Private Patients' Hospital Charter (Cth)

ISBN 0 642 82761 3
Online ISBN:  0 642 82883 0
Publications Approval Number: 3723

Print Copyright
© Commonwealth of Australia 2006  
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney General’s Department, Robert Garran Offices, National Circuit, Canberra ACT 2600 or posted at Copyright
© Commonwealth of Australia 2006
This work is copyright. Your may download, display, print and reproduce this material in unaltered form only (retaining notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to Commonwealth Copyright Administration, Attorney General’s Department, Robert Garran Offices, National Circuit, Canberra ACT 2600 or posted at JANE HALTON, Secretary of the Australian Government Department of Health and Ageing,
issue the following statement, called the Private Patients’ Hospital Charter, under section 73F
of the National Health Act1953. This statement revokes all previous statements issued under
section 73F of the National Health Act1953.





JANE HALTON
Secretary
Department of Health and Ageing

Dated: 14.4.2006

Contents   Purpose of the Private Patients’ Hospital Charter	2
Planning your hospital health care	3
Private health insurance	5
What you can expect from your doctor(s) and hospital	12
What you can expect from your health fund	16
How to make a complaint	18
Contacts for complaints and further information	19
Glossary	23

The Private Patients’ Hospital Charter is a free guide to what it means to be a private patient in a public hospital, a private hospital or a day hospital facility. It also sets out what you can expect from:

?  the doctor(s) providing your treatment

?  the hospital in which you receive your treatment

?  your health insurance fund.

The Charter also provides information about
what to do if you have a problem with your medical treatment or your private health insurance. A poster and a flyer with information about the Charter are also available.

The Charter is available on the Internet at
copies
(booklet, poster and flyer)

Free copies of this booklet, the flyer and
poster are available from the Department
of Health and Ageing by e-mailing [email protected] or telephoning
[phone] (24-hour answering machine).

Community languages

Some information about the Charter is also available in other languages on the Department
of Health and Ageing web site at patient or private patient?

One of the first steps in planning for your care in hospital is to decide whether you wish to be treated as a public patient or a private patient.

What does it mean to be a public patient?

Under Medicare, Australian residents and ‘eligible persons’ from countries with reciprocal health care agreements who choose to be admitted as a public patient are entitled to free treatment in a public hospital, including free accommodation, doctor(s) services, diagnostic tests and medications (but excluding personal expenses such as TV hire or telephone calls). A public patient is treated by a doctor(s) appointed by the hospital.

What does it mean to be a private patient?

A private patient can either be self-funded (that is, pays all the costs except those medical costs covered by Medicare) or have private health insurance. Depending on your circumstances,
 if you choose to be a private patient you may attend a public hospital or a private hospital or
a private day hospital facility.

A private patient in a public hospital

Being a private patient in a public hospital gives you a choice of doctor(s). Depending on your illness or condition and your needs, this may or may not be the same doctor(s) who would have been allocated to you by the hospital as a public patient.

As a private patient in a public hospital, you may be charged for a range of services which could include:

?  hospital accommodation

?  doctor(s) services (including diagnostic tests)

?  surgically implanted prostheses
(e.g. artificial hips)

?  personal expenses such as TV hire and telephone calls.

The hospital and the treating doctor(s) should, where possible, advise you about the services for which you will be billed.

A private patient in a private hospital

Depending on the circumstances, being a private patient in a private hospital or a private day hospital facility allows you to choose the doctor(s) who treats you at a time that suits you. This is provided your doctor(s) has an arrangement with that hospital to treat private patients and that the hospital you have chosen has beds and has available the services you will need.

As a private patient in a private hospital, you
may be charged for a range of services which could include:

?  care in intensive/critical care units

?  doctor(s) services (including diagnostic tests)

?  operating theatre fees

?  allied health services (eg. physiotherapy)

?  dressings, medications/drugs, other consumables

?  surgically implanted prostheses
(eg. artificial hips)

?  personal expenses such as TV hire
and telephone calls.

The hospital and the treating doctor(s) should, where possible, advise you about the services
for which you will be billed.

Types of health insurance cover

You may purchase private health insurance to cover all or some of your health care costs as a private patient in either a public hospital or a private hospital or a private day hospital facility.

There are two types of private health insurance cover available:

?  hospital cover

?  ancillary (or extras) cover.

