The glossary of terms provides definitions of private health insurance related terms.

Use the index to get to the right section of the list, then click on an item to see its definition. Follow these links for hospital Clinical categories and services included under General Treatments (Extras) cover.

Accident Cover

Some hospital policies do offer accident cover, for treatment of injuries sustained in an accident. Accident cover differs between insurers so check with your insurer as to what is covered. It may include transportation in an ambulance for emergencies and the option to attend an emergency department at a private hospital when you have an accident.

Accidents

An accident for private health insurance purposes is commonly defined as an injury that occurred unintentionally or unexpectedly that requires treatment by a registered medical practitioner at a hospital. Other conditions may apply. Check with your insurer for details.

Accommodation

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

Admission

To receive treatment as a private patient in a hospital you need to be admitted by a doctor. Treatment in the emergency room is not considered admission.

Age-based discount

Australians aged 18-29 years of age can be offered discounts of up to 10 per cent of their private hospital insurance premiums - check with your insurer for details.

Agreement hospital

Private hospital or day surgery contracted with an insurer to provide services at low or no out-of-pocket costs.

Ambulance cover

Medicare does not cover the cost of emergency transport or other ambulance services. Depending on your state of residence, you can purchase ambulance cover from an insurer or subscribe to a state ambulance service, or you may be covered by state government arrangements. For more information see: What is covered - Ambulance

Ancillary policy

See General treatment policy.

Annual limits

The maximum benefit payable for a particular service within a 12 month period. Annual limits can be calculated based on a calendar year, or financial year, or for every 12-month period from the anniversary date of taking out a private health insurance policy.

Appliance

Small item used to compensate for reduced functionality, such as a hearing aid or colostomy pouch.

APRA

The Australian Prudential Regulation Authority is an independent body that regulates the financial aspects of the private health insurance industry.

Artificial aids

See: Health aids

Australian Government Rebate

Most Australians with private health insurance currently receive a Rebate from the Australian Government to help cover the cost of their premiums. The Private Health Insurance Rebate is income tested. For more information see Private Health Insurance Rebate.

'Available From' date

The 'Available From' date on a PHIS is the date that the policy is available for purchase. This date only appears when the policy is only available for purchase date is in the future. Once that date has passed the 'Available From' information disappears from the PHIS.

Basic private hospital policy

A basic level of private hospital policy which excludes or restricts one or more major medical services, such as cardiac and cardiac-related services. No benefits are paid for excluded services and only limited benefits are paid for restricted items. For more information on Basic hospital cover, see How health insurance works.

Benefit limitation period

Before 1 July 2018 some private health insurers imposed benefit limitation periods (BLPs) of up to 24 months for some categories of hospital treatment. During a BLP, you were only entitled to restricted benefits for a particular condition or treatment. BLPs are no longer in use in private health insurance.

Benefit limits

The benefit limit is the most amount of money you can claim for a service, usually in a 12 month period.

Benefit

The amount you can claim from the insurer for a specific service. This may be listed on the PHIS as a dollar amount (maximum benefit) or as a percentage amount (percentage benefit). For example: Maximum benefit - for each visit to a physiotherapist you can claim up to $50; Percentage benefit - for each visit to a physiotherapist you can claim up to 75% of the total cost. Some policies may use a combination of both dollar and percentage amounts (for example: for each visit to a physiotherapist you can claim 75% of the cost up to a maximum of $50) - this kind of benefit is not currently displayed on the PHIS so it’s important to check with your insurer about what your policy covers.

Benefits for travel & accommodation (outside of hospital)

If you require travel to a hospital for treatment and/or accommodation once you get there, you may be able to claim some of the costs back if your policy covers this. Check with your insurer for details.

Brand

Additional trading name for an insurer, used in one or more states.

Bronze cover (hospital)

Bronze policies will provide cover in hospital for some treatments covered by Medicare.

Call-out fees

A fixed fee charged every time an ambulance is called. Per-kilometre charges also apply to most ambulance trips.

Classification

The general level of cover on a given policy, to allow easy comparisons. Hospital policies are classified as Gold, Silver, Bronze or Basic. For more information, see Private Health Insurance Basics.

Closed policy

A policy which is no longer available for sale, but which continues to cover existing members.

Co-payment

For a hospital policy a co-payment is a set amount that you agree to pay for each day you are in hospital, in exchange for lower premiums. For example, you may agree to pay the first $50 per day in hospital. Most co-payments have a limit on the number of days they apply per stay. It can also be called an overnight excess, daily excess or patient moiety.

