Love Jargon-busting

Love Jargon-busting

Access Gap

Also called ‘Gap Cover’ or ‘Medical Gap Cover’

This program aims to reduce the gap between the Medicare fee and what doctors actually charge. Doctors can choose to take part in Access Gap on a case-by-case basis, and if they do take part you'll have either no gap or known gap (where you'll be told exactly what your out-of-pocket costs will be).  

Accident

An unforeseen event which causes injury and needs hospitalisation.

Accommodation

Accommodation covers meals and a bed in hospital, and includes in-hospital services including nursing care. This is separate to fees for your doctor 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, visit our Hospital Search page.

Ancillary cover

Also called 'extras' cover or 'general treatment'. Health cover for health services that aren’t provided in hospital or covered by Medicare, like dental, optical, physio, chiro and other therapies.

Annual limit

This is the maximum amount we'll pay for a particular service in a financial year (1 July - 30 June). Our annual limits reset on 1 July each year.

Benefit

The amount we pay back to you for a health treatment or service.

Clearance Certificate

Also called a 'Transfer Certificate'. This is what you receive when you transfer to another health fund. It shows details of the cover you've held, including claims history and Lifetime Health Cover loading. It 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', 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.

Day surgery

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

Dependant

A dependant is an unmarried (and not in a de facto relationship) child under the age of 21 (or 25 if they’re studying full-time).

Drugs, dressings and other consumables

These are extra services provided during a hospital stay. They 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, 7 days a week.

Emergency treatment

Emergency treatment is when a patient is in danger of loss of life, limb, bodily function or mental stability, is in severe pain or is severely bleeding, and is treated by a medical practitioner within 30 minutes.

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. 

Extras

Also known as 'ancillary' cover or 'general treatment'. Health cover for health services that aren’t provided in hospital or covered by Medicare - like dental, optical, physio, chiro and other therapies.

Fund

Private health insurer.

Gap

A 'gap' is the amount you pay for treatment when a doctor or hospital charges more than what Medicare and your health fund are able to pay.

Gap cover arrangements

Also called ‘Access Gap’. This arrangement aims to lower your out-of-pocket costs. Doctors can decide whether to use gap cover arrangements on a case-by-case basis, and If they take part you'll will either have No Gap or a Known Gap (where you'll be told exactly how much your out-of-pockets will be before you're admitted).

General treatment

Also called 'Extras' or 'ancillary' cover.Health cover for health services that aren’t provided in hospital or covered by Medicare - like dental, optical, physio, chiro and other therapies.

General dental

Minor dental services, like annual checkups, cleaning and fluoride treatment. General dental includes diagnostic services, preventive treatment, extractions, oral surgery and fillings. If you ask your dentist what your dental item numbers will be and contact us before you start your treatment, we'll be able to tell you exactly how much you'll get back on your claim.

HICAPS

Stands for ‘Health Industry Claims And Payment Service’. This lets you claim on-the-spot once you've received a service using your Peoplecare membership card.

High cost dental

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

Hospital cover

Hospital cover helps with your costs as a private patient in hospital, including hospital accommodation, medical treatment and ambulance.

Informed financial consent (IFC)

IFC is being told about the charges and likely out-of-pocket costs (gap), for a service by any healthcare service provider. 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

This is the code the which identities 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

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

Lifetime Health Cover (LHC)

Lifetime Health Cover is a 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. If 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 before they're 31.

LHC loadings stop after 10 years of continuous hospital cover (conditions apply).

The Australian Government Rebate on Private Health Insurance isn't available for the LHC loading portion of your membership payments (if you have one).

Loyalty bonuses

Members who have continuously had Gold Extras cover for more than 5 years have higher annual limits 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 scheduled fee

Medicare sets a "scheduled fee" for all medical services - this is their suggested price. You can claim 75% of the scheduled fees for in-hospital services through Medicare. With our Hospital products, we'll take care of the remaining 25% of the scheduled fees for in-hospital services.

Health funds don't cover out-patient services, but Medicare will cover 85% of the scheduled fees for these.

Doctors and healthcare providers can charge above scheduled fees for both in-hospital and out-patient services. If they do, you'll have an out-of-pocket (or gap) cost.

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 ($90,000 per year for singles in 2016/17). 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 between 1% and 1.5%, depending on your household income level. It is on top of the Medicare Levy of 2%, 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. The income threshold changes each financial year. You don’t have to pay the surcharge if your household income is below the income threshold.

Obstetrics

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

PBS

Stands for ‘Pharmaceutical Benefits Scheme’, which is a Government subsidy that reduces the cost of some prescription medicines. The PBS amount as at 1 January 2017 is $38.80.

PHIO

Stands for 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 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 applies to Hospital cover, not Extras cover.

Premium

What you pay for your health cover.

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. Your rebate is based on your age, taxable household income (for Medicare Levy Surcharge purposes), CPI (inflation) and average health fund industry increases in premium using a complex Government formula. Read more info here.

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 (eg. artificial hips)
  • personal expenses, like TV hire and telephone calls

The hospital and your doctors should let you know about any services that they’ll bill you for.

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 (eg artificial hips)
  • personal expenses, like TV hire and telephone calls

The hospital and your doctors should let you know about any services that 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

Public hospital cover pays towards treatment as a private patient in a public hospital only. If you have public hospital cover and you're admitted to a private hospital, you'll have large out-of-pocket costs.

Public patient

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

Rate

What you pay for your health cover.

Rebate

The Private Health Insurance Rebate was introduced by the Commonwealth Government as a financial incentive to help Australians afford private health cover. Your rebate is based on your age, taxable household income (for Medicare Levy Surcharge purposes), CPI (inflation) and average health fund industry increases in premium using a complex Government formula. Read more info here.

Restricted benefits

A restricted benefit only pays the standard public hospital rate, rather than a private hospital rate. For example, our Basic Private Hospital cover has some restricted services, and for these services you are covered as a private patient in a public hospital only. 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 standard public hospital rate and you'll have large out-of-pocket costs.

Click here for the full list of restricted benefits on our Basic Private Hospital cover.

 

Restrictions

A restriction is a service that is only paid at the standard public hospital rate, rather than a private hospital rate. For example, our Basic Private Hospital cover has some restrictions, and for these services you are covered as a private patient in a public hospital only. 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 standard public hospital rate and you'll have large out-of-pocket costs. 

Click here for the full list of restrictions on our Basic Private Hospital cover.

 

Same-day patient

Also called 'day surgery'. Same-day patients are admitted, treated and discharged on the same day.

SIS

Stands for ‘Standard Information Statement’. This is a summary of health insurance policy details in a standard format to make choosing the right cover for you 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.

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 and can’t claim during this time. It’s important that you 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 you’re suspended. Your Lifetime Health Cover status won't change whilst your cover is suspended.

Theatre fees

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

Waiting period

How long you need to be a member before you can make a claim. You can find out the waiting periods for your level of cover here, or in the cover description we've given you.