Jargon buster

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Access Gap

AKA Gap Cover or Medical Gap Cover.

Access Gap is a program that aims to reduce the difference between the Medicare fee and what doctors charge. Doctors can choose to take part in Access Gap on a case-by-case basis, and if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be.

Accident

An unforeseen event which causes injury and needs hospitalisation.

Accommodation

Accommodation covers a bed and meals in hospital. It also includes in-hospital services like nursing and is separate to your doctors’ bills.

Agreement hospital

An agreement hospital is a private hospital or day surgery that we’ve got an agreement with to provide services with low or no out-of-pocket costs. Find your closest agreement hospital by logging in to Online Member Services.

Ancillary cover

AKA extras cover or general treatment.

Cover for services that aren’t covered by Medicare or done in hospital. Things like dental, optical, physio and chiro.

Annual limit

The most we’ll pay in a financial year for a specific extras service. Our annual limits refresh on 1 July each year. 

Check your extras limits at any time via Online Member Services or on our mobile app.

Australian Government Rebate on Private Health Insurance

A Government rebate to help with the cost of private health insurance (so that more people take out private cover).

It’s income tested and is applied to both hospital and extras cover. If you have a Lifetime Health Cover loading, the Rebate isn’t applied to that portion of your payments.

The Rebate you get is based on the age of the oldest person of your membership, your taxable household income (for Medicare Levy Surcharge purposes), CPI (inflation) and average health fund industry premium increases.

Benefit

What we pay back for a health treatment or service.

Chronic disease

A chronic disease is one that’s long-lasting and impacts on your quality of life. Some of the most common chronic diseases are cardiovascular disease, diabetes, mental health, cancer and osteoarthritis.

Clearance Certificate

AKA Transfer Certificate.

You get this when you transfer from one health fund to another. It shows all the details of your last cover to help your new fund work out things like waiting periods, benefits and Lifetime Health Cover loading for your new cover.

Community rating

Private health insurance in Australia is 'community-rated', which 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.

Cooling off period

Changed your mind about your cover? No worries! Just let us know within 30 days of joining or upgrading your cover and you'll get a full refund of amy premiums paid (as long as you haven't made any claims in that time, of course).

Day surgery

AKA day facility.

A private hospital or facility where patients are admitted, treated and sent home on the same day.

Default benefit

The Government’s set rates for public and private hospital accommodation.

If you’re admitted to a private hospital for a restricted service, we’ll only be able to pay the default private rate (which is only a small amount of the cost of a private hospital stay). This means you’ll have big out-of-pocket costs. The same goes if you’re admitted to a hospital that doesn’t have an agreement with us – we’ll only be able to pay the default rates.

Dependant

A child under 21 (or 25 if they’re studying full-time) who isn’t married or in a de facto relationship.

Drugs, dressings and other consumables

These are other services provided while you’re in hospital. Things like medications, bandages, crutches and surgically implanted prostheses (like hip replacements, artificial lenses and heart valves).

Elective surgery

Surgical treatment that’s not medically necessary, or 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. This system is available online 24 hours a day, 7 days a week.

Emergency treatment

Treatment is considered emergency when a patient is in danger of losing their life, a limb, bodily function or mental stability, is in severe pain or badly bleeding and is treated within 30 minutes.

Excess

An amount you agree to pay when you’re admitted to hospital in exchange for a lower premium. Our excesses are halved if it’s a day stay or you’re admitted to a public hospital, and you only have to pay your full excess once each financial year.

Exclusion

Something you’re not covered for.

Extras

AKA ancillary or general treatment.

Cover for services that aren’t covered by Medicare or done in hospital. Things like dental, optical, physio and chiro.

Fund

Private health insurer (like us!).

Gap

AKA out-of-pocket cost.

The amount you pay when your doctor or hospital charges more than what Medicare and your health fund can pay.

For example, as a private patient in a hospital or a day surgery centre your doctor and any specialists who treat you will each raise a bill for their services. The Australian Government sets a schedule of fees for all medical treatments called the Medicare Benefits Schedule (MBS).