Hospital cover helps with the cost of medical treatment such as hospital accommodation and your doctor(s) charges for admitted hospital services. This applies when you are a private patient in a public hospital or a private hospital or a private day hospital facility.

Ancillary cover (also known as extras cover) helps with the cost of services that occur both in and out of hospital and which are not covered by Medicare such as physiotherapy, dental treatment and optical appliances. Some funds offer packaged products that cover both hospital and ancillary services.

Generally, the more extensive the health insurance cover, the higher the price (premium). When choosing your private health insurance, it is important to make sure it suits your particular needs, as well as your budget. Health funds should provide you with the information you need to make an informed choice about the private health insurance cover that is appropriate for you.

You should regularly check your cover to make sure it meets your needs.

What costs does your private
health insurance cover?

As a private patient with private health insurance, all your hospital and medical bills may be covered by your insurance, or you may have to pay an amount out of your own pocket. The amount you will have to pay, if anything, depends on your type and level of cover. It also depends on whether your health fund, doctor(s) and/or hospital have a ‘gap agreement’ or ‘gap cover scheme’ in place (see Glossary).

Gap agreements and gap cover schemes are explained in more detail below under Medical Costs.

Medical costs

When you receive medical treatment in hospital as a private patient, Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee for the service of the doctor(s) who treat you in hospital and your health fund pays the remaining 25% of the MBS fee, provided you have hospital cover.

If your doctor(s) charges above the MBS fee, your health fund may be able to cover this gap if:

?  there is a gap agreement between your fund, hospital and/or doctor(s); or

?  the fund has a gap cover scheme.

When there is a gap agreement or gap cover scheme, you will either have no out-of-pocket expenses or you will be provided with details of your out-of-pocket expenses.

All funds offer gap benefits under agreements
or schemes. In most cases these benefits have been added to existing policies - so you may already be covered for all or part of the gap.

You should contact your fund to find out if it offers gap benefits under your policy - if it does not, you might consider transferring to another policy or health fund which does provide such benefits. 

Before you change health funds make sure you are aware what you will be entitled to, including if any waiting periods apply.

To ensure you know all the expected costs involved before agreeing to be admitted to hospital for treatment you should, if circumstances permit, speak to your doctor(s) about their
fees and those for associated specialists.
You should also ask your doctor(s) whether
he or she participates in your fund’s gap agreement or scheme. You can also talk to your fund about whether your doctor(s) participates
in the fund’s agreement or scheme. This will
help to ensure you don’t receive any unexpected bills after your treatment.

In certain circumstances, you may be referred by your general practitioner to a specialist who has a private practice in rooms at a public hospital or a private hospital. If this happens, you are not an admitted patient of the hospital and will only receive 85% of the MBS fee from Medicare. In this situation you will not be able to claim any amount from your health fund. This is because the law does not permit health funds, if there is a Medicare benefit payable, to provide any benefits for medical treatment provided outside hospital (that is when you are not admitted to hospital).

You are entitled to and should always ask your doctor(s) for an estimate in advance of the costs of your treatment, whether or not a gap agreement or gap cover scheme applies.

Hospital costs

The benefits paid by your health fund for hospital services will depend on the type of cover you purchase. It will also depend on whether your fund has an agreement in place with the hospital in which you choose to be treated. When there is an agreement you will have either no out-of-pocket expenses or you will be provided with details of your out-of-pocket expenses.

You are entitled to and should always ask your hospital or health fund for an estimate in advance of the costs of your treatment.

Emergency department treatment

If you go to an emergency department of a private hospital, you are not an admitted patient of the hospital.  You will only be admitted to hospital if you are transferred to a hospital ward.

Health funds do not cover the medical fees and charges for services provided in private hospital emergency departments. Fees for private hospital emergency departments are covered by Medicare as services to non-admitted patients at 85% or 100%  of the MBS fee depending on whether you are treated by a specialist or a general practitioner.  If tests are required in the emergency department (e.g. blood tests or x-rays), the gap between the MBS fee and the amount charged cannot be covered by your health fund.

Many private hospitals charge a facility fee for attendance at their emergency department to
help off-set the cost of establishing and running this high cost facility. If you have ancillary cover, your health fund may provide benefits covering
a facility fee.

In an emergency, it is very unlikely there will be enough time to provide you with an estimate of out-of-pocket expenses prior to your admission. However, you should be advised of these costs as soon as you are well enough.

