- Accommodation: This refers to the cost of a hospital bed, meals and nursing care. It does not include fees charged by doctors and other specialists.
- Acute: A medical condition that comes on suddenly and for a relatively short period of time.
- Admission: The administrative process by which you become a patient in a hospital and can receive treatment. Receiving treatment in a hospital’s emergency department does not constitute an admission
- Admitted patient: A patient who is admitted to hospital to receive treatment and care.
- Agreement hospital: Also referred to as a contract hospital, this is a private hospital or day surgery with which your health fund has an agreement. Under this arrangement, health fund members can access treatment with little or no out-of-pocket costs.
- Allied health professional: A health professional other than a doctor, nurse or dentist. For example, a physiotherapist or a dietitian may be referred to as an allied health professional.
- Ambulance cover: A health insurance product that provides benefits for ambulance transport and treatment.
- Ancillary cover: Ancillary cover is another name for extras cover.
- Annual limit: This is the maximum amount your health fund will pay per year for a particular service or treatment.
Before going to hospital
During your stay
When you're leaving
- Benefit: The amount your insurer will pay for a specific service
- Benefit limitation period: A period of time during which you are only entitled to receive restricted benefits from your health insurer for a specific condition or treatment
- Co-payment: Applies to hospital cover and is a set amount you agree to pay for each day you are in hospital. In return for accepting a co-payment, you will receive lower premiums
- Cosmetic surgery: Surgery to enhance appearance and that is not medically necessary.
- Day surgery: A private hospital where patients are admitted, treated and then discharged on the same day. Sometimes also referred to as a day facility
- Dependant child: An unmarried child under 18 years of age. Some health insurers will continue to cover your children as dependants until they reach 25 years of age when certain conditions are met, for example if your child is a full-time student
- Diagnostic tests: Tests to diagnose your condition, for example X-rays and blood tests
- Elective surgery: Surgery for a condition that does not require immediate medical attention
- Emergency treatment: Emergency treatment is given when a patient is treated within 30 minutes of presentation and if they are in danger of suffering loss of life, limb, bodily function or mental stability, if they are in severe pain or if they are bleeding
- Excess: A set amount that you agree to pay upfront as a contribution towards the cost of hospital treatment. By agreeing to pay an excess when you are hospitalised, you can access lower premiums
- Exclusions: Conditions or services that are not covered by your health insurance policy
- Extras cover: Health insurance that covers out-of-hospital health services that are not covered by Medicare, including optical, dental, physiotherapy and natural therapies. Also referred to as ancillary cover or general treatment cover
- Fund: A private health insurance organisation registered under the Private Health Insurance Act 2007 in Australia.
- Fixed fee: A daily fee charged by some hospitals in addition to a co-payment or excess.
- The gap: The difference between what you are charged for medical or hospital services and the amount covered by Medicare or your private health insurance. You will need to pay this “gap” out of your own pocket (unless your health insurer has a gap cover arrangement)
- Gap cover scheme/arrangement: An arrangement your health fund has with your doctor to limit your out-of-pocket costs when receiving treatment
- General treatment cover: See extras cover
- Health fund: Private health insurance organisation
- HICAPS: Health Industry Claims and Payment Service. This allows you to electronically claim a private health insurance benefit at the point of service by swiping your health fund membership card
- Hospital cover: Health insurance that covers the cost of receiving hospital treatment as a private patient, including accommodation, medical treatment and ambulance (in some states and territories)
- Informed financial consent: The provision of information about the cost of treatment, including any out-of-pocket expenses you will have to pay. This information must be provided to you by all service providers before you are admitted to hospital
- Inpatient: A patient who has been formally admitted to hospital or a day surgery
- Insurer: Private health insurance organisation
- Intensive care: Hospital treatment for a life-threatening condition
- Joint replacements: Surgery to replace impaired shoulder, knee, hip and elbow joints with artificial joints
- Kinesiology: An alternative therapy employing muscle monitoring to identify imbalances in the body. It is used to treat stress, muscular, nervous and nutritional issues and emotional and learning and behavioural problems.