For items on the MBS, Medicare covers 75 per cent, while your Peoplecare health cover picks up the remaining 25 per cent. However, some doctors and specialists charge more than the MBS fees, with the extra amount referred to as the ‘medical gap’ or your out-of-pocket cost.

We take part in Access Gap, which is a program that aims to reduce the difference between Medicare’s fee and what doctors charge. Doctors can choose to take part in Access Gap on a case-by-case basis, and if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be.

Gap cover arrangements

AKA Access Gap or Medical Gap Cover.

An arrangement that aims to reduce the difference between the Medicare fee and what doctors charge. Doctors can choose to take part in Access Gap on a case-by-case basis, and if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be.

General dental

Minor dental services like annual check-ups, cleaning and fluoride treatment. General dental includes diagnostic services, preventive treatment, extractions, oral surgery and fillings.

General treatment

AKA ancillary or extras cover.

Cover for services that aren’t covered by Medicare or done in hospital. Things like dental, optical, physio and chiro.

HICAPS

Health Industry Claims And Payment Service. This lets you claim on the spot at your provider using your Peoplecare card.

High cost dental

High cost dental covers things like crowns and bridges, dentures, implants and orthodontics (braces).

Hospital cover

Covers you as a private patient in a private or public hospital. It includes hospital accommodation as well as medical treatment received in hospital (i.e. as an in-patient).

Informed financial consent (IFC)

IFC is being told what your out-of-pocket costs will be for a procedure. You should be told how much you will have to pay before you’re admitted to hospital (preferably in writing).

In-patient

A patient who is admitted to hospital (or a day surgery) for the day or overnight. Treatment that’s received in the emergency ward of a hospital without being officially admitted isn’t classed as in-patient and is covered by Medicare only.

Intensive care

Hospital treatment for life-threatening conditions, injuries or complications. Intensive care is a type of special unit accommodation.

Item number

This is the code that identifies the treatment you’ve received and is needed to process your claims. The code is provided by Medicare, your dentist or other healthcare provider.

Labour ward fees

Fees for the delivery of a baby in a birthing suite.

Lifetime Health Cover (LHC)

Lifetime Health Cover is designed to get people to take out private hospital cover earlier in life.

If you have private hospital cover by 1 July after your 31st birthday and keep it, you don’t have to worry about it. If you decide to get hospital cover later, you’ll pay 2% more for cover for every year you’re over 30. This is called your Lifetime Health Cover loading.

LHC loadings stay on your cover for 10 years. Once you’ve had hospital cover for 10 years straight, the loading is removed.

 
Limits

The most you can claim for a service in a certain time.

Medical expenses

Fees for medical services while you’re in hospital. Things like doctor & specialist fees, radiology, pathology and anaesthetists.

Medical Gap

AKA Access Gap or Gap Cover.

Medical Gap aims to reduce the difference between the Medicare fee and what doctors charge. Doctors can choose to take part in Access Gap on a case-by-case basis, and if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be.

Medical service

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

Medicare Benefits Schedule (MBS)

Health funds can’t pay benefits for medical services outside of hospital (things like going to your GP), but Medicare pays 85% of the MBS fee for these.

A list of fees for medical services set by the Government. Medicare pays 75% of the MBS fee for in-hospital medical services and private health cover pays the other 25% (sometimes more if the doctor agrees).

 

Medicare Levy Surcharge (MLS)

The Medicare Levy Surcharge is paid by high income earners (that’s singles who earn over $90,000 and families that earn over $180,000 in the 2017/18 financial year) who don’t have private hospital cover.

The surcharge is between 0% and 1.5% (depending on your household income) and is paid on top of the 1.5% Medicare Levy paid by most Australian taxpayers.

Medicare Scheduled Fee

The fee set by the Government for an individual item on the Medicare Benefits Schedule (MBS).

