Access Gap
Also called ‘Gap Cover’ or ‘Medical Gap Cover’
Gap cover arrangements minimise any gaps between the Medicare fee and what doctors actually charge. Doctors can decide to use the gap cover arrangements on a case-by-case basis. If they do participate you will either have No Gap or Known Gap.
Accident
An unforeseen event which causes injury and needs immediate treatment.
Accommodation
Accommodation covers meals and a bed in hospital, and includes all in-hospital services including nursing care. It doesn’t include treatment by doctors or other health professionals.
Agreement hospital
A private hospital or day surgery that we have an agreement with to provide services with low or no out-of-pocket costs. To find an agreement hospital go to our Hospital Search page.
Ancillary cover
Health cover for non-hospital health services that aren’t covered by Medicare, like dental, optical, physio, chiro and other therapies. Some funds call this 'general treatment' or extras' cover.
Annual limit
The maximum benefit we pay for a particular service in a 12 month period. Our annual limits are all financial year limits which are renewed on 1 July each year.
Benefit
The amount we pay you back for a health treatment or service.
Clearance Certificate
Is a document a health fund issues when a member is transferring to a new health fund. It has details of their level of cover, claims history and Lifetime Health Cover loading. This is used by the new fund to work out which benefits and any waiting periods that should apply.
Community rating
Private health insurance in Australia is 'community-rated'. This means that everyone can buy the same product, at the same price. A health fund can’t refuse to insure you, or refuse to sell you any current policy you want to buy. There are some exceptions to this - for example, you’ll pay a higher premium if you have a Lifetime Health Cover loading.
Day surgery
A private hospital or facility where patients are admitted, treated and discharged on the same day. Also called ‘day facility’.
Dependent
A dependent child is an unmarried person under the age of 21 years (or 25 if they’re studying full-time).
Drugs, dressings and other consumables
Drugs, dressings and other consumables are extra services provided during hospital treatment. These include 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 doesn’t think needs immediate attention.
Eligibility Checking System
An online system that hospitals can use to confirm your membership details and benefits before you’re admitted to hospital for treatment. This system is available on-line 24 hours a day.
Emergency treatment
Emergency treatment is when the patient is treated by the medical practitioner within 30 minutes and they’re in danger of loss of life, limb, bodily function or mental stability, is in severe pain or is bleeding.
Excess
An amount that you agree to pay up front towards the cost of your hospital treatment, in exchange for a lower premium.
Exclusions
An exclusion means that you’re not covered for treatment as a private patient in a public or private hospital for that condition. We don’t have exclusions on any condition that has a Medicare benefit.
Extras
Health cover for non-hospital health services that aren’t covered by Medicare, like dental, optical, physio, chiro and other therapies. Some funds call this 'general treatment' or 'ancillary' cover.
Fund
Private health 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 what you get back from Medicare or your private health fund.
Gap cover arrangements
Or ‘Access Gap’. Gap cover arrangements minimise any gaps between the Medicare fee and what doctors actually charge. Doctors can decide to use the gap cover arrangements on a case-by-case basis. If they do participate you will either have No Gap or Known Gap.
General treatment
Health cover for non-hospital health services that aren’t covered by Medicare, like dental, optical, physio, chiro and other therapies. Some funds call this 'general treatment' or 'extras' cover.
General dental
Minor dental services, like annual checkups, cleaning and fluoride treatment. General dental includes diagnostic services, preventive treatment, extractions, oral surgery and fillings. Ask your dentist what your dental item numbers will be and then contact us before you start your treatment so we can tell you exactly how much you will get back on your claim.
HICAPS
Stands for ‘Health Industry Claims And Payment Service’. This lets you claim at the point of service using your EFTPOS style membership card.
High Cost Dental
High cost dental covers things like crowns and bridges, dentures, implants and orthodontics (braces).
Hospital cover
Health insurance to cover your costs as a private patient in hospital, including hospital accommodation, medical treatment and ambulance.
Informed financial consent (IFC)
Information about the charges and likely out-of-pocket expenses (gap), by all healthcare service providers. Providers should give you this information before your treatment or admission to hospital, preferably in writing.
In-patient
A patient who has been formally admitted to a hospital or day facility.
Intensive care
Hospital treatment for life-threatening illnesses, injuries or complications.
Item number
Is the code which identities the treatment you’ve received. The code is provided by Medicare, your dentist or other healthcare provider.
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 Commonwealth Government initiative to reward people who keep their hospital cover. LHC recognises the length of time a person has private hospital cover with a registered health fund. Provided you start your private hospital cover by 1 July after your 31st birthday, you won’t have to pay a LHC loading. If you don’t take out hospital cover until you’re older, your premium will be 2% higher for each year that you’re over 30. The maximum LHC loading of 70% is reached at age 65.
People who were born on or before 1 July 1934 are exempt from LHC and can join a health fund at any time and pay the same premium as someone who takes out cover at age 30.
LHC loadings stop after 10 years continuous hospital cover (conditions apply).
Loyalty bonuses
Members who have more than 5 years continuous membership with Gold Extras have a higher annual limit for some High Cost Dental items.
Medicare Benefits Schedule (MBS)
The list of fees set by the government for medical services. 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. The Medicare rebate is 75% of the MBS fee for in-hospital medical fees and 85% of the MBS fee for medical fees outside hospital. Your private health cover will pay the remaining 25% of the MBS fee and gap cover if your doctor agrees.
