private hospital cover, and where possible, to use the private system to reduce the demand on the public system. The Surcharge is calculated at the rate of 1% of taxable income. It is in addition to the Medicare Levy of 1.5%, which is paid by most Australian taxpayers. The Medicare Levy Surcharge is imposed on individuals earning over the threshold who do not have an appropriate level of hospital insurance. The threshold is $70,000 for individuals, and $140,000 for families.

Medicare Levy Surcharge exemption

Many hospital cover policies are sufficient to exempt you from being liable to pay the Medicare Levy Surcharge. If you plan to use your insurance for an exception, check with your insurer to ensure it meets the surcharge requirements.

Medical service

A service provided by a doctor, specialist, radiologist, pathologist or anaesthetist.

Medium cover

General treatment cover with at least general dental, major dental, optical, physiotherapy, chiropractic, podiatry, occupational therapy, but without orthodontics, health management, appliances, etc.

Medium private hospital cover

Private hospital policy with restrictions for some MBS payable items, but no exclusions.

Monthly premium

The amount you pay for your health insurance each month. Note that the price shown on the Standard Information Statement is not a quote and should only be used to compare the cost of different health insurer policies. The price is the monthly premium with the 30% Rebate deducted. It does not include any Lifetime Health Cover loading or factor in any discounts that may be available or a higher level of Rebate that may apply. Contact your insurer for a specific quote.

Obstetrics top of page

Management of pregnancy, labour and delivery and associated care, provided in hospital.

Overnight excess

See Co-payment

Patient moiety top of page

See Co-payment

PBS

The Pharmaceutical Benefits Scheme (PBS) provides a Government subsidy to reduce the price of some prescription medicines.

Performance report

An annual report card developed by PHIO for each insurer in each state. The report is available on each insurer's information page on this website.

PHIAC

The Private Health Insurance Administration Council (PHIAC) is an independent Statutory Authority that regulates the private health insurance industry.

PHIO

The Private Health Insurance Ombudsman (PHIO) provides an independent service to help consumers with health insurance problems and enquiries. The Ombudsman also publishes reports and consumer information about private health insurance.

Portability

The ability for people to transfer from one insurer to another, without re-serving waiting periods.

Pre-existing condition

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 six months prior to taking out hospital cover or upgrading to a higher level of cover. Health insurers are able to impose a maximum 12-month waiting period for hospital treatment for ailments, illnesses or conditions that are considered to be pre-existing. For psychiatric care, rehabilitation and palliative care, the maximum waiting period is two months, even if the condition is pre-existing. If you have a pre-existing ailment, it is important to check with your health insurer whether a waiting period applies, prior to your admission to hospital.

Preferred provider

Providers of ancillary services who have an arrangement with an insurer to provide services with low or no out-of-pocket costs.

Premium

Fee payable for health insurance policy. See also Monthly premium.

Premium discounts

Insurers may offer discounts on premiums, such as an administration discount for members who pay by direct debit.

Previous name

If a health insurance policy has changed its name, the website will link to the SIS showing the new name.

Private Health Insurance Rebate

For every dollar that you contribute to your private health insurance premium, the government will give you back at least 30 cents.
For people aged between 65 and 69 years, the Rebate is 35% and for people aged 70 years and over, the Rebate is 40%.

Private hospital

A hospital run as a commercial and/or charitable operation.

Private patient in a private hospital

Depending on the circumstances, being a private patient in a private hospital or a private day hospital facility allows you to choose the doctor(s) who treats you at a time that suits you. This is provided your doctor(s) has an arrangement with that hospital to treat private patients and the hospital you have chosen has beds and has available the services you will need.

As a private patient in a private hospital, you may be charged for a range of services which could include:

care in intensive/critical care units,
doctor(s) services (including diagnostic tests),
operating theatre fees,
allied health services (eg. physiotherapy),
dressings, medications/drugs, other consumables,
surgically implanted prostheses (eg. artificial hips),
personal expenses such as TV hire and telephone calls.

The hospital and the treating doctor(s) should, where possible, advise you about the services for which you will be billed.

Private patient in a public hospital

Being a private patient in a public hospital gives you a choice of doctor(s). Depending on your illness or condition and your needs, this may or may not be the same doctor(s) who would have been allocated to you by the hospital as a public patient.

As a private patient in a public hospital, you may be charged for a range of services which could include:

hospital accommodation,
doctor(s) services (including diagnostic tests),
surgically implanted prostheses (eg artificial hips),
personal expenses such as TV hire and telephone calls.

The hospital and the treating doctor(s) should, where possible, advise you about the services for which you will be billed.

Policy

Health insurance cover on a specific range of services, with specific levels of excess/co-payment, offered at a set price within one state.

Product code

The code used by an insurer to identify their own specific policies.

Prostheses (surgically implanted)

Surgically implanted prostheses include such things as hip replacements, artificial lenses and heart valves.

Provider

A person or business qualified to supply medical services, such as a clinic, therapist, dentist, etc.

Public hospital

A hospital funded by the Government. 'Recognised' public hospitals have access to the Medicare Benefits Schedule, the Pharmaceutical Benefits Scheme and private health insurance arrangements.

Public hospital cover

A hospital policy with restricted benefits for all conditions. This policy is sometimes called a 'basic table'. You will be covered for treatment as a private patient in a public hospital, but may face considerable out-of-pocket costs for treatment in a private hospital.

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.

Rate top of page

See Premium.

Rebate

See Private Health Insurance Rebate.

Restricted benefits

See Restrictions.

Restricted access insurer

See Restricted membership insurer.

Restricted fund

See Restricted membership insurer.

Restricted membership insurer

A health insurer providing cover to a specific industry or group, usually on a not-for-profit basis. You must be a member of the industry or group to join the fund. In some cases, family members are also eligible.

Restrictions

Condition or services which this insurance policy covers to a limited extent, and will pay reduced benefits on hospital or medical costs.

Same-day patient top of page

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

SIS

Standard Information Statement. A summary of health insurance policy details provided in a standard A4 format for easy comparison.

State

Australian State or Territory. Also called Jurisdiction.

State of the Health Funds Report

The annual report on insurer performance and service delivery, prepared by PHIO and available online at the PHIO website.

Status

Availability of specific policy: Available or Closed

Suspension

A suspension of health cover means that, with the agreement of your health insurer, you may stop paying your premiums for an agreed period of time. You will not be able to claim any benefits during your suspension. It is important to check whether you will need to re-serve any waiting periods after a period of suspension as rules vary between health funds. In addition, if you are over the income threshold you will be required to pay the Medicare Levy Surcharge for the period that you are suspended. Health insurers may grant suspensions at their own discretion for circumstances such as working or studying overseas, financial hardship or temporary unemployment. Your Lifetime Health Cover status is not altered during a period in which your health fund suspends your health insurance.

Table top of page

Former name for health insurance products.

Theatre fees

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

Top private

A private hospital policy with no restrictions or exclusions on MBS payable items.

Treatment exclusions

See exclusions.

Type

Type of health cover: general treatment cover, hospital cover or combined cover.

'Valid from' date top of page

The date a new health insurance policy will be available for purchase.

Waiting period top of page

How long you will need to be a member before you are eligible for benefits. The Government has set maximum waiting periods for benefits for hospital services, but insurers can set their own waiting periods for general treatment cover on ancillary services. The SIS list waiting periods in months for standard services.