Medicare pays 75% of the MBS fee for in-hospital medical services and private health cover pays the other 25% (sometimes more if the doctor agrees).

Health funds can’t pay benefits for medical services like going to your GP or specialist consultations etc.

Obstetrics

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

Outpatient

Treatment or services received without being admitted to hospital. Things like visits to your GP and specialist appointments.

Pharmaceutical Benefits Scheme (PBS)

This is a Government subsidy that reduces the cost of some prescription medications. The PBS amount changes on 1 January every year and is $39.50 as at 1 January 2018.

We’re only able to pay benefits on the cost of prescription medication that’s above the PBS amount. For example, if your medication costs $50, we’ll pay a benefit on the difference between the PBS amount and $50.

Portability

The ability to transfer between health funds without having to re-serve waiting periods.

Pre-existing condition

A pre-existing condition is any aliment, illness, or condition that you had signs or symptoms of (in the opinion of a medical practitioner appointed by the health insurer) that existed during the 6 months before you joined a hospital cover or upgraded to a higher hospital cover. It is not necessary that you or your doctor knew what your condition was or that the condition had been diagnosed. A condition can still be classed as pre-existing even if you hadn't seen your doctor about it before joining the hospital cover or upgrading to a higher hospital cover.

This waiting period only applies to hospital cover, not extras cover.

Premium

AKA membership payment or rate.

What you pay for health cover.

Private Health Insurance Ombudsman (PHIO)

PHIO is an independent service for health insurance problems and enquiries. The Ombudsman also publishes reports and information about private health insurance.

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 day surgery lets you choose the doctors who treat you at a time that suits you (as long as the doctor you choose operates from the hospital or day surgery you'd like to be admitted to, and that the hospital or day surgery has the services you need). As a private patient in a private hospital, you might be charged for things like:

  • care in intensive/critical care units

  • doctors’ services (including diagnostic tests)

  • operating theatre fees

  • other health services (like physiotherapy)

  • dressings, medications and other consumables

  • surgically implanted prostheses (like artificial hips)

Private patient in a public hospital

Being a private patient in a public hospital lets you choose your doctor, as long as the doctor you choose operates from the hospital or day surgery you're being admitted to. As a private patient in a public hospital, you might be charged for things like:

  • hospital accommodation
  • doctors' services (including diagnostic tests)
  • surgically implanted prostheses (like artificial hips)
  • personal expenses, like TV hire and telephone calls
Prostheses

A prosthesis is a surgically implanted medical device or artificial body part, like hip and knee joints and heart pacemakers.

You may have out-of-pocket costs for your prosthesis, depending on how your doctor charges for it. We'll pay the Government's set benefits for prostheses that are listed on their Prostheses List, and if your doctor charges above that amount, you'll need to pay the difference. 

Provider

A person or business qualified to provide medical or healthcare services, like a clinic, dentist or therapist.

Provider number

A registration number given to a provider by the organisation that they’re registered with. 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 eight digits long.

Provider number

For online claims, providers are only registered with Medicare and the Provider Number will be seven digits followed by one 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

Pays benefits for treatment as a private patient in a public hospital only.

Public patient

Public patients are treated in a public hospital under Medicare by a doctor chosen by the hospital.

Rate

AKA premium or membership payment.

What you pay for health cover.

Rebate

AKA the Australian Government Rebate on Private Health Insurance.

A Government rebate to help with the cost of private health insurance (so that more people would take out private cover).

It’s income tested and is only applied to the standard cost of cover. If you have a Lifetime Health Cover loading, the Rebate isn’t applied to that portion of your payments.

The Rebate you get is based on the age of the oldest person of your membership, your taxable household income (for Medicare Levy Surcharge purposes), CPI (inflation) and average health fund industry increases in premium.

Restricted benefits

A restricted benefit is only paid at the default rate, rather than a private hospital rate. If you have restricted services on your cover and you're admitted to a private hospital for one of these services, we can only pay the default rate and you'll have large out-of-pocket costs.