Medical expenses
Medical expenses are charges for medical services during a hospital stay. This covers items such as doctors and specialists, radiology, pathology and anaesthetists. Medicare pays 75% of the MBS fee for these services.
Medical gap
Also called ‘Gap Cover’ or ‘Medical Gap Cover’
Gap cover arrangements minimise any gaps between the Medicare fee and what doctors actually charge. Doctors can decide to use the gap cover arrangements on a case-by-case basis. If they do participate you will either have No Gap or Known Gap.
Medical service
A service provided by a doctor, specialist, radiologist, pathologist or anaesthetist.
Medicare Levy Surcharge (MLS)
The Medicare Levy Surcharge applies to Australian taxpayers who don’t have private hospital cover and who earn above a certain income. The surcharge aims to encourage people to take out private hospital cover, and use the private system wherever possible. The aim is to reduce the demand on the public system.
The surcharge is 1% of taxable income. It is on top of the Medicare Levy of 1.5%, which is paid by most Australian taxpayers. The Medicare Levy Surcharge is paid by people earning over the income threshold who don’t have private hospital insurance.
You don’t have to pay the surcharge if your taxable income is below the income threshold. The income threshold for 2010/2011 is $73,000 for individuals and $154,000 for families.
All Peoplecare hospital covers exempt you from the 1% Medicare Levy Surcharge.
Obstetrics
Management of pregnancy, labour, delivery and associated care, provided in hospital.
PBS
Stands for ‘Pharmaceutical Benefits Scheme’, which is a Government subsidy to reduce the price of some prescription medicines.
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 health fund 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.
Premium
The fee you pay for your health insurance policy.
Private Health Insurance Rebate
The Private Health Insurance Rebate was introduced by the Commonwealth Government as a financial incentive to help Australians afford private health cover. The Private Health Insurance Rebate applies to all Peoplecare products and the amount of your rebate depends on the age of the oldest person on your membership:
| Age |
Rebate |
| Up to age 65 |
30% rebate |
| 65 to 70 years old |
35% rebate |
| Over 70 years old |
40% rebate |
Most people choose to take their rebate up front as a lower premium, but if you’d prefer to claim your lump sum through your tax at the end of the financial year, just let us know.
Private hospital
A hospital run as a commercial or charitable operation.
Private patient in a private hospital
Being a private patient in a private hospital or a private day hospital facility allows you to choose the doctor(s) who treat you at a time that suits you. This is provided your doctor has an arrangement with that hospital to treat private patients and the hospital you have chosen has the services and bed you’ll 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
- doctors’ 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 doctors should advise you about the services they’ll bill you for.
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 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 doctors should advise you about the services they’ll bill you for.
Prosthesis (surgically implanted)
Surgically implanted prostheses include things like hip replacements, artificial lenses and heart valves.
Provider
A person or business qualified to supply medical or healthcare services, such as a clinic, therapist, dentist, etc.
Provider Number
Every provider is given a registration number by the organisation that they’re registered with, this is called a Provider Number. Providers are generally registered with either Medicare or the ARHG (Australian Regional Health Group).
On your invoice, you’ll find the Provider Number near the provider’s name and address. It’ll generally be a mix of letters and numbers, and can be up to 8 digits long.
For online claims, providers are only registered with Medicare and the Provider Number will be 7 digits, followed by 1 letter.
For manual claims, some services don’t have registered providers. If you can’t find the Provider Number on your invoice, just leave the field blank.
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. You’ll be covered for treatment as a private patient in a public hospital, but may face large out-of-pocket costs if you have 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
The fee you pay for your health insurance policy.
Rebate
The Private Health Insurance Rebate was introduced by the Commonwealth Government as a financial incentive to help Australians afford private health cover. The Private Health Insurance Rebate applies to all Peoplecare products and the amount of your rebate depends on the age of the oldest person on your membership:
| Age |
Rebate |
| Up to age 65 |
30% rebate |
| 65 to 70 years old |
35% rebate |
| Over 70 years old |
40% rebate |
Most people choose to take their rebate up front as a lower premium, but if you’d prefer to claim your lump sum through your tax at the end of the financial year, just let us know.
Restricted benefits
Condition or services where the benefit is only the public hospital rate, which means there will be large out-of-pocket expenses if treated in a private hospital. Our Basic Private Hospital Cover has these type of restrictions.
Restrictions
Condition or services where the benefit is only the public hospital rate, which means there will be large out-of-pocket expenses if treated in a private hospital. Our Basic Private Hospital Cover has these type of 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’.
SIS
Stands for ‘Standard Information Statement’. A summary of health insurance policy details provided in a standard A4 format for easy comparison available at the Private Health Insurance Ombudsman’s website privatehealth.gov.au. Your health fund must give you a copy of your SIS once a year and if you join a new cover. You can ask for an SIS at any time.
Suspension
If you’re having financial troubles or traveling overseas, you can ask us if you can suspend your health cover for an agreed time period. If you suspend your health cover, you don’t have to pay your premiums (and can’t claim during this time either). It’s important that you reactivate your membership within the agreed time or you’ll have waiting periods again. Also, if you earn over the Medicare Levy Surcharge income threshold, you’ll have to pay the Surcharge for the time you’re suspended. Your Lifetime Health Cover status doesn’t change during your suspension.
Theatre fees
Theatre fees are costs for procedures performed in an operating room, including day surgery facilities.
Waiting period
How long you’ll need to be a member before you can claim. You can find out your waiting periods, or your Cover Description or SIS.