glossary

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• Access Gap

  When you are treated by your Doctor in hospital, Medicare pays 75% of the Government Schedule fee and Transport Health pays the remaining 25%.  However, some doctors charge above the government schedule fee and you are usually required to pay the difference.  This out-of-pocket cost is referred to as “the gap”.

   

  Transport Health’s Access Gap cover seeks to reduce or eliminate ‘the gap’, resulting in no or less out-of-pocket costs to you.  Transport Health Access Gap has its own schedule of fees which are generally higher than the current government schedule of fees.  If your doctor chooses to charge using our schedule of fees, there may be no out-of-pocket cost to you or, alternatively, your doctor may choose to charge a co-payment, which is an agreed amount doctors can charge above the fee set in our schedule.  This co-payment will be known as an out-of pocket cost for you.  Usually when a doctor charges a co-payment they should inform your prior to treatment.

   

  It is important to be aware that your doctor can choose to participate in Access Gap on a patient by patient basis, so you should check with your Doctor whether they will participate. Also be aware that more than one doctor may be involved in your treatment.

   

  Participating doctors will generally send their accounts direct to Transport Health.  If the doctor does send you an account, you need to submit it directly to Transport Health and not to Medicare.

   

  Please contact our Office on 1300 806 808 if you have any further queries.

   

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• acupuncture

  Acupuncture is a family of procedures involving the stimulation of anatomical locations on or in the skin by a variety of techniques. The most thoroughly studied mechanism of stimulation of acupuncture points employs penetration of the skin by thin, solid, metallic needles, which are manipulated manually or by electrical stimulation.
• adult dependant

  Persons are considered dependants of the contributor in the following instances:
  

  • Unmarried children between the age of 21-25 and are not full- time students and not eligible for cover under the family membership as detailed under the definition of “dependant children”
  • Singles up to the age of 25 and not living in a de facto relationship
• agreement private hospital

  Transport Health has negotiated set benefit arrangements with 98% of private hospitals and day facility hospitals throughout Australia, eliminating or minimising out-of-pocket expenses for members according to their level of cover. Product excesses and/or co-payments still apply.

  To find an agreement hospital, please use the hospital finder.

• ancillary cover

  Ancillary cover is another term for extras cover.
• assisted reproductive services

  Assisted reproductive services includes, but is not limited to:

  • IVF
  • GIFT
  • Vasectomy and reversals
  • Sterialisation
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• benefit limitation periods

  Benefit Limitation Periods are a feature of some Hospital covers – They are initial periods of membership during which only minimal benefits are paid for some types of treatment.  Benefit limitation periods will not apply to you if you are transferring from another Hospital product with Transport Health or another Fund.

  On some tables Transport Health applies BLP’s to psychiatric, palliative care, rehabilitation and cardiac inpatient medical treatment for the first 12 months of membership if previously uninsured.  BLP means benefits are restricted to basic cover.  Basic cover provides public hospital cover as a private patient in a shared ward, with your own choice of doctor.  Treatments for these services are not recommended in a private hospital under these covers.  Please contact the Fund for further information on these benefits within the first 12 months of cover.

• benefit replacement periods

  A benefit replacement period is the period of time you will need to wait after claiming an item before you can receive further benefits to replace the item.

  i.e. if you received a claim benefit for a full set of dentures on 1/7/2011 you would not be eligible to claim on dentures again until  after 1/7/2014.

   

  Item	Period before replacement can be claimed
  Dentures – Full	36 months
  Dentures – Upper/Lower/Partial
  Hearing Aids

   

• broader health cover

  Broader Health Cover is an initiative designed to utilise non-hospital forms of treatment, including early release and preventative health care.