- Knee replacements: See joint replacement
- Labour ward fees: These fees cover the cost of delivering a baby in a hospital maternity ward
- Lifetime limit: The maximum benefit a health fund will pay for a specific service during a member’s lifetime
- Medical expenses: Fees and charges for medical procedures performed while you are in hospital
- Medicare Benefits Schedule (MBS): The schedule of fees for standard medical services set by the Australian Government. Based on this schedule, Medicare pays 75% of the scheduled fee for in-hospital medical services and 85% for out-of-hospital specialist medical fees
- Minimum benefit: The minimum amount an insurer is allowed to pay for a hospital service included in your policy. Sometimes also referred to as a default benefit
- National Private Patient Claim Form: A form you sign to acknowledge that you have obtained informed financial consent for your procedure and that you agree to pay any out-of-pocket expenses that have been outlined to you before admission. This form must be completed before you can be admitted as a private patient
- Non-PBS pharmaceuticals: Prescription pharmaceuticals that are not listed on the Australian Government’s Pharmaceutical Benefits Scheme (PBS). When non-PBS pharmaceuticals are covered by your health insurance, you will usually need to make a co-payment (equivalent to the normal PBS payment) before your health fund will pay a benefit
- Out-of-pocket expenses: Fees and charges that aren’t covered by Medicare or your private health insurer and that will need to be paid by you
- Outpatient: Patients that do not require admission to hospital
- Palliative care: The care of patients with a serious illness for which there is little or no prospect of cure
Pharmaceutical Benefits Scheme (PBS)
- Pharmaceutical Benefits Scheme (PBS): A government subsidy designed to reduce the cost of a wide range of prescription medications
- PHIO: The Private Health Insurance Ombudsman. The Ombudsman is an independent service to help Australian consumers who have questions about or problems with their health insurance
- Pre-existing condition: An ailment, illness or condition which, in the opinion of a medical practitioner chosen by your health fund, existed at any time in the six months prior to you taking out hospital cover or upgrading your level of cover
- Preferred provider: An extras or general treatment service provider with which your health fund has an arrangement allowing members to receive higher benefits
- Premium: This is the amount you pay for health cover
- Private hospital: A hospital run for commercial and/or charitable purposes
- Private patient in a private hospital: If you’re treated as a private patient in a private hospital, you can choose your doctor and receive treatment at a time that suits you
- Private patient in a public hospital: As a private patient in a public hospital, you get to choose your doctor but the time you will have to wait for treatment will depend on public hospital waiting lists
- Prostheses: Prostheses are surgically implanted items, for example artificial knee joints. Some surgically implanted prostheses are included on The Prostheses List, which features items that private health insurers must pay benefits for when they are provided to someone with an appropriate level of hospital cover
- Public hospital: A hospital funded by the government
- Public hospital policy: Hospital cover health insurance that provides restricted benefits for all conditions. If you have this type of cover, you will be able to access treatment as a private patient in a public hospital but you may incur significant out-of-pocket costs if treated in a private hospital
- Qualifying event: An insured event that triggers a member’s protection under their policy (eg loss of employment, divorce or death).
- Quit Smoking: Some quit smoking programs are claimable on your extras cover.
- Restricted membership insurer: A health fund that provides health insurance for people within a specific industry or group, for example the education sector. These insurers typically offer insurance on a not-for-profit basis, but you must be a member of the industry or group (or potentially a family member of someone in the industry or group) to join a fund
- Restrictions: Also known as restricted benefits, restrictions are conditions or services that are covered by your health insurance policy but only to a limited extent. If you receive treatment in a private hospital for a condition that is restricted under your policy, you will need to pay significant out-of-pocket expenses
- Same-day patient: A patient who is admitted, treated and discharged on the same day
- State of the Health Funds Report: Annual report on the performance and service delivery of health insurers, prepared by the Private Health Insurance Ombudsman
- Theatre fees: Fees for procedures performed in a hospital operating room
- Underwriting: The process by which an insurer determines the level of risk of an applicant and the associated cost of the monthly premium.
- Valid from date: This is the date a new health insurance policy is available for purchase.
- Waiting period: This is the period of time which you must be a member of a health fund before you are eligible to make a claim for a particular service
- X-ray/lab: Any diagnostic lab test or x-ray performed in support of basic health services. Lab tests include services like blood work and urinalysis and X-ray services include basic skeletal x-rays, ultrasounds, MRIs, and CT scans.
- Yearly limit: This is the maximum amount you are able to claim in a calendar year.
- Zero gap: A scheme in which participating doctors affiliated with a health fund charge a set fee, with the result that there is no gap between the Medicare benefit and health insurance benefit and therefore zero for the member to pay.
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