For a general treatment policy you may be required to pay a co-payment for some services before a benefit will be paid. For example, it is common for pharmacy items to require a co-payment of the equivalent to the amount listed for the items on the Pharmaceutical Benefits Scheme (PBS). Always check with your insurer about what co-payments you may need to pay.

Combined limit

In a general treatment policy some of the services that are covered may have a combined limit - this means that for all of the services in the combination, you can only claim a certain amount across all of them.

Combined policy

Most insurers offer combined policies that provide a packaged cover for both hospital and general treatment services.

Community rating

Private health insurance is 'community-rated'. This means that everyone is entitled to buy the same policy, at the same price, and is guaranteed the right to renew their policy. A health insurer cannot refuse to insure you, or refuse to sell you any policy you want to buy. There are some exceptions to this - for example, you will pay a higher premium if you have a Lifetime Health Cover loading.

Corporate policy

A policy developed by a health insurer for a specific company, generally available to employees of that company only.

Covered

If a PHIS has marked a service as 'covered' this means that the policy provides some level of coverage for that service. Contact your insurer for details.

Daily excess

See Co-payment.

Day surgery

A private hospital or facility where patients are admitted, treated and discharged on the same day. Also called day facility or day hospital.

Default benefit

The “default” or minimum benefit is the lowest amount that a health insurer is permitted to pay for a hospital admission that is included on policy. See: Minimum Benefit

Department of Health and Aged Care

The government department which is responsible for policies relating to private health insurance.

Dependant

A dependent child is an unmarried person under the age of 18 years. An insurer may choose to continue considering a person between the ages of 18 and 31 years as a dependent child, but will usually require certain conditions to be met - for example, the person may have to be a full-time student. Insurers can also choose to cover dependents with a disability without any age limit. These conditions vary between insurers, so check with your insurer to see which rules they apply.

Diagnostic tests

The most common diagnostic tests include x-rays, scans and blood tests.

Drugs, dressings and other consumables

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

Elective surgery

Surgical treatment of a condition that your doctor considers does not require immediate (emergency) attention.

Eligibility Checking System

An online system that hospitals can use to electronically confirm the membership details and benefits for a patient who is to be admitted to hospital for treatment. This system is available on-line 24 hours a day.

Emergency ambulance

Cover for ambulance transport in an emergency situation (situation requiring immediate medical treatment)

Emergency treatment

Emergency treatment occurs when the patient is treated by the medical practitioner within 30 minutes of presentation and the patient is in danger of suffering loss of life, limb, bodily function or mental stability, is in severe pain or is bleeding. For insurance purposes, your health insurer may have a different definition of 'emergency' - check with your health insurer for details.

Examples of maximum benefits

In the PHIS for a general treatment policy, each service that is covered includes an example of the maximum benefit you can claim for common treatments.

Excess

Also called a front-end deductible, 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 type of hospitalisation (e.g day surgery or overnight stays) you may only have to pay a part excess (for example an excess of $500 may apply to overnight hospitalisation but only $100 applies to day surgery.)

What excess (if any) you will need to pay depends on the policy you take out. Always check with your insurer.

Exclusions

Conditions or services which your health insurance policy does not include, meaning that your insurer will not pay benefits towards hospital or medical costs for these items. If you choose to proceed as a private patient for an excluded service, you will have very large out of pocket expenses. If the services are eligible under Medicare, you can still receive treatment as a public patient – however, public hospital waiting lists will apply and you should discuss this option with your doctor. For more information, see: Policy Exclusions and Restrictions

Extras

See General treatment policy.

Front-end deductible

See Excess.

Fund

Private health insurance organisation - also known as an Insurer.

Gap cover arrangements

Gap cover arrangements minimise any gaps between the Medicare Benefit Schedule (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.

Gap

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.

General dental

Minor dental services, such as annual checkups, cleaning and fluoride treatment. Whether specific items are classified as general or major dental depends on each insurer’s rules, so check with your insurer for details.

General treatment policy

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

Gold hospital cover

Gold policies will provide cover in hospital for all treatments covered by Medicare.

Health aids

Also called ‘artificial aids’, this category covers a range of devices which health insurers may cover under General Treatment policies. Two common examples are hearing aids and blood glucose monitors. Contact your insurer for more details about health aids covered on your policy.

Health insurers

Private health insurance organisation - also known as a Fund.

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 insurer membership card.

Home nursing

Home nursing may cover medical care after you have been discharged from hospital e.g. wound care and medication management. In some cases this can be provided instead of being admitted to a hospital. See your insurer for details.

Hospital insurance

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

Hospital treatment for which Medicare pays no benefit

Medicare does not recognise or pay benefits towards some forms of hospital treatment, such as treatment that is not medically necessary (for example, cosmetic surgery) or experimental treatments. Health insurers are not required to pay benefits towards hospital treatments where Medicare does not pay a benefit.