Having a baby in hospital

When you have a baby in a private hospital as a private patient you are an admitted patient of the hospital but generally your newborn baby is not an admitted patient. The newborn (who is nine days old or less) will only be an admitted patient of the hospital if the baby:

?  is admitted to an Australian Government approved neonatal intensive care unit; or

?  is the second or subsequent baby born
in a multiple birth; or

?  is in hospital without their mother.

If your baby is not an admitted patient of the hospital and you, for example, elect to have your baby seen by a paediatric specialist, Medicare pays the first 85% of the MBS fee and you must meet all costs not covered by Medicare.

You should check with your hospital and health fund to determine the health insurance status of your baby. The hospital and treating doctor(s) should advise you about the services for which you will be billed.

Long-stay patients

If your hospital stay is longer than 35 days and your doctor(s) considers that you no longer need acute care (that is care for a short term illness or health problem), you will need to pay a contribution to your living costs in much the same way as nursing home residents contribute to the cost of their care. The patient contribution is payable by both public hospital patients and private hospital patients and cannot be reimbursed by your health fund.

However, if your doctor considers that you still need acute care, they will complete a certificate and you will not be required to pay a contribution to your living costs.

If you would like more information about the arrangements for long-stay patients, please talk
to your hospital or health fund.

Waiting periods

When you take out private health insurance or upgrade your existing hospital cover, you may have to wait before you can claim for some services. The maximum waiting periods allowed under legislation are:

?  12 months for pre-existing ailments, and ailments, illnesses or conditions relating to
an obstetric condition

?  2 months for all other ailments, illnesses or conditions.

Health funds can waive or reduce these waiting periods but they cannot increase them. Check with your health fund before you are admitted
to hospital.

Waiting periods for ancillary services may vary between products and health funds. You should check the waiting periods on ancillary services carefully when choosing your health insurance fund and product.

Pre-existing conditions

When you take out private health insurance or upgrade your existing hospital cover, you may have to wait up to 12 months before you can claim benefits for hospital treatment for a pre-existing ailment. 

A pre-existing condition is an ailment, illness or condition, the signs or symptoms of which existed at any time during the six months before the day on which you joined or upgraded to a higher level of hospital cover. Whether a condition is ‘pre-existing’ is determined by a doctor appointed by the health fund.

It is unnecessary for a doctor to have diagnosed
the condition, simply that signs and symptoms
were in existence. In making this judgement, however, the fund-appointed practitioner must
take into account the medical evidence presented by your own treating doctor(s).

This means that if you have less than 12 months membership of your current hospital cover and you need hospital treatment, you should confirm with your fund whether or not the pre-existing ailment waiting period applies to you. It is important you do this before you are admitted to hospital if possible.

Funds will need a few days to make this assessment, so contact your fund as soon as you know you have to go to hospital.

Outreach Services

Some hospitals and day hospital facilities are able to provide treatment outside hospital (such as in the patient’s home) where the hospital or day hospital facility has an approved outreach service. Treatment provided through an outreach service is a direct substitute for the treatment that would have been provided to the patient in the hospital or day hospital facility.

If you receive treatment through an outreach service, you are an admitted patient of the

hospital or day hospital facility, even though your treatment is being provided elsewhere. You will be under the care of the hospital or day hospital facility and your treatment will be provided by the same doctor(s) and nursing staff who would have treated you if you had been in the hospital or day hospital facility.

If you have hospital cover, your private health insurance will cover some or all of the costs of
the treatment you receive.

Your hospital or day hospital facility will be
able to advise whether it has an approved outreach service.

Confirm your level of health
insurance cover

As soon as you know that you will need hospital treatment, you should if you can: 

?  ask your health fund about your level of
hospital cover to make sure your private
health insurance does not exclude the procedure you need

?  ask your health fund whether waiting periods apply to your cover. If you purchased or upgraded your hospital cover in the past
12 months, be aware that there is a 12 month waiting period on payment of hospital
benefits for any pre-existing ailments and obstetric conditions

?  ask your doctor(s) whether they are participating in your health fund’s gap agreement or scheme

?  ask your hospital, doctor(s) or fund for an estimate of your admitted hospital medical costs not covered by Medicare or your private health insurance

?  ask your doctor(s) or fund if you will need to make any additional payments for surgically implanted prostheses you may require.

Make sure you allow a few days for the hospital, health fund and doctor(s) to reply.

