Confused about a health insurance term? One of the things we aim for is to cut out the confusion and use less jargon. Sometimes it's a bit unavoidable, if it's a government term, or if there's no other way to describe it.
We've put together a glossary of terms to help out in those cases.
Access Gap Cover
Our initiative to help policyholders minimise, or in some cases, eliminate out of pocket expenses for inpatient medical services at a hospital or day surgery.
We refer to accommodation in two ways. Accommodation in a hospital refers to meals and a bed, and the associated hospital provided services such as nursing care. It does not include treatment by doctors or other health professionals. s such as nursing care. It does not include treatment by doctors or other health professionals.
We also refer to accommodation when we’re talking about our subsidised facilities in Brisbane or Townsville, available to Members who need to travel to these cities for their medical care.
A type of alternative medicine that treats the patient by inserting and manipulating fine needles into specific points on the body, with the aim of relieving pain and for therapeutic purposes.
A dependant over the age of 21, who is still living at home and dependent on their parents. Up to the age of 21, all children are included on the policy at no extra charge. From the ages of 21-25, an adult can remain on the policy at no extra charge if they’re a full-time student or apprentice on a low income and are not married or in a de facto relationship.
If they are not studying full-time or an apprentice, we still provide cover under our “Extended Family” cover. The premium is higher than standard family cover, but it can be more cost effective than if they were to take out cover of their own at the same level.
Most commonly referred to as “Extras cover”, ancillary covers you for services such as optical, dental and physiotherapy that are not subsidised by Medicare. Extras cover can be packaged with hospital cover.
The maximum amount of benefits that can be paid to a Member in their Membership Year.
Assisted reproductive services
Services such as IVF.
Treatment for hearing loss and the proactive prevention of hearing damage by an approved audiologist.
Australian Government Rebate on private health insurance
The Australian Government Rebate on private health insurance provides a financial incentive to assist Australians in affording private health cover. Rebate eligibility is based on a Member/s age and assessable income* and will be indexed by CPI (Consumer Price Index) each year. The rebate is available for Australian residents that hold a green or blue Medicare card, and is applicable on both hospital and extras products.
You can choose to claim the rebate automatically through reduced premiums, or claim it back on completion of your annual tax return.
The amount we’ll pay towards services received by an approved provider.
Cardiac and cardiac related services
Cardiac means the heart.
Involves the removal of the “opaque” natural lens of the eye (the cataract), and replaces it with an artificial transparent lens to restore the individual’s sight. Cataract surgery is usually performed by an ophthalmologist (an eye surgeon) in a hospital using local anaesthetic.
A claim is your request for a benefit to be paid on a service received by an approved provider. You can claim on-the-spot through the HICAPS or CSC HealthPoint electronic claims systems, to pay a reduced amount on that service, or claim through our mobile app, online claiming or by dowloading a claim form to submit via email or post.
We’ll rebate (pay) your benefit directly to your nominated financial institution account within 3-5 business days of receipt of your claim.
Cooling off period
A period of 30 days from the commencement date of your new policy or upgrade of cover. If you change your mind and haven’t made any claims, you can cancel your membership and receive a full refund of any premiums paid.
Cosmetic surgery is elective surgery concerned with correction or restoration to parts of the body for the purposes of enhancing the appearance. Cosmetic surgery includes but is not limited to services such as breast augmentation, rhinoplasty, facelifts, liposuction, tummy tuck, filler injections etc., that does not attract a Medicare benefit.
Two people in a marriage or de facto relationship, covered by one policy.
A private hospital or facility where patients are admitted, treated and discharged on the same day.
A dependant is a person that is reliant on a primary member, including a partner and children, stepchildren or legally adopted children under the age of 21, unmarried and not in a de facto relationship.
An adult dependant, aged 21-25, may also be classed as a dependant if they are a full-time student or apprentice on a low income and are covered by their parents policy. Adult children who are not full-time students or apprentices and who are unmarried and not in a de facto relationship can also be classed as dependants and covered by Extended Family cover, which attracts a higher premium.
Dental services including examinations, consultations and x-rays.
Dieticians provide advice on food and nutrition, to promote good health and proper eating. Dieticians play an important role in educating individuals and groups on good nutritional habits.
Elective surgery is the surgical treatment of a condition that a doctor does not consider as requiring immediate treatment.