In-patient

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

Informed financial consent

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.

Insurer

Private health insurance organisation - also known as a Fund.

Insurer type

The public availability of the insurer: 'Open' for anyone to purchase a policy, or 'Restricted' to providing insurance to a specific industry or group, usually on a not-for-profit basis.

Intensive care

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

Item number

Identifying number for a 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 PHIS.

Jurisdiction

See State.

Labour ward fees

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 who take out (and keep) hospital insurance before their 'base day' pay lower premiums throughout their lifetime than people who join later. Generally, your base day is the later of 1 July 2000 or the 1 July following your 31st birthday. 

If you join after your base day, you pay 2% more for each year you are aged over 30 for your private hospital insurance premiums than someone who joined before their base day. If you join at 35, you pay 10% more and if you join at 50, you'll pay 40% more. LHC only applies to hospital policies - there are no age penalties or incentives for general treatment policies. Some exceptions apply for Australians who have been living overseas and new migrants. For more on LHC, please see: Lifetime Health Cover.

Lifetime limit

The maximum benefit payable for a particular service for the lifetime of the member. If you use up your lifetime limit and transfer to a new insurer, your new insurer may deduct the benefits you have already claimed from your new policy’s lifetime limit – check with your insurer for details.

Loyalty incentive schemes

Some insurers have loyalty incentive schemes that reward long-term members by increasing either the annual limit or the benefit amount you can claim for specific services. Please contact your insurer for further information about loyalty incentive schemes.

If you change insurers, loyalty limits and benefits are generally not transferrable.

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 the MBS, such as elective cosmetic surgery.

Medical expenses

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

Medical gap

See gap.

Medical service

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

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 hospital insurance to cover the remaining 25% of the MBS fee and gap cover to assist in minimising any potential additional fees incurred in-hospital if the doctor charges more than the MBS fee.

Medicare Levy Surcharge (MLS)

The Medicare Levy Surcharge is levied on Australian taxpayers who earn above a certain income and do not have private hospital insurance. 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% to 1.5% of taxable income. It is in addition to the Medicare Levy of 2%, 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. For the current income thresholds, see Medicare Levy Surcharge.

Medicare Levy Surcharge exemption

Most hospital policies are sufficient to exempt you from being liable to pay the Medicare Levy Surcharge. If you plan to use your insurance for exemption from the Surcharge, check with your insurer to ensure it meets the Surcharge requirements. General treatment policies, overseas visitors and overseas students health cover policies do not exempt you from the Surcharge.

Medicare

Medicare is the publicly funded universal health care system in Australia. Operated by Services Australia, Medicare is the primary funder of health care in Australia, funding primary health care for Australian citizens and permanent residents including Norfolk Island.

Minimum benefit

The minimum benefit (sometimes called the "default" benefit) is the lowest amount that a health insurer is permitted to pay for a hospital admission that is included on policy. It is equivalent to the amount a public hospital would charge a private patient for a shared room, usually as an all inclusive daily rate of approximately $250-$300 depending on where you are in Australia.

If you are entitled to only the minimum benefit and are attending a private hospital, the extra charges you will need to pay yourself include the amount above what the hospital charges for accommodation as well as theatre or labour ward plus any fees for medical services and other items such as pharmaceuticals that aren’t covered by your insurer (see What is covered? for further details).

The cost of theatre or labour ward in a private facility depends on the complexity of the procedure being performed and can range from a couple of hundred dollars to several thousand dollars. If you are proceeding with private hospital treatment and are only entitled to a minimum benefit, it is strongly recommended that you obtain a quote from the hospital and medical practitioners before admission.

Monthly premium

The amount you pay for your health insurance each month. Note that the price shown on the Private Health Information Statement is not a quote and should only be used to compare the cost of different health insurer policies. The PHISs show the full monthly premium and the monthly premium with the Standard Rebate deducted. It does not include any Lifetime Health Cover loading or factor in any discounts that may be available or the different level of Rebate that may apply - most people are eligible for the Standard Rebate, but this may vary depending on your income and age group. Contact your insurer for a specific quote.

Naturopathy

Naturopathy uses a range of alternative approaches to medical treatments. Naturopathy can include nutrition, dietetics, herbal medicine, homoeopathy and massage but is not covered by private health insurance.

Non-emergency ambulance

Non-emergency ambulance includes transport where immediate medical treatment is not deemed necessary, or for transportation from a hospital to your home or another hospital.