Choice of being a public patient or
a private patient in a public hospital
You can expect to be asked before or on admission to a public hospital whether you wish to be treated as a private patient or a public patient. You can choose to be admitted to hospital as a public patient even if you have health insurance.

You will be asked to sign a Patient Election Form, which will record your choice. This form should provide a clear and unambiguous explanation of the consequences of your choice. If you are unable to make a choice at the time of admission, you will be asked to make a choice as soon as you or your legal guardian is able to do so.
You will be treated as a public patient until you make a choice.

Note: If you choose to be a private patient, you may not be able to change to be a public patient unless there are unforeseen circumstances such as complications requiring additional procedures or an extension of your length of stay.

Obtaining your consent to the treatment
Your doctor(s) should give you a clear explanation of your diagnosis, your treatment and other treatment options available. You should be told that you are able to withdraw from treatment at any stage (with some exceptions).  You should also be advised about what each doctor involved in your treatment charges.

In an emergency, where it is not possible to obtain your consent, you will receive treatment.

If you do not understand English, you should ask for an interpreter.

Advice about seeking
other medical opinions

You can ask for referrals for other medical opinions. There will most likely be additional
costs associated with doing this that may
not be covered by Medicare or your private
health insurance.

Visiting rights
You should ask your hospital about visiting rights while you are in hospital. For example, you may wish to ask about:

?  facilities for visitors

?  rights of family access

?  who is considered family

?  arrangements for the parents if the patient
is a child.

Advice about the likely costs

If your health fund has a gap agreement or a gap cover scheme with your doctor(s) and/or hospital, the law requires that you are provided with the following information before you are admitted:

?  the doctor(s) fees relating to your treatment (for a gap cover scheme this advice must be in the form of a written estimate and you must acknowledge receipt of this advice)

?  the amount of any likely out-of-pocket expenses for the services provided by the hospital

?  in the case of gap cover schemes, any
financial interest the doctor(s) involved in
your treatment may have in recommending
any products or services.

Each of the doctors and health care professionals involved in your care may charge a fee.  Doctors and health care professionals may include medical specialists, surgeons, anaesthetists, physiotherapists, pathologists and radiologists.  These fees are additional to the fees the hospital may charge for accommodation and other hospital services.

You are entitled to, and should always ask your doctor(s), hospital and health fund about the expected costs of your treatment, even where no agreement or scheme exists.

If your treatment includes a prosthesis, such as a pacemaker or an artificial knee, your doctor(s) should tell you about any out-of-pocket expenses for that prosthesis.  Your doctor(s) should tell you about the alternatives with no cost and explain which prosthesis is the most clinically suitable for your treatment.

Confidentiality and access
to your medical records
Your personal details will be kept strictly confidential. However, there may be times when information about you needs to be provided
to another health worker to assist in your care,
or if this is required or authorised by law.

Your health fund needs access to certain information to allow payments to be made
for your medical treatment. You will need to
sign a form to agree to this.

Under Freedom of Information (FOI) legislation, you are entitled to see and obtain a copy of your medical records (with some exceptions or limitations) kept in a public hospital. You can
also request that information be corrected if
there are any mistakes.

You can also approach private hospitals and
your doctor(s) to access the medical records they keep about you. The Privacy Act 1988 provides you with a general right under the National Privacy Principles to access personal information collected about you by the private sector.

Treatment with respect and dignity

You can expect to be treated with courtesy
and to have your ethnic, cultural and religious practices and beliefs respected.

You can legally discharge yourself at any time (with some exceptions), even against the advice of your doctor(s) or hospital staff. However,
if you discharge yourself, you must accept the associated risks and sign a form taking responsibility.

You should treat your health care workers and other patients with respect and courtesy. Staff who attend you should always identify themselves.

Care and support from nurses and
allied health professionals
Nurses and allied health professionals (for example physiotherapists) are a very important part of your treatment in hospital. Nurses provide vital care and support for patients, while allied health professionals provide a range of services.

You should feel confident to discuss any issues in relation to your treatment or hospital experience with your nurse(s) or allied health professional(s).

Help doctor(s) and hospital staff provide you with better care

You can help doctor(s) and hospital staff to provide you with better care by:

?  letting your doctor(s) and hospital know about any physical or psychological conditions affecting you, for example any allergies

?  providing your doctor(s) with information such as your medical and family history when required

?  informing your doctor(s) and hospital about any other treatment you are receiving or medication or complementary medicines you are taking even if they are not prescribed by a doctor. You should take your medicines with you when you go to hospital.

