Access Gap Cover (AGC) is a billing scheme that aims to reduce or eliminate out-of-pocket expenses to members for doctor and specialist services received in hospital. Doctors may choose to participate in AGC on a patient-by-patient basis, so you should discuss this with your doctor.
Accident means an injury to the body inflicted as a result of unintentional, unexpected actions or events caused by an external force or object, which occurred in Australia and after joining the Fund that requires, within 7 days of the accident, in-patient hospital treatment by a recognised medical practitioner, health care provider or dentist, but excludes pregnancy. Benefits are payable for the initial in-patient hospital treatment for injuries resulting from the accident, as well as ongoing in-patient hospital treatment where the services are provided within 180 days of the date of the accident and which form part of the initial course of treatment covered by the Fund.
Accommodation means accommodation charges for in-patient services in hospital. This covers meals and a bed in hospital, and includes hospital provided services including nursing care. It does not include treatment by doctors and other health professionals.
Agreement private hospital means a hospital with which Nurses & Midwives Health has an agreement regarding accommodation, theatre fees and other hospital charges.
Australian Government Rebate on private health insurance or Rebate means the incentive rebate offered by the Federal Government to reduce Premiums of private health insurers to encourage permanent residents in Australia to take out private health insurance. The rebate applies to both Hospital and Extras cover.
Bariatric surgery (weight-loss surgery) includes a variety of procedures performed on people who are obese including gastric banding.
Benefit means a benefit payable under the Nurses & Midwives Health Rules and includes access to service to be provided directly to the insured member in lieu of a payment.
Boarder fees means the fee charged by a hospital for the accommodation of an individual assisting with the care of a member who is undergoing in-patient treatment, for example a parent staying with a child who is in hospital.
Certified age of entry (CAE) is the age a person is assigned when first purchasing Hospital cover, as relevant to Lifetime Health Cover.
Calendar year means the time from 1 January to 31 December inclusive, in a given year.
Clearance certificate is a certificate issued by a fund when a member terminates a policy or wishes to transfer to another fund.
It is a record of your private health insurance cover including details about:
- Type of cover
- Level of cover
- Join and cancellation dates
- Waiting periods served
- Certified age of entry (CAE)
- A history of recent claims
Continuity refers to the transfer of waiting periods between policies, including internal transfers between products and between funds.
Cosmetic surgery means surgical procedures that are listed in the Plastic and Reconstructive Section of the Medicare Benefits Schedule (MBS) that do not meet the eligibility conditions for the payment of Medicare benefits, or surgical procedures of a plastic or reconstructive nature that are not listed in the MBS.
Dependant child means a child, adopted child, stepchild or foster child who is under the age of 21, does not have a partner and is dependent on the relevant primary member or the partner of the primary member; or is a student dependant of a primary member or of the partner of a primary member.
Emergency ambulance means an ambulance service that consists of transporting a seriously ill person to a hospital by a state government ambulance service or by a private ambulance service recognised by Nurses & Midwives Health in order to receive urgently needed treatment. This includes transportation from the scene of an accident or the scene of a medical event such as a heart attack or stroke, but does not include transportation to hospital for the routine management of an ongoing medical condition or transportation between hospitals.
Excess means an amount of a benefit that a policy holder agrees to forgo, in return for a lower premium.
Excluded service If a service is listed as Excluded on your hospital cover, we pay no benefits towards it. If you have the service, you’ll need to pay all costs.
Extended Family Cover (EFC) means a policy that covers the primary member, their partner and the dependant children of the primary member, of which at least one person is a dependant aged between 21-25 and not a student dependant.
Extended Family Cover – Single Parent means a policy that covers the primary member and the dependant children of the primary member, of which at least one person is a dependant aged between 21-25 and not a student dependant.
Gap means the difference between what a doctor charges and what Medicare and the Fund (combined) will pay for an inpatient service.
HICAPS means Health Industry Claims and Payment Service which is an EFTPOS type service used at the point of sale/services that allows Nurses & Midwives Health members to claim benefits with the Nurses & Midwives Health member card. Only available for some services, and where the provider has access to the HICAPS system.