Norfolk Island residents

From 1 July 2016, residents of Norfolk Island are eligible for Medicare benefits and can therefore also purchase Australian private health insurance policies. Residents of Norfolk Island can purchase the same policies as residents of NSW.

Not covered

Conditions or services which your health insurance policy does not include, meaning that your insurer will not pay benefits towards hospital or medical costs for these items. If you choose to proceed as a private patient for an excluded service, you will have very large out of pocket expenses. If the services are eligible under Medicare, you can still receive treatment as a public patient – however, public hospital waiting lists will apply and you should discuss this option with your doctor.

Occupational therapy

An occupational therapist can help people improve their everyday motor skills after injury or illness.

Other features

Generally used by Insurers to display any features or information about the policy that does not fit into the Private Health Information Statement format. This may include disease management programs and other programs that support healthy lifestyles, discounts, bonus schemes, waivers, reductions, or additional services offered.

Other services

Where a Private Health Information Statement lists ‘Other services’, you should check with your insurer for details about items which are not listed on the PHIS.

Out-of-pocket costs

Out-of-pockets costs are the costs 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.

Overnight excess

See Co-payment.

Patient moiety

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.

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.

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.

PolicyID

The PolicyID on a Private Health Information Statement is the unique identifier of the particular PHIS.

Portability

The ability for people to transfer from one insurer to another, without re-serving waiting periods. Portability usually only applies if you transfer within a set period of leaving the previous insurer. Check with your new insurer for details.

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 are going to hospital during your waiting period, it is important to check with your health insurer prior to the admission as to whether you will be covered or if the condition will be deemed pre-existing.

Preferred provider

Some health insurers have arrangements with general treatment providers (known as preferred providers) to provide services to their members at a higher benefit rate than that of a non-preferred provider.

Each insurer has their own preferred provider network - please contact your insurer for further information about their preferred providers.

Premium discounts

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

Premium

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

Previous name

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

Private Health Insurance Rebate

Most Australians with private health insurance currently receive a Rebate from the Australian Government to help cover the cost of their premiums. The Private Health Insurance Rebate is income tested. For more information see Private Health Insurance Rebate.

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. Check with your insurer to find out which costs are covered by your policy.

Private room

Depending on your level of cover you can request a private room - that is, one that is not shared with another patient.

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.

Psychiatric services

The treatment of mental illness, including drug and alcohol rehabilitation, eating disorders, and post-natal depression. In-hospital psychiatric treatment is included or restricted on all Hospital policies. The maximum waiting period on this item is 2 months, even if the condition is pre-existing. In some cases, you may be able to upgrade and obtain an exemption from this waiting period - see Waiting periods.

Public hospital

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

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

See Premium.

Rebate

See Private Health Insurance Rebate.

Restricted access insurer

See Restricted membership insurer.

Restricted benefits

See Restrictions.

Restricted fund

See Restricted membership insurer.

Restricted membership insurer

A health insurer providing insurance 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 insurer. In some cases, family members are also eligible.

Restrictions

Condition or services which an insurance policy covers to a limited extent and will pay reduced benefits on hospital admissions. It is not sufficient to cover the cost of a private room in a public hospital or any room in a private hospital. If you are admitted to a private hospital for treatment that is restricted by your policy, large out of pocket expenses will apply. You will have to pay the full theatre fees and other costs as well as the difference for accommodation fees; in some cases theatre fees can exceed the cost of accommodation. If the services are eligible under Medicare, you can still receive treatment as a public patient – however, public hospital waiting lists will apply and you should discuss this option with your doctor. For more information, see: Factsheet - Policy Exclusions and Restrictions

Same-day patient

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

Shared room

A shared room is one that you share with other patients in the hospital - that is, not a private room.

Silver cover (hospital)

Silver policies will provide cover in hospital for most treatments covered by Medicare.

Special features text

In a general treatment policy, if particular services have extra information they will display with an asterisk and extra text is added in the Special Features text.

State of the Health Funds Report

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

State

Australian State or Territory. Also called Jurisdiction.

Status

Availability of specific policy: Available or Closed.

Sub-limits

The maximum benefit payable for a particular service within a 12 month period, which is deducted from a larger limit. For example, a policy may have a combined $500 limit for acupuncture, naturopathy and remedial massage, with a sub-limit of $300 for each service – meaning the most you could claim in a single year for one of those services is $300, while the remaining $200 could be claimed against one or both of the other two.

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 insurers. In addition, if you are over the income threshold you will be required to pay the Medicare Levy Surcharge for the period that your hospital policy is 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 insurer suspends your health insurance.

Theatre fees

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

Treatment exclusions

See Exclusions.

Waiting period

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 benefits. The PHIS lists waiting periods in months for standard services.