Key terms to help you understand cover, costs and how the system works.
- Age-Based Discount – Discount on hospital premiums if you join between ages 18-29 (reduces over time after 41).
- Agreement Hospital – Hospital that has a contract with your insurer to help reduce out-of-pocket costs.
- Ambulance Cover – Cover for ambulance services depending on your policy and state.
- Annual Limit – The maximum amount your insurer will pay for a service in a year.
- Benefit – The amount your insurer pays towards treatment/claim.
- Bronze Hospital Cover – Mid-level hospital cover with a range of treatments included.
- Bulk Billing – Where your provider bills Medicare directly, so you pay nothing.
- Claim – Request to your insurer after receiving treatment.
- Clinical Categories – Different types of treatments covered (e.g. heart, pregnancy, joints).
- Combined Cover (or Combined Policy) – A policy including both hospital and extras.
- Community Rated – Everyone pays the same premium for the same policy regardless of health.
- Cooling-off Period – First 30 days of cover during which you can cancel and receive a refund where no claims have been submitted.
- Co-payment – A fixed amount you pay when receiving a service.
- Downgrade – Switching to a lower level of cover (fewer benefits).
- Excess – The amount you pay before your insurer contributes to hospital costs.
- Excluded – Treatments not covered at all by your policy.
- Exclusions – Services not covered at all.
- Extras Cover – Cover for services like dental, optical and physio.
- Gap – The difference between what is charged and what is covered.
- Gold Hospital Cover – The highest level of cover with the most treatments included.
- Hospital Cover – Cover for treatment as a private patient in hospital.
- Inclusions – Services covered by your policy.
- Informed Financial Consent (IFC) – Estimate of treatment costs provided before you receive care.
- Lifetime Health Cover (LHC) Loading – A loading added if you take out cover after 31.
- Medicare – Australia’s public healthcare system.
- Medicare Benefits Schedule (MBS) – List of services and fees Medicare uses to determine benefits.
- Medicare Levy – A tax that helps fund Medicare.
- Medicare Levy Surcharge (MLS) – Extra tax for higher income earners without hospital cover.
- No Gap Dental – Eligible dental services fully covered at participating providers.
- Out-of-pocket Costs (or Gap) – Costs not fully covered by insurance or Medicare.
- Policy Limit – Maximum benefits payable for a service within a set period.
- Policy Review – Regular check to ensure your cover still suits your needs.
- Pre-existing Condition – Any illness, injury, or health issue that you had before (usually within 6 months) your cover started.
- Preferred Providers – Healthcare providers with agreements for better value.
- Premium – The amount you pay for insurance.
- Private Health Insurance Rebate – Government contribution that reduces premiums.
- Private Patient – A person using private cover in hospital.
- Product Disclosure Statement (PDS) – Official document explaining your policy detail, this can also be called Fund Rules, Member Guides and or Fact Sheets.
- Rebate – Government Discount.
- Remaining Limits – the number of benefits left.
- Restrictions (or Restricted Cover) – Limited cover for some services.
- Suspension (Policy Hold) – Temporary pause of your policy.
- Tier (Basic, Bronze, Silver, Gold) – Government categories for hospital cover. Understanding these terms can help you compare policies, manage costs, and choose cover with confidence.
- Utilisation – How much of your insurance you have used.
- Waiting Period – Time before you can claim benefits.