Electronic claiming allows you to claim on-the-spot for extras services using your Queensland Country Membership Card and the HICAPS or CSC HealthPoint systems. Your benefit will be deducted immediately from your service fee, and you’ll only have to pay any additional out-of-pocket expenses, if there are any.
Dental services including root canal therapy and root fillings.
An excess is the amount you agree to pay before a hospital benefit is paid by Queensland Country Health Fund, just like any insurance policy. You can choose your level of excess from a $250 or $500 excess on Top Hopsital or Intermediate Hospital cover options. The higher your level of excess, the lower your premium will be, as you agree to pay a larger sum towards your hospital costs.
At Queensland Country, the maximum excess that applies per person within any one Membership Year is $250 or $500, depending on the chosen excess option. If the excess contribution on your first visit is less than your chosen excess option, if admitted to hospital again in the same Membership Year you will be required to pay the remainder of your excess obligation.
Conditions or services that are not covered by your health insurance policy, meaning we won’t pay a benefit towards these services.
Extras is a commonly used term to describe ancillary health services such as dental, optical, chiropractics and physio treatment.
A family unit, consisting of one or two adults and dependant children, all included under the one policy.
Foot inserts designed to help support the feet, improve foot posture and correct imbalances. A podiatrist can help make and fit foot orthoses. Also known as orthotic devices or orthotics.
Other providers that can assist with the provision of these servcies include an Orthotist or Prosthetist and other allied health professionals dependant on your level of cover. Check your benefit availability before visiting the provider.
Healthy Living benefit
Healthy Living benefits are included as part of our Extras options, to encourage our Members to stay healthy. Healthy Living benefits are payable on services such as quit smoking programs, skin cancer mole mapping, yoga, weight management and more.
The Health Industry Claims and Payments Service (HICAPS) is an electronic claiming service, which allows customers to make claims at the time they receive their medical service. Members simply need to swipe their membership card to claim electronically and receive their benefit on the spot as a reduction in their fees.
A form of alternative medicine that aims to stimulate the body’s own healing response to disease using highly diluted preparations.
Hospital cover policies help cover the cost of in-hospital treatment by your doctor and hospital costs such as accommodation and theatre fees.
A person who has been admitted to an approved hospital or day surgery facility and discharged following treatment.
Lifetime health cover loading
Lifetime Health Cover (LHC) is a Federal Government initiative designed to reward people for taking out private health insurance at a younger age and keeping it, by securing lower premium payments.
Under LHC, if you’re aged over 30 and don’t have hospital cover, for each year you delay joining, you’ll pay an additional loading on your membership fees. This means, for every year you are aged over 30 and don’t have hospital cover, you’ll pay an additional 2% loading on the base rate, up to a maximum of 70%.
Limits are the number of times you can claim on a particular service, or a set dollar value of claims that you can make each Membership Year. Limits apply to Extras cover and to Mechanical Aids and Appliances covered by hospital cover.
Any significant dental service, such as a tooth extraction.
Massage therapy involves healing by working with the soft tissues of the body, to improve the functioning of joints and muscles and promoting circulation. Benefits are paid for remedial massage, Bowen therapy and myotherapy.
Mechanical aids and appliances
Mechanical aids and appliances include products such as blood pressure monitors, glucometers, tens machines, crutches, walking frames, or wigs. Some restrictions, including benefit limits and hire only conditions apply to certain mechanical appliances or artificial aids. Mechanical aids and appliances are covered under Top Hospital products only. Contact us for more information before purchasing an aid or appliance.
The Medical Gap is the 25% gap between the 75% Medicare rebate and the Medicare Benefits Schedule fee for inpatient services. If your doctor doesn’t participate in the Access Gap program, Queensland Country will only cover the medical gap.
Treatment that is deemed necessary by a medical practitioner.
Medicare benefits schedule
The Medicare Benefits Schedule (MBS) is the schedule of fees set by the government for standard medical services. Whether you have private health insurance or are a patient paying for all your own costs, the government provides a rebate on nearly all medical fees. The rebate is currently 75% of the MBS for in-hospital medical fees and 85% of the MBS fee for specialist medical fees incurred out of hospital.
Medicare levy surcharge
An additional 1-1.5% surcharge levied on high income earners in Australia who don’t have private hospital cover. The surcharge is calculated on taxable income and is on top of the standard 1.5% Medicare Levy paid by all Australian taxpayers.
A Member means a person covered by a health insurance policy who pays contributions or on whose behalf contributions are paid.
