HEALTH INSURANCE GLOSSARY

A

Accident

Unintentional or unexpected actions or events resulting in injury that requires immediate treatment from a registered healthcare practitioner. Excludes accidental illness, pregnancy or aggravation of a pre-existing condition. Generally all health funds will allow you to claim for accidents immediately after joining, but some special rules may exist – check health insurance policy descriptions for details.

Accommodation

Accommodation is included in your health insurance plan as part of your hospital cover, and generally includes all in-hospital services such as meals, bed and nursing care. These costs are covered by your health fund. 'Accommodation' does not include treatment by health professionals, including doctors, although these fees are also covered by your health insurance.

Acupuncture (health insurance Extras feature)

Acupuncture involves the insertion of fine needles into the surface of the body at major pressure points to restore health and well-being. Your health fund will cover acupuncture consultations/treatments with a recognised acupuncturist to the extent that it is covered by your particular health insurance policy.

Agreement Private Hospital

These are private hospitals or day surgeries that have agreements in place with your health fund to provide services at a set charge or involving no out-of-pocket expenses. Agreement private hospitals provide a higher level of benefit under your health insurance policy than non-agreement private hospitals.

Allied Health Services

Allied health care professionals include naturopaths, occupational therapists and psychologists, whose services may be offered through a hospital, but are not necessarily included in hospital cover. Health funds often include Allied Health Services as part of their Extras/Ancillary Cover, and offer rebates for these services as part of your health insurance plan.

Ambulance Services

Queensland and Tasmanian residents are covered for the full costs of ambulance cover by the state governments, who charge a levy for this service. In other states, ambulance cover can be purchased either as part of your private health insurance or as a separate cover. Your chosen health fund may reimburse you for all or part of your annual subscription to your state ambulance authority or the costs associated with transportation.

The details of ambulance cover can vary between health funds, as some provide full cover for ambulance travel and others offer only a basic service. Check the details of your private health insurance plan to ensure you obtain the cover that best suits your needs.

Ancillary Cover/ Extras

Refers to non-hospital medical services that health funds will cover under private health insurance, such as dental, optical and physiotherapy. See Extras for more details.

Annual Limit

This is the maximum benefit payable for any of the services included in your health insurance plan within a 12 month period. Some health funds pay these limits within a calendar year, while others count 12 months from the time you join the health fund. Check with your health fund for specific information. See Benefit Limits for more details.

Assisted Reproductive Services (health insurance Hospital feature)

Services and treatment relating to methods of conception other than through natural means, including artificial insemination and invasive techniques such as IVF, GIFT and ICSI. Assisted Reproductive Services is covered by the Hospital component of your private health insurance policy and health funds generally do not include this feature in basic level plans.

• back to top •

B

Basic Hospital Cover

Basic Hospital Cover refers to a search category on the moneytime website that automatically excludes health insurance plans that cover a private room in a private hospital. Search results for Basic Hospital Cover will show health insurance plans that offer budget-level cover in private hospitals or policies that cover public hospital only, as these are often the most cost-effective. This type of health insurance is ideal for those who wish to avoid the Medicare levy surcharge.

Benefit

A benefit is a specific service offered by a health fund as part of their health insurance plans.

Benefit Limit

This is the maximum amount payable for any of the services included in your health insurance policy within a 12 month period. These may be calculated based on a calendar year or 12 months from the date you joined health insurance, depending in your health fund. moneytime's comparison table shows the benefit limits for all Extras benefits featured in the health insurance policies that you choose to compare.

Benefit Limitation Period

A benefit limitation period is an agreement that entitles you to restricted benefits for a particular service over a set period of time, in exchange for a lower premium. For example, your health insurance plan may include a restricted benefit on hip replacement for the first two years, after which time, you would become entitled to full benefits for that service.

Keep in mind that the benefit limitation period generally commences after standard waiting periods have already been served. For example, if the standard waiting period for hip replacement with your health fund is 12 months, you would first need to serve the 12 month standard waiting period, then the 2 year benefit limitation period, before becoming eligible for full cover for hip surgery.