Restrictions

A restriction is a service that’s only paid at the default rate, rather than a private hospital rate. If you have restricted services on your cover and you're admitted to a private hospital for one of these services, we can only pay the default rate and you'll have large out-of-pocket costs.

Same day patient

Same day patients are admitted, treated and sent home on the same day.

SIS

Standard Information Statement. This is a summary of health cover details in a standard format to make choosing cover easier. SISs for all Australian health funds are available from the Private Health Insurance Ombudsman's website, privatehealth.gov.au.

Your health fund must give you a copy of the SIS for your level of cover once a year, but you can ask for an SIS at any time.

Special unit accommodation

A facility or unit dedicated to the treatment or care of patients with particularly complex conditions that need a high level of attention, like an intensive care unit.

Suspension

If you’re having financial troubles or travelling overseas, you can ask us to suspend your health cover for an agreed length of time. If you suspend your health cover, you don’t have to pay your premiums, but can’t claim during this time.

Please contact the fund on 1800 808 690 or info@peoplecare.com.au to see if you're eligible for suspension.

Following a suspension, it’s important to reactivate your membership within the agreed time or you’ll have to re-serve your waiting periods. If you earn over the Medicare Levy Surcharge income threshold, you’ll still have to your pay the surcharge for the time your cover is suspended. Also, your Lifetime Health Cover status won't change while your cover is suspended.

Theatre fees

Costs for procedures performed in an operating room, including day surgery facilities.

Transfer Certificate

AKA Clearance Certificate.

You get this when you transfer from one health fund to another. It shows all the details of your last cover to help your new fund work out things like waiting periods, benefits and Lifetime Health Cover loading for your new cover.

Waiting period

How long you have to be a member before you can make a claim. Find out more about our waiting periods here.

What's not covered?

Hospital:

Dependent on your level of cover, there are a few things that aren’t covered by your hospital cover. They are:

  • Treatment & services received within your waiting periods
  • Treatments & services that Medicare doesn’t cover (like cosmetic surgery)
  • Treatment & services received outside Australia
  • Treatment & services covered by compensation or another type of insurance (like third party or sports club insurance)
  • Treatment & services received more than 2 years ago
  • Outpatient treatment & services (unless there’s a special agreement between us and the hospital)
  • Some high cost drugs
  • Prostheses that aren’t approved by the Commonwealth Government. (A prosthesis is an artificial substitute for a body part)
  • Ambulance subscriptions or state-based ambulance levies
  • Ambulance services paid for by the Government, compensation or another type of insurance
  • Ambulance services that aren’t medically necessary
  • Pharmacy - most pharmacy items that you’re given while you’re in hospital are covered by your hospital bill. The hospital may charge you extra for pharmacy items that you take home with you and this isn’t covered by your hospital cover.

Extras:

This list looks bad, but we promise it’s fair (or decided by the Government).

  • Treatment & services you have in your waiting periods
  • Treatment & services received outside of Australia
  • Treatment & services that are covered by compensation or another type of insurance (like third party or sports insurance)
  • Treatment & services received more than 2 years ago
  • Contraceptives, over-the-counter medications and prescriptions less than the Pharmaceutical Benefits Scheme amount
  • Naturopathic & herbal medicines
  • First aid kits & courses
  • Non-prescription glasses, contacts & sunglasses
  • Treatment & services received from providers that aren’t registered or recognised by Peoplecare
  • Treatment & services received from a family member, relative, business partner or yourself
  • Treatment & services you weren’t charged for
  • Services for sport, recreation or entertainment
  • Receipts issued by a third party, like group buying websites or group deals
  • If you’re using a gift voucher, we can’t pay the difference between the cost of the service and the value of the voucher. For example, if you use a $60 voucher to pay for a $40 service, you can only claim back the $40 as the official fee for the service
  • Benefits higher than the amount you paid for the service. For example, if you receive treatment that’s discounted from $65 to $30, we only pay a benefit towards the fee you paid (e.g. $30)

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