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• chiropractic

  Chiropractic employs manipulation and adjustment of body structures, such as the spinal column, so that pressure on nerves coming from the spinal cord may be relieved. This treatment based on the concept that the nervous system coordinates all of the body's functions, and that disease results from a lack of normal nerve function. Chiropractic treatment has been shown to be effective in treating muscle spasms of the back and neck, tension headaches, and some sorts of leg pain.
• co-payment

  Co-payments under Top Hospital cover are an amount payable by the member and applicable to each hospital admission during a calendar year. Top Hospital with Co-payment has a daily co-payment of $100 per night, capped at $500 per person, per calendar year. This is also capped annually at $500 per person to a maximum of $1000 per couple / family per calendar year. Co-payments do not apply to same day accommodation.

  Healthy Choice Hospital has a daily co-payment of $100 for overnight accommodation capped at $500 per person with a family maximum of $1000 in any calendar year. There is also a daily co-payment of $100 for day stays / day procedures excluding in-patient dental treatment.

• cosmetic surgery

  Benefits are only payable for cosmetic surgery or services where it is required for a medical purpose  and for which Medicare benefits are payable.

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• CPAP

  CPAP stands for "Continuous Positive Airway Pressure".

  
  

  Benefits can only be claimed from either a hospital or extras table but not from both. Benefits are payable for replacement parts i.e. masks.

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• dependant children

  Persons are considered dependants of the member in the following instances:
  

  • Unmarried children up to the age of 21
  • Unmarried children between the ages of 21 and 25, who are full-time students in an approved apprenticeship / study course
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• emergency ambulance transportation

  Ambulance benefits are payable for recognised emergency ambulance transport. Ambulance transport is covered in full except in the following circumstances, which are not considered emergencies:

  • Transport from the hospital to your residence (home or a nursing home)
  • Transport from the admitting hospital to another hospital for treatment
  • Transport for regular treatment (eg chemotherapy)
  • Treatment by ambulance officers, which does not result in transport to a hospital
• excess

  The Excess is an amount payable by the Member on making a claim, and applicable only once in the calendar year.

  The excess, as in Top Hospital with Excess cover, is $250 per person, on the first overnight admission, per calendar year. A single membership has a maximum excess of $250 annually. A family membership has an excess of $250 up to a family maximum of $500, for overnight admissions, per calendar year.

  
  

  Young Singles Cover has a $250 excess payable on overnight and/or day stays per admission. This excess is capped annually at $500. Young Couples cover has a $250 excess payable on overnight and/or ay stays per admission. This excess is capped annually at $500 per person, per calendar year.

• exclusions

  An excluded service is one on which benefits will not be paid by Transport Health.

  
  

  Transport Health does not pay benefits for hospital treatment of any of these conditions when you elect to be treated as a private patient. You re, however, covered by the public system under your Medicare entitlement, only when treated as a public patient by hospital appointed doctors in a public hospital.
  

• extras cover

  Extras cover is a form of health insurance which allows a member to claim back some or all of the cost of non-hospital treatment, such as dental, physiotherapy, chiropractic and osteopathy.
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• gap payments

  Under all hospital covers, medical benefits are paid in accordance with the Medicare Benefits Schedule Fee for inpatient medical treatment. Medicare will cover 75% of schedule fee and Transport Health will pay the remaining 25% of the schedule fee up to the Medicare Benefits Schedule (MBS).

  
  

  If a doctor charges more than the MBS this is known as the ‘gap’ and is payable by the member.

• general dental

  "General" dental usually refers to preventative dentistry and the normal maintenance required to sustain oral and dental health.

  
  

  Usually this includes regular check-ups, hygeineist, fillings etc.

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• GIFT

  Stands for in gamete intrafallopian transfer, which is when a mixture of sperm and eggs are placed directly into the fallopian tuves using laparoscopy.
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• hospital cover

  Hospital cover is a type of health insurance which covers a member for the cost of treatment in hospital, should they require it.

  
  

  The price of hospital cover is based on the level of care covered, and on whether services are excluded from the policy. For example, Basic Hospital Cover covers only treatment in public hospitals as a private patient, whereas comprehensive plans cover treatment in private hospitals. Mid-range plans often exclude certain expensive treatments in order to reduce the cost of the member's premium, or offer restricted benefits on some services.