• back to top •

C

Calendar Year

This refers to the period between 1 January and 31 December. Benefits on your health insurance may be paid by your health fund on a per calendar year basis, or a per 12 month basis starting from the day you join – check with your health fund for specific information relating to your health insurance policy.

Cardiac (health insurance Hospital feature)

The cardiac feature of health insurance covers procedures including open heart and bypass surgery, and invasive cardiac procedures such as angiograms and stents. Your health fund will cover cardiac treatment to the extent that it is covered by your particular health insurance policy.

Cataract (health insurance Hospital feature)

Surgery to remove cataracts and associated eye lens procedures. Your health fund will cover cataract treatment to the extent that it is covered by your particular health insurance policy.

Certified Age of Entry

This refers to the age assigned to you when you purchase private health insurance (including or consisting of hospital cover) for the first time.

People born before 1 July 1934, and those who take out private health insurance by 1 July following their 31st birthday are assigned the lowest Lifetime Health Cover age of 30. That entitles you to the lowest possible premium for as long as you continue to hold health insurance.

Those who do not have health insurance by 1 July following their 31st birthday have 2% loading added to their premium for every year that they have been without it (in particular, hospital cover) since turning 30. For more information read our article on Lifetime Health Cover

Chiropractic (health insurance Extras feature)

Covers consultations/treatment by a recognised chiropractor to address neck, back and other 'muscular-skeletal' problems. Some policies include osteopathy. Your health fund will cover chiropractic consultations/treatments with a recognised chiropractor to the extent that it is covered by your particular health insurance policy.

Claim

This is an invoice submitted to a health fund for the payment of benefits under a health insurance plan. Claims may be made electronically via HiCaps or Ezyclaim at the time of treatment, or by a claim form submitted to the health fund with the appropriate receipts relating to the claim. Claims must be made within two years of receiving treatment.

Claimant

This is the person or entity submitting a claim (see above) on their health insurance policy to their health fund.

Community Rating

This rating method sets premiums for health insurance by spreading the cost of providing medical benefits across the whole community, without discriminating based on age, gender or health. This means that everyone is entitled to buy the same product at the same price.

The only exceptions to this rule are waiting periods for pre-existing ailments, state-based contributions (prices may vary across different states) and Lifetime Health Cover Loading .

Comprehensive Cover

This is the highest level of health insurance made available from the health funds, with the most number of features paying the highest level of benefit limits. With moneytime's search options, you can shortcut straight to Most Comprehensive Hospital, Most Comprehensive Extras or both.

Co-payment

Co-payment options allow you to lower your health insurance premium in exchange for agreeing to pay a certain amount towards the cost of each day spent in hospital. Different health funds have different co-payment maximums, so check your policy for details.

For example, a co-payment of $50x4 means you agree to pay the first $50 for each day/night you spend in hospital up to a maximum of 4 days.

Conditions of Membership

All health funds have a set of rules that govern the conditions of your membership with them. Full copies of these can be obtained by contacting the health fund. Any breach of these rules may result in the termination of your membership.

Couple Membership

Couple membership refers to health insurance cover for the primary applicant (the member or policy holder) and one other person, usually a spouse or de facto partner. The extra person cannot be a dependent child of the member.

• back to top •

D

Dependant

A dependant usually describes children under a certain age (often 17 or 21 years) who are still eligible for cover under the family health insurance. Some health funds also allow older dependants to be covered by family health insurance up to a certain age (often 25 years old), provided they are single and studying full-time. Check your policy or contact your health fund for details.

Dialysis (health insurance Hospital feature)

Dialysis is used to treat chronic renal (kidney) failure, involving a process of cleansing the blood by passing it through a special machine. Your health fund will cover dialysis benefits to the extent that it is covered by your particular health insurance policy.