Hospital means a facility registered under relevant state or territory legislation and issued with a commonwealth provider number, includes: same day hospitals, private hospitals, or public hospitals, or any other premises declared by the Minister to be a hospital. These may include, but are not limited to, facilities that are not in a normal hospital environment, such as ‘hospital in the home’ arrangements.
Hospital pharmaceuticals means any drug or medicine listed in the PBS that is dispensed to a hospital patient and is part of the episode of care the hospital treatment provided.
Informed financial consent means the procedures that hospitals and doctors have in place to inform a patient, in writing, of the hospitals and doctors charges, health fund benefits and out-of-pocket costs (where applicable) that exist in respect of medical and hospital treatment.
Inpatient means a person who has been admitted to hospital.
Lifetime Health Cover (LHC) means a Federal government initiative; a policy that applies to everyone born after 1 July 1935, that sets a premium rating for life when an adult first takes out private health insurance. For each year an adult remains uninsured after the age of 31, there is a penalty increase of 2% on top of the general premium. Applies to hospital cover only; does not apply to extras cover.
Lifetime limit means benefits paid under categories with a lifetime limit will take into account any amount already paid for that type of service, including under other policies with other funds. The total benefit paid will not exceed the limit claimable under the current policy.
Medical practitioner means a person registered or licensed as a medical practitioner under a law of a state that provides for the registration or licensing of medical practitioners but does not include a person so registered or licensed:
- whose registration, or licence to practise, as a medical practitioner in any state has been suspended, or cancelled, following an inquiry relating to his or her conduct; and
- who has not, after that suspension or cancellation, again been authorised to register or practise as a medical practitioner in that state.
Medicare Benefits Schedule (MBS) or Schedule Fee is a list of services for which Medicare pays a benefit and the rules that apply to the payment of those benefits. Each service has a fee that has been set by the Federal Government for the purpose of calculating the Medicare benefit payable for that service.
Medicare safety net provides families and individuals with financial assistance for high out-of-pocket costs for out-of-hospital Medicare Benefits Schedule (MBS) services. Once you meet a Medicare safety net threshold, you may be eligible for additional Medicare benefits for out-of-hospital MBS services for the rest of the calendar year.
Medicare levy surcharge (MLS) (MLS) means a tax paid over and above the 2.0% levy all taxpayers are charged. It applies to singles without a level of hospital cover that exempts them from the levy and who earn over $90,000. MLS also applies to couples earning a combined income over $180,000 (increases by $1,500 for each child after the first) who do not have a level of hospital cover that exempts them from the levy. (All Nurses & Midwives Health hospital products will exempt those covered by a policy from the MLS.)
Members or insured persons means all people covered by a policy, including the policy holder, spouse, dependant children and student dependants.
Non-emergency ambulance includes all ambulance services provided by a state government ambulance service or a private ambulance service recognised by Nurses & Midwives Health, other than those defined under emergency ambulance transport and not including inter-hospital transfers. Examples of services payable include:
- call out or attendance fee where no transport occurs;
- admission or discharge between hospital and home where transport is deemed medically necessary.
Medically necessary transport is transport where the patient requires stretcher transport, is not able to travel in a normal seated position or has impaired cognitive function, and patient requires active management or monitoring while in transit.
Non-emergency ambulance transport deemed medically necessary must be supported by a letter from the treating doctor explaining the medical requirement for ambulance transport.
Outpatient means a patient who undergoes minor surgery or medical treatment in a same day hospital facility, private hospital or dental clinic, but is not formally admitted as an in-patient.
Per admission means a period where a member is admitted to hospital for treatment as an in-patient.
Pharmaceuticals means a substance which:
- has been prescribed by a medical practitioner or a dentist; and
- has been supplied by a pharmacist in private practice or a medical practitioner; and
- can only be supplied on prescription under applicable state law; but does not include substance which:
a. is available under the Pharmaceutical Benefits Scheme in any formulation, presentation, strength, pack size with or without repeat dispensing or combination of the preceding regardless of whether of such availability is subject to the specified purpose, authority required, pensioner concession or special patient contribution conditions of that scheme; or
b. was prescribed in the absence of illness or disease or for enhancement of sporting or employment performance.