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• Lifetime Health Cover

  If you are aged over 30 and you are taking out private hospital cover for the first time, you may have to pay an additional loading on top of your premium, known as Lifetime Health Cover. The loading increases 2% for every year where you are not covered, and will be applied to your premium for 10 years.

  
  

  Your age	Loading	Your age	Loading	Your age	Loading	Your age	Loading
  30	0%	39	18%	48	36%	57	54%
  31	2%	40	20%	49	38%	58	56%
  32	4%	41	22%	50	40%	59	58%
  33	6%	42	24%	51	42%	60	60%
  34	8%	43	26%	52	44%	61	62%
  35	10%	44	28%	53	46%	62	64%
  36	12%	45	30%	54	48%	63	66%
  37	14%	46	32%	55	50%	64	68%
  38	16%	47	34%	56	52%	65+	70%

   

  After contributing to a hospital plan for 12 continuous months, you may cancel or cease your cover for a combined period of 1094 days without incurring a further penalty.

  
  

  A more detailed explanation can be found here, or visit www.privatehealth.gov.au

  
  

  You can calculate your exact loading, taking into account all gaps in coverage and overseas absences, using the Department of Health and Ageing's Lifetime Health Calculator.

• Limited benefits

  Limited benefits refers to a service which is covered by Transport Health but at a reduced rate.

  
  

  Normally, services have limited benefits during the first few months of coverage, but in some cases benefits are reduced through the lifetime of the policy.

  
  

  For hospital services with limited benefits, members are restricted to treatment in a public hospital as a private patient, and cannot claim for the cost of treatment in a private hospital.

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• loyalty reward

  The loyalty reward offers you the option, after 24 months continuous membership of Young Couples  cover, to upgrade to a Top Cover plan for pregnancy and birth-related services with no further waiting  periods applying.
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• major dental

  Major dental refers to restorative and cosmetic dentistry, including crowns, bridges, implants etc.
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• Medicare

  Medicare is the Australian Government's universal health insurance scheme, which covers all eligible citizens and residents for hospital treatment in public hospitals by hospital-appointed doctors.

  
  

  www.medicareaustralia.gov.au

  
  

  Individuals with private hospital insurance are still entitled to receive treatment under Medicare through the public system.

• medicare surcharge levy

  The medicare surcharge levy is a taxation penalty of an additional 1% applied to those with a taxable income of over $80,000 ($160,000 for a couple) who have not held a complying hospital insurance policy for the previous 12 months.

  For more information see [our article] or visit www.privatehealth.gov.au

   

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• naturopathy

  Naturopathic medicine integrates traditional natural therapeutics - including botanical medicine, clinical nutrition, homeopathy, acupuncture, traditional oriental medicine, hydrotherapy, and naturopathic manipulative therapy - with modern scientific medical diagnostic science and standards of care.
• newborns

  When a newborn baby is in hospital with the mother a separate accommodation charge is not usually raised for the child during the hospital stay. Single cover should be changed to family or single parent family at least 3 months prior to the birth, however, single parent family or family cover is required to cover accommodation costs for:

  • Newborns admitted to hospital and / or intensive care

  • The second and later children of a multiple birth

• non-agreement private hospital

  A non-agreement hospital is a provider which does not have a contract with a health insurer outlining the agreed benefits which will be paid for treatment.

  
  

  You should check with Transport Health before seeking treatment to ensure that your hospital or provider has an agreement with us, or you may be liable for additional costs.

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• optical

  For members with Extras cover, optical benefits are available from all Optical retailers in private practice who are registered with Transport Health. All eligible members can claim a benefit* on frames, prescription lenses and contact lenses.

  A claim for services can usually be made on the spot at Optical Outlets around Australia. After your treatment, swipe your membership card and the claim will be processed automatically. There are no forms for you to complete and you'll only pay the balance of the account.

  For those members forwarding a claim directly to Transport Health, a copy of the Optical prescription must accompany an Itemised account, together with a completed claim form. Members should note that Optical supplies and/or services received overseas or purchased from overseas including items sourced over the internet are not claimable.