• back to top •

E

Elective surgery

Surgical treatment of a condition not considered to require immediate attention by a medical professional. Private health insurance that covers you for admission into a private hospital ensures:

• choice of doctor and hospital
• more choice about the timing of the procedure
• a private room (depending on the level of your cover)
• part or all costs of the procedure covered by your health insurance

To expedite your elective surgery with private hospital cover, select 'private hospital' in your moneytime search options before choosing the features you want fully covered by your health insurance policy. Alternatively, you can choose Most Comprehensive Cover under the hospital component to get the best that moneytime's participating health funds have to offer.

Endodontic (health insurance Extras feature)

Dental services for the treatment of exposed tooth nerves and root canal therapy. Your health fund will cover endodontic treatment to the extent that it is covered by your particular health insurance policy.

Excess

Including an Excess as part of your health insurance lowers your premium in exchange for agreeing to pay a certain amount for admission to hospital. Depending on your Health Fund, the excess may either be charged only the first time you go to hospital, or each time you go to hospital in the 12 month period covered by your health insurance.

Exclusions

Exclusions are services that are not covered by your health insurance policy, and therefore will not be paid for by the health fund. For example, if your health insurance plan excludes hip replacement, then no benefits will be paid for that procedure.

To ensure that the services important to you are not excluded in your health insurance cover, make sure you select them as part of your moneytime search – this ensures that your results bring up only those health insurance policies that fully cover the services you have selected.

Extras (or Ancillary services)

Extras cover provides protection for non-hospital medical services that are not covered by Medicare, such as dental, optical, chiro and other therapies. To choose the Extras you want covered in your health insurance plan, tick them as part of your moneytime search.

• back to top •

F

Family Membership

Health insurance that covers all your family members, including your spouse/partner and dependant children. Student dependants up to 25 may also be eligible for cover so long as they are single and studying part-time.

Federal Government Rebate

See Rebate

Fund

See Health Fund

• back to top •

G

Gap

A 'gap' is the difference between how much a particular treatment costs and the Medicare Benefits Schedule, which is covered by Medicare (75%) and your health fund (25%). This amount may need to be paid out of your own pocket unless your health fund has a gap cover arrangement in place to insure you again some or all of these additional costs. Read more about the gap

General Dental (health insurance Extras feature)

Typically includes diagnostic and preventive services such as x-rays, examinations, consultations, scale and cleans, fluoride treatments etc.) and minor restoratives (fillings). Your health fund will cover general dental treatment to the extent that it is covered by your particular health insurance policy.

Glucose Monitor (health insurance Extras feature)

Glucose Meters/Monitors are used in the management of diabetes. Certain policies may also cover supplies or consumables, it is important to check coverage before purchase. Your health fund will cover the cost of glucose monitors to the extent that it is covered by your particular health insurance policy.

Government Rebate

See Rebate

• back to top •

H

Health Fund

A health fund is an organisation that offers private health insurance cover. moneytime's partner health funds include (in alphabetical order) ahm, Australian Unity, GMHBA, HBA, HCF, MBF, Mutual Community, and nib.

Hearing Aids (health insurance Extras feature)

A device worn on the person that assists with their hearing, including behind the ear and spectacle types. Your health fund will cover the cost of hearing aids to the extent that it is covered by your particular health insurance policy.

Hospital Accommodation

See Accommodation

Hospital Cover

Hospital cover helps cover your costs as a private patient in hospital, including medical treatment, accommodation and ambulance (in some states). To avoid the Medicare Levy Surcharge, you must have Hospital Cover with an excess no greater than $500 for individuals or $1000 for families/couples. Hospital cover is often purchased in conjunction with Extras Cover for full protection for your health needs.

• back to top •

J

Joint Replacement (health insurance Hospital feature)

Surgery to replace or revise joints in order to improve movement and use. Joint Replacement coverage is generally divided into two categories by the health funds:

1. Hip and knee
2. Shoulder and elbow

Any health insurance policy that covers one or both of these categories also includes the minor joints. Your health fund will cover the cost of joint replacement procedures to the extent that it is covered by your particular health insurance policy.