Pharmaceutical Benefits Scheme (PBS) gives all Australian residents and eligible overseas visitors access to prescription medicine in a way that is affordable, reliable and timely. Through the PBS, the Australian government subsidises the cost of prescription medicine.
Policy means rules, conditions and benefits relating to or provided by or under any product of Nurses & Midwives Health.
Policy holder means the person in whose name the membership is held and who is responsible for the payment of premiums.
Portability is the term used to describe entitlements for policy holders to transfer from one health fund to another without the imposition of new waiting periods, or with reduced waiting periods where the waiting period has been served in part; does not necessarily include additional benefits available due to years of service.
Pre-existing condition is an illness, ailment or condition where the signs or symptoms of which, in the opinion of the Fund Medical Advisor or other relevant medical practitioner appointed by Nurses & Midwives Health, existed at any time during the six months before taking out private health insurance or transferring to a higher level of cover. This rule applies to new members to private health insurance and existing members who are upgrading their level of cover.
Pregnancy and birth-related services means any type of treatment related to the management of a pregnancy by a certified medical practitioner, including but not limited to management of labour and delivery and complications arising from the condition of being pregnant.
Private Health Information Statement (PHIS) is an industry-wide standard format summary for your policy, replacing the Standard Information Statement (SIS). PHIS help you compare or review your policy with other policies from any health insurer in Australia.
Private Health Insurance Ombudsman (PHIO) is an independent and free service for consumers with private health insurance problems, enquiries and complaints.
Private hospital means:
- a hospital that is approved as such under a law of the Commonwealth, or of a State or Territory, or
- any other hospital recognised by Nurses & Midwives Health as a private hospital for the purpose of paying benefits.
Private patient means an inpatient who is not a public patient.
Public hospital means a hospital that is operated by a Australian state or territory government.
Public patient or Medicare patient means an in-patient of a public hospital who receives treatment without charge.
Recognised provider is a qualified person who provides services that are eligible for benefits, recognised by Nurses & Midwives Health in a particular discipline, modality or calling as a provider for whose services, provided to an eligible member with cover for the provider’s services.
Restricted service When a hospital service is classed as Restricted, we pay limited benefits.
In a public hospital:
- We pay - accommodation in a shared room up to the default rate set out by the Federal Government, and medical costs.
- You pay - any excess (if applicable), and any gap if your hospital charges above the default rate.
In a private hospital:
- We pay – accommodation in a shared room up to the default rate set out by the Federal Government, and medical costs.
- You pay – any excess (if applicable) and the balance of accommodation costs, plus any theatre costs. This could be costly, so ensure the hospital provides you with the potential costs upfront.
Savings provision entitlement (SPE) as it relates to the Australian government rebate on private health insurance: a provision to ensure that people remaining on a policy do not have their rebate reduced when an eligible person leaves the policy under certain circumstances.
Single Parent Family membership means a membership that includes two or more members with all but one of them being dependant children of the other member.
Spouse of a person means the spouse recognised by law of that person and also includes a same sex partner or de facto spouse.
Standard information statement (SIS) is a summary for your policy, in an industry-wide format. SIS’s will be replaced between 2019 and 2020 (depending on the health fund) by Private Health Information Statements (PHIS). Teachers Health moved to PHIS in 2019. View Teachers Health PHIS’s here (link to privatehealth.gov.au).
Student dependant means a child, stepchild or foster child of the relevant primary member or the partner of that primary member, registered with Nurses & Midwives Health, who:
- does not have a partner;
- and is between 21 and 25 years of age (both inclusive);
and is either:
- a full-time student at a school, college, TAFE or university; or
- a registered apprentice or trainee.
Transfer generally means the transfer of a policy holder or dependents from another health fund to Nurses & Midwives Health, or the change to another membership within Nurses & Midwives Health.