  * for eligible services up to your annual optical limit

• orthodontic

  Orthodontics is the specialty of dentistry that is concerned with the treatment of malocclusions (improper bites), which may be a result of tooth irregularity, disproportionate jaw relationships, or both. Orthodontic treatment can focus on dental displacement only, or can deal with the control and modification of facial growth.
• osteopathy

  A system of medicine based on the theory that disturbances in the musculoskeletal system affect other bodily parts, causing many disorders that can be corrected by various manipulative techniques in conjunction with conventional medical, surgical, pharmacological, and other therapeutic procedures.
• out-of-pocket expense

  An out-of-pocket expense is a sum payable by the member where their insurance does not cover the full cost of their treatment. Out-of-pocket expenses can occur in either hospital or general treatment.
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• physiotherapy

  Physiotherapy is a science-based healthcare profession which views movement as central to health and well-being. Physiotherapists aim to identify and make the most of movement ability by health promotion, preventive advice, treatment and rehabilitation. Core skills used include manual therapy, therapeutic exercise and the application of electrophysical modalities.
• podiatry

  The branch of medicine that deals with the diagnosis, treatment, and prevention of diseases of the human foot.
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• Pre-existing Ailments

  It is standard practice in the Health Insurance Industry to apply a 12 month waiting period before benefits are paid on any pre-existing conditions.

  A pre-existing condition is defined by law as any ailment, illness or condition that you had signs or symptoms of during the six months before you joined a hospital table or upgraded to a higher hospital table.  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 table or upgrading to a higher hospital table.

  If you knew you weren’t well, or had signs of an ailment that a doctor would have detected (if you had seen one) during the six months prior to joining the hospital table, then the ailment would be classed as pre-existing.

  Transport Health will appoint a medical practitioner to determine whether you have a pre-existing condition based on your treating doctors’ information.

• Preferred provider

  Transport Health has negotiated arrangements with health care providers to participate in programs that eliminate or minimise out-of-pocket expenses for some extras treatments like physiotherapy, chiropractic and osteopathy. Members can claim on their extras policy for treatment by any registered provider, however, by using a preferred provider out-of-pocket costs will be reduced or eliminated.

• pregnancy & birth-related services

  Pregnancy and related services includes, but is not limited to, antenatal and postnatal care and management of labour and delivery.
• private health insurance rebate

  All eligible member under 65 years old, regardless of their income, receive a 30% rebate for contributing to private health insurance. Members between 65 and 69 receive a 35% rebate, and those 70 or over receive a 40% rebate.

  Prices quoted on this site are usually inclusive of a 30% rebate.

  More information can be found at www.privatehealth.gov.au

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• reflexology

  Reflexology is a therapeutic method of relieving pain by stimulating predefined pressure points on the feet and hands. This controlled pressure alleviates the source of the discomfort.
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• Restricted benefits

  A restricted benefit is where a form of treatment is covered but at a reduced level to other treatments on the same plan. For example, cover may be restricted to treatment as a public patient, or may be capped at a certain total cost. Access Gap cover is not normally available where benefits are restricted.

  
  

   Restricted benefits usually refer to hospital insurance.

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• shiatsu

  Shiatsu is a manipulative therapy developed in Japan and incorporating techniques of anma (Japanese traditional massage), acupressure, stretching, and Western massage. Shiatsu involves applying pressure to special points or areas on the body in order to maintain physical and mental well being, treat disease, or alleviate discomfort.
• sub-limit

  Benefits payable during the first 6 months of membership and after serving the specified waiting  periods, cannot exceed 50% of the full annual benefit limit entitlement. If further treatment is required in the subsequent 6 months, members are entitled to the balance of the annual limit. The overall benefit payable over 12 months is equal to the normal quoted annual limit but this amount cannot be claimed totally within the first 6 months. Sub-limits do not apply to members who are transferring from other  funds, providing they have held equivalent membership and served the required waiting periods.

  In general, sub-limits apply to those who were previously uninsured. After 12 months of membership (or the stated waiting period for the service - whichever is the greater), members are entitled to unrestricted benefits as stipulated on the relevant plan's page.