• back to top •

L

Lifetime Health Cover (LHC)

Lifetime Health Cover is a Government initiative that sets health insurance rates depending on when you first take out hospital cover. Those who join health insurance (hospital cover) before 1 July following their 31st birthday are assigned a Lifetime Health Cover age of 30 for as long as they continue to hold that cover. This means they receive the lowest base rate premium for as long as they continue to hold hospital cover. Those who take out health insurance (hospital cover) after that date have 2% loading added for each year that they do not have hospital cover, up to a maximum of 70%. Read more about Lifetime Health Cover

• back to top •

M

Major Dental (health insurance Extras feature)

Typically includes complex restorations, crowns, bridgework, implants, dentures etc. Your health fund will cover the cost of major dental procedures to the extent that it is covered by your particular health insurance policy.

Medicare

Medicare is the public health system established by the Federal Government to provide basic medical care for all Australian residents. It is funded partially by the Medicare Levy on taxable income and fully covers public hospital treatment. Medicare also covers free or subsidised treatment by some medical practitioners, including general practitioners, specialists and participating optometrists and dentists (for specific services only) for those eligible for Medicare benefits.

Massage (health insurance feature)

See Remedial Massage

Medicare Benefits Schedule (MBS)

This is a schedule of medical fees set by the Government based on a fair price and how much Australia can afford to pay for the total health system. For private patients, the Government provides a rebate of 75% of the MBS fee for in-hospital medical fees and 85% of the MBS fee for specialist services incurred out of hospital. Private health insurance can cover you for the extra 25% or 15% to make up the difference, and health funds may also cover the gap incurred when doctors and specialists charge above the MBS fee, depending on your health insurance policy.

Medicare Levy Surcharge (MLS)

The Medicare Levy Surcharge is an extra 1% tax incurred by individuals earning over $70,000 p/a and couples/families with a combined annual income over $140,000 who do not have private health insurance (hospital cover).

Membership

If you have taken out health insurance with a health fund, you generally become a member of that health fund. Your membership entitles you with certain rights as long as you comply with the rules of membership published by your health fund.

Monthly Premium

This is the monthly fee paid to the health fund in order to continue your health insurance cover. See Premium for more information.

• back to top •

N

Naturopathy (health insurance Extras feature)

Covers consultations/treatments with a recognised naturopath. Naturopathy uses non-invasive treatments like nutrition, dietetics, herbal medicine, homeopathy and tactile therapies like massage, and acupressure to stimulate the patient's vitality and help the body heal itself. Your health fund will cover the cost of naturopathy consultations/treatments with a recognised naturopath to the extent that it is covered by your particular health insurance policy.

Non-cosmetic Plastic Surgery (health insurance Hospital feature)

Includes procedures considered medically necessary, eg. facial or breast reconstruction, skin cancers, skin grafts etc. that Medicare will not cover. Your health fund will cover the cost of non-cosmetic plastic surgery to the extent that it is covered by your particular health insurance policy.

Non-PBS Pharmaceuticals (health insurance Extras feature)

PBS (Pharmaceutical Benefits Scheme) is a Government scheme which helps pay for pharmaceutical items. If you are prescribed non-PBS drugs (those not listed under this scheme), you may be able to claim a benefit for the difference between the actual cost of the drug and the maximum PBS specified charge. This does not cover over-the-counter items or vitamins. Your health fund will cover the cost of non-PBS pharmaceuticals to the extent that it is covered by your particular health insurance policy.

• back to top •

O

Obstetrics (health insurance Hospital feature)

Medical treatment related to childbirth including pregnancy, labour, delivery and associated care provided in hospital. Your obstetrics costs will be covered by your health fund if it is included in your health insurance policy. See also Pregnancy/Birth Related Services. 

Optical (health insurance Extras feature)

These benefits include spectacle frames, lenses (single-, bi- and multi-focal) and contact lenses (permanent and disposable). Your health fund will offer optical benefits to the extent that it is covered by your particular health insurance policy.

Orthodontic (health insurance Extras feature)

Dental services that involve fixed appliances (braces) or removal appliances (retainers) to treat teeth, jaw and bite misalignments. Your health fund will cover the cost of orthodontic treatment to the extent that it is covered by your particular health insurance policy.

