Get the most out of your Family Health Insurance and Extras Cover.

Annual limits

The maximum benefit payable for a particular service within a 12 month period.
Annual limits can be calculated based on a calendar year, or financial year, or for every 12-month period from the anniversary date of taking out a private health insurance policy.

Benefit

The amount you can claim from the insurer for a specific service. This may be listed on the PHIS as a dollar amount (maximum benefit) or as a percentage amount (percentage benefit). For example: Maximum benefit - for each visit to a physiotherapist you can claim up to $50; Percentage benefit - for each visit to a physiotherapist you can claim up to 75% of the total cost. Some policies may use a combination of both dollar and percentage amounts (for example: for each visit to a physiotherapist you can claim 75% of the cost up to a maximum of $50) - this kind of benefit is not currently displayed on the PHIS so it’s important to check with your insurer about what your policy covers.

Benefit limits
The benefit limit is the most amount of money you can claim for a service, usually in a 12 month period.

Closed policy

A policy which is no longer available for sale, but which continues to cover existing members.

Covered

If a PHIS has marked a service as 'covered' this means that the policy provides some level of coverage for that service. Contact your insurer for details.

Daily excess

See Co-payment.

Dependant

A dependent child is an unmarried person under the age of 18 years. An insurer may choose to continue considering a person between the ages of 18 and 31 years as a dependent child, but will usually require certain conditions to be met - for example, the person may have to be a full-time student. Insurers can also choose to cover dependents with a disability without any age limit.

These conditions vary between insurers, so check with your insurer to see which rules they apply.

Excess

Also called a front-end deductible, an excess is an amount that you agree to pay towards the cost of hospital treatment, in exchange for lower premium costs.

You may be required to pay an excess every time you go to hospital, or only the first time. Depending on the type of hospitalisation (e.g day surgery or overnight stays) you may only have to pay a part excess (for example an excess of $500 may apply to overnight hospitalisation but only $100 applies to day surgery.)

What excess (if any) you will need to pay depends on the policy you take out. Always check with your insurer.

Eligibility Checking System

An online system that hospitals can use to electronically confirm the membership details and benefits for a patient who is to be admitted to hospital for treatment. This system is available on-line 24 hours a day.

Exclusions

Conditions or services which your health insurance policy does not include, meaning that your insurer will not pay benefits towards hospital or medical costs for these items. If you choose to proceed as a private patient for an excluded service, you will have very large out of pocket expenses. If the services are eligible under Medicare, you can still receive treatment as a public patient – however, public hospital waiting lists will apply and you should discuss this option with your doctor. For more information, see: Policy Exclusions and Restrictions

Extras
See General treatment policy.

Gap

A 'gap' is the amount you pay out of your own pocket for treatment in hospital, either for medical or hospital charges over and above what you get back from Medicare or your private health insurer. Some health insurers have gap cover arrangements to insure against some or all of these additional payments.

General treatment policy

Health insurance to cover non-hospital medical services that are not covered by Medicare, such as dental, optical, physiotherapy, other therapies and ambulance. Also known as 'extras' or 'ancillary' insurance.

Health insurers
Private health insurance organisation - also known as a Fund.

Lifetime Health Cover (LHC)

Lifetime Health Cover is a government initiative introduced from 1 July 2000. It was designed to encourage people to take out hospital insurance earlier in life, and to maintain their cover. People who take out (and keep) hospital insurance before their 'base day' pay lower premiums throughout their lifetime than people who join later. Generally, your base day is the later of 1 July 2000 or the 1 July following your 31st birthday.

If you join after your base day, you pay 2% more for each year you are aged over 30 for your private hospital insurance premiums than someone who joined before their base day. If you join at 35, you pay 10% more and if you join at 50, you'll pay 40% more. LHC only applies to hospital policies - there are no age penalties or incentives for general treatment policies. Some exceptions apply for Australians who have been living overseas and new migrants. For more on LHC, please see: Lifetime Health Cover.

Medicare Benefits Schedule (MBS)

The schedule of fees set by the government for standard medical services, based on a fair price and how much Australia can afford to pay for the total health system. 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. This rebate is currently 75% of the MBS fee for in-hospital medical fees and 85% of the MBS fee for specialist medical fees incurred out of hospital.

You can purchase hospital insurance to cover the remaining 25% of the MBS fee and gap cover to assist in minimising any potential additional fees incurred in-hospital if the doctor charges more than the MBS fee.

Medicare Levy Surcharge (MLS)

The Medicare Levy Surcharge is levied on Australian taxpayers who earn above a certain income and do not have private hospital insurance. The Surcharge aims to encourage individuals to take out private hospital cover, and where possible, to use the private system to reduce the demand on the public system.

The Surcharge is calculated at the rate of 1% to 1.5% of taxable income. It is in addition to the Medicare Levy of 2%, which is paid by most Australian taxpayers. The Medicare Levy Surcharge is imposed on individuals earning over the threshold who do not have an appropriate level of hospital insurance. For the current income thresholds, see Medicare Levy Surcharge.

Occupational therapy

An occupational therapist can help people improve their everyday motor skills after injury or illness.

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 are going to hospital during your waiting period, it is important to check with your health insurer prior to the admission as to whether you will be covered or if the condition will be deemed pre-existing.

Private Health Insurance Rebate

Most Australians with private health insurance currently receive a Rebate from the Australian Government to help cover the cost of their premiums. The Private Health Insurance Rebate is income tested. For more information see Private Health Insurance Rebate.

Waiting period
How long you will need to be a member before you are eligible for benefits. The Government has set maximum waiting periods for benefits for hospital services, but insurers can set their own waiting periods for general treatment benefits. The PHIS lists waiting periods in months for standard services.