A period of 12 months in which the member makes contributions, commencing from the anniversary of your joining date.
Naturopathy is a type of alternative medicine that uses treatments like nutrition, dietetics etc. for a non-invasive approach to the treatment of symptoms of illness.
The management of pregnancy, labour and delivery and the care associated with the birth of the child, provided in hospital.
The treatment or rehabilitation of individuals suffering physical or emotional disabilities.
Dental services specialising in the diagnosis, prevention and treatment of problems in the alignment of teeth and jaws.
A form of manual medicine which recognises the link between the structure of the body and the way it functions, using hands-on techniques to identify types of dysfunction in the body.
Out-of-pocket expenses are the additional costs once all Medicare and private health insurance benefits have been expended. Usually, out-of-pocket expenses apply when you’re not fully covered for a particular treatment or service, or when a set benefit limit applies.
A patient who has received medical treatment in a doctor’s surgery or casualty department and has not been admitted into hospital.
Specialised gum treatment.
Pharmaceutical Benefits Scheme (PBS)
The Pharmaceutical Benefits Scheme provides a Government subsidy to reduce the price of some prescription medicines
The Private Health Insurance Administration Council (PHIAC) is an independent Statutory Authority that regulates the private health insurance industry.
The Private Health Insurance Ombudsman provides an independent service to help consumers with health insurance problems and enquiries. The Ombudsman deals with complaints from health fund members, health funds, private hospitals or medical practitioners
Medically necessary surgery to correct functional impairments resulting from injury.
Treatment of the foot, ankle or lower leg by a qualified podiatrist.
A Queensland Country Health Fund health insurance cover arrangement. A policy may include cover for hospital, extras or a combination thereof.
The policyholder is a holder of a policy that is referable to the fund.
The ability to transfer between registered health funds, without the need to re-serve waiting periods.
A pre-existing ailment, illness or condition is one where signs or symptoms of the condition were present at any time during the six months prior to applying for membership of Queensland Country Health Fund or an upgrade of cover, determined by a Queensland Country-appointed medical practitioner. You may have a pre-existing condition, ailment or illness without even being aware of it.
Dental services such as cleaning and scaling, fluoride treatment, oral hygiene instruction and mouth guards.
A prosthesis is a surgically implanted medical device or artificial body part, like hip and knee joints and heart pacemakers. There will always be a prosthesis type that is covered by your hospital cover if your surgery requires the implantation of a prosthesis. However, other types of prostheses may cost more than the standard "no gap" item, in which case you will need to pay the additional costs.
Dental services relating to dentures etc.
A recognised provider is a practitioner that is registered by a state registry body, if existing for that particular modality, or otherwise a practitioner accredited to practice privately with an accreditation or practitioners’ body nominated or to be nominated in these Rules.
A “Recognised practitioner” does not mean a practitioner that is “recognised” solely by Queensland Country Health Fund for the purpose of only paying benefits for that practitioner’s services.
Dental services such as composite and amalgam fillings.
Under a restricted service, you will only be covered for your choice of doctor for shared ward accommodation in a public hospital. Undergoing treatment in a private hospital for a restricted service is likely to result in large out-of-pocket expenses.
Standard tooth removal provided by a qualified dentist.
An individual policyholder.
Standard Information Statements
Standard information Statements (SIS) are available on all private health insurance policies in Australia and can be found on the website www.privatehealth.gov.au.
Health Funds are required by law to provide a copy of these statements to their Members every 12 months to allow you to review your existing policy or compare private health insurance products (e.g. to see where products differ in price and features).
Surgical removal of teeth, such as wisdom teeth removal or removal of impacted teeth, by a qualified dentist or surgeon.
High income earners are required to pay a Medicare Levy Surcharge of 1%-1.5% if they do not have private health insurance. For individuals, couples or families earning over the threshold, having private health insurance means they will avoid this surcharge, which may cost more than your private health insurance premiums.
The costs for performing a procedure in an operating room, including those performed at a day surgery facility.
A document transferred between registered health funds, which provides the details of the Member’s history at their previous fund, including the Certified Age of Entry (CAE), financial status and claims history.
A transfer certificate is required before a Member is eligible to claim on services from Queensland Country Health Fund.
A waiting period is the length of time you need to wait after taking out your health cover, before you are able to receive benefits for services or items covered. Members transferring to an equivalent level of cover from other recognised Australian health funds will not need to re-serve waiting periods unless a service or item was not covered under the previous cover.