Out-of-pocket Expenses

Out-of-pocket expenses are incurred when there is a difference between the benefit provided by your health fund under your health insurance plan and the fee for the medical service provided to you. For example. additional charges for luxury hospital suites, medical fees above the Medicare Benefits Schedule (gap) or services by providers which are not covered by your health insurance. It is always best to speak with your health fund and hospital prior to undergoing treatment so you are aware of any out-of-pocket expenses you may incur. Read how to reduce the gap and other out-of-pocket expenses

• back to top •

P

Palliative Care (health insurance Hospital feature)

Specialised health care to support and comfort people with life-limiting illnesses. Your health fund will cover the cost of palliative care to the extent that it is covered by your particular health insurance policy.

Physiotherapy (health insurance Extras feature)

Consultations/treatments from a recognised physiotherapist to treat bone and muscular conditions and injuries or disabilities, and may include exercise classes such as hydrotherapy. pilates or antenatal exercises. Your health fund will cover the cost of physiotherapy to the extent that it is covered by your particular health insurance policy.

Podiatry (health insurance Extras feature)

Consultations/treatments by a recognised podiatrist involving disorders of the feet, ankles and lower limb. Your health fund will cover the cost of podiatry to the extent that it is covered by your particular health insurance policy.

Policy

This refers to your health insurance agreement with your health fund. Your health insurance policy (also known as a health insurance plan) covers a specific range of services with a set Excess or Co-payment agreement in exchange for a set premium. In order for your health insurance policy to be valid, you must abide by the rules set by the health fund.

Preferred provider

Preferred providers are those providers who have an arrangement with your health fund to offer Extras/Ancillary services with low or no out-of-pocket costs.

Pregnancy /Birth Related Services (health insurance Hospital feature)

Services and treatment for pregnancy, pre- or post-conception and delivery of a baby. Your health fund will cover the cost of pregnancy and birth-related services to the extent that it is covered by your particular health insurance policy.

Premium

This is the amount payable to your health fund for a health insurance policy. Payments may be made fortnightly, monthly, quarterly, half yearly or annually. With the approval of the Minister for Health, health funds are able to increase their premiums once a year to cover the cost of rising 'medical inflation', and these changes generally come into effect on 1 April. Some health funds allow you to lock in the lower premium before the higher one comes into effect by opting to pay your next 12 months in advance.

Pre-existing Condition

Any illness or condition, the signs or symptoms of which exist during the six month period before you take out a health insurance policy, is considered to be pre-existing. The existence of the condition is determined by a medical practitioner appointed by your health fund. All health funds impose a 12 month waiting period on pre-existing conditions for new policies, or for higher level benefits on upgraded health insurance policies.

The exception to this rule is psychiatric care, rehabilitation and palliative care. The maximum waiting period for these conditions, whether pre-existing or not, is two months.

Private Health Insurance Ombudsman (PHIO)

PHIO is an Australian Government agency which acts and reports in the area of private health insurance. The Ombudsman can help consumers by dealing with enquiries and complaints about health insurance or health funds.

Private Hospital Cover

The 'Private Hospital Cover' option in the moneytime search option allows you to choose a health insurance plan that covers you as a private patient in a private hospital. This means your choice of doctor, a choice of private hospitals and a shorter wait for elective procedures. Depending on your health insurance plan, you could also be eligible for your own private room.

The alternative is Basic Hospital Cover.

Psychiatric Services (health insurance Hospital feature)

Approved programs designed to assist recovery and manage mental illnesses including schizophrenia, depression, anorexia, bulimia, etc. Your health fund will cover the cost of psychiatric treatment to the extent that it is covered by your particular health insurance policy.

Psychology (health insurance feature)

Benefits for psychology include consultations/treatments by a recognised psychologist. Psychologists assess, diagnose, prevent, and treat problems associated with the human mind and behaviour. Some policies specifically exclude assessments and/or group sessions - be sure to check the details. Your health fund will cover the cost of psychological treatment to the extent that it is covered by your particular health insurance policy.

• back to top •

R

Rate (health insurance)

See Premium.

Rebate

The Federal Government Rebate on health insurance is available to everyone who is eligible for Medicare and has private health insurance. The rebate entitles persons under 65 years of age to receive back 30% of the cost of their health insurance, while those aged 65-69 receive 35% and those over 70 years of age receive 40%. The most common way to claim your rebate is to reduce the cost of your premium. The figure shown on the health insurance quotes produced by moneytime include a 30% rebate on the premiums set by the health funds.

Rehabilitation (health insurance Hospital feature)

Benefits include approved programs designed to assist recovery from strokes, surgery, accidents, etc. to regain as much function as possible. The aim is for clients to become as independent as possible despite his/her disabilities. Rehabilitation also aims to teach strategies for ongoing disabilities. Your health fund will cover the cost of rehabilitation to the extent that it is covered by your particular health insurance policy.

Remedial Massage (health insurance Extras feature)

May cover a range of massage techniques by recognised providers including remedial, oriental, therapeutic, sports, Myotherapy, Shiatsu, Reflexology, Bowen Technique etc - check policies for details regarding coverage. Your health fund will cover the cost of remedial massage to the extent that it is covered by your particular health insurance policy.

Restricted or Partial Cover

You may choose a health insurance policy that offers a lower premium in exchange for restricted or partial cover on certain services. That means those services are not fully covered by your health insurance plan, so any hospital or medical costs incurred would be only partially paid for by your health fund. moneytime's comparison page shows a green tick for all services that are fully covered and a grey outlined tick for restricted or partially covered services in the health insurance plans you choose to view.

• back to top •

S

Single Membership

A single membership covers one person (the policy holder) only under their chosen health insurance plan.

Sterilisation (health insurance Hospital feature)

Vasectomy, tubal ligation etc to prevent pregnancy. Your health fund will cover the cost of sterilisation to the extent that it is covered by your particular health insurance policy.

Student Dependant

Dependants aged up to 25 who are still fully or partially maintained by you may be eligible for cover under your family health insurance policy, provided they are:

• full time students
• not entitled to receive an invalid pension or disability allowance
• not in receipt of a taxable income from the school, college or university

Check with your health fund for details relating specifically to them.

Suspension

Health funds may grant a suspension of your health insurance plan at their discretion for particular circumstances, eg. financial hardship, temporary unemployment or study or work overseas. During a period of suspension, you do not need to pay your premium and you cannot claim any benefits under your health insurance policy. It is important that you check with your health fund whether you will need to re-serve any waiting periods after the suspension period is over, as rules vary between health funds.

Your Lifetime Health Cover status is not altered during a suspension period, however if your income is over the current threshold, you will be required to pay the Medicare Levy Surcharge for that period.

Switching Health Funds

Transferring between Australian health funds is easy. Simply complete the application for the health insurance plan you wish to transfer to, and your new health fund will take care of the rest for you. They will send you a Transfer Form which you need to sign and return (this part cannot be done electronically at this stage) to terminate your health insurance policy with your previous health fund. However, if you have a direct debit agreement in place, you will need to cancel it with your financial institution.

If you have already ceased your health insurance policy with your previous health fund, you must transfer within 60 days to your new health fund to ensure that you will not have to serve your waiting periods again and your Lifetime Health Cover will not be affected.

• back to top •

T

Theatre Fees

Theatre fees are costs for procedures performed in an operating room, including those performed in day surgery facilities. These costs are generally covered by your health fund, as they are part of your hospital cover when you have health insurance.

• back to top •

W

Waiting period

This is how long you are required to wait after joining a health fund before you are eligible for certain benefits. For example, pre-existing conditions have a waiting period of 12 months, with the exception of palliative, rehabilitation and psychiatric services, which have a maximum waiting period of 2 months.

You will find the waiting periods listed in the moneytime comparison table, and we frequently have special offers by our partner health funds that waive 2 and 6 month waiting periods, so you can access a host of services (like general dental and optical) immediately.

Back to Private Health Insurance: Information