Advice about care after discharge

Before you leave hospital you should expect to be consulted about the continuing care that you may need after you leave hospital. This includes being given information about any care and medication you will need after you have been discharged, as well as any costs. For example, after you have been discharged from hospital you may need:

?  medical care

?  medication

?  home nursing or other community services.

You should also be asked whether you need
help with transport home. Some health funds can help patients arrange their care after discharge.

You should actively participate in the planning
of your after-discharge care.

Clear, timely and accurate advice

Your health fund is able to provide you with information about:

?  the types of health insurance cover available, as well as the premiums and benefits of each type of cover, including advice about reviewing your health cover when your needs change

?  your level of cover and the likely out-of-pocket expenses, including any excess (see Glossary) or co-payments (see Glossary) that you may face while you are in hospital

?  your certified age at entry under the Lifetime Health Cover (see Glossary) arrangement and any periods of absence accrued

?  any conditions of the health insurance cover such as waiting periods before benefits are payable, inclusion of newborns, health fund rules regarding pre-existing ailments or illnesses, and treatment not covered by your health insurance.

Funds can only provide advice about definite
out-of-pocket costs when there is a gap cover agreement or scheme in place with the relevant doctor(s) or hospital. Funds should, nevertheless, be able to provide information as to the likely benefit level even in the absence of an agreement or scheme.

You can help your health fund provide you with a better service by:

?  obtaining confirmation of your entitlements in writing from your fund, before going ahead with any treatment or hospitalisation

?  reviewing your health cover regularly so that it continues to meet your needs.

Reassurance

At any time you can:

?  upgrade your cover with the same fund and be advised of any waiting and benefit limitation periods that apply before you are eligible to claim higher benefits

?  transfer from one fund to another without being faced with any additional waiting periods, provided that you are taking out a comparable or lower level of cover with your new fund.

You may have to serve additional waiting periods if you upgrade your level of cover even
if it is with your current fund.

If you have hospital cover, you can transfer between funds at the same or a lower level cover, without serving additional waiting periods. The fund you transfer to must give you credit for any waiting periods already served.

Check your entitlements with your new health fund before transferring.

Advice on how to comment on or
make a complaint about your health
carers or hospital

You are entitled to comment or complain about the services you received in hospital. You should approach the staff caring for you and raise your concerns at the time.

If you have concerns regarding your hospital care under your health insurance cover, your health fund would like to know. You should, however, advise the hospital about your concerns first.

If you would like to make a formal statement about the care you received, you should contact or write to the officer responsible for handling complaints at the hospital where you were treated. You should be advised who the Complaints Officer is within the hospital.

If you would like to make a complaint about your health care or treatment but you are incapacitated, you should be provided with assistance to make the complaint, including the writing down of details about the complaint.

There are a number of complaints bodies listed at the end of this publication that you can approach if you are not satisfied with the manner in which your complaint has been dealt with by the hospital.

Your hospital would also appreciate hearing from you if you have a compliment or a suggestion for improvements.

Advice on how to make a
complaint about your health fund

You are entitled to have a complaint satisfactorily addressed by your health fund when you have concerns about any aspect of the service provided by your health fund. If you have a complaint you should first formally approach your health fund and proceed through their complaints handling process.

If you think your health fund has not dealt with your complaint in a satisfactory manner you can contact the Private Health Insurance Ombudsman (see next page for details).

Private Health Insurance Ombudsman

The Private Health Insurance Ombudsman is an independent national body established to deal with inquiries and complaints about private health insurance arrangements.

Level 7
362 Kent Street
SYDNEY NSW 2000

Phone: [phone]
Fax: [phone]
Toll free: 1800 640 695
Web site: 
E-mail: [email protected] 

The Office of the Federal
Privacy Commissioner

The Office of the Federal Privacy Commissioner is an independent national office established to deal with enquiries and complaints about privacy and the handling of personal information. The Privacy Commissioner is able to deal with complaints on the handling of personal information held in the private sector. If you have a complaint you should raise the complaint with the relevant organisation or individual prior to raising it with the Privacy Commissioner.

GPO Box 5218
SYDNEY NSW 2001

Phone: [phone]
(for the cost of a local call anywhere in Australia)
TTY for hearing impaired: 1800 620 241
Fax: [phone]
E-mail: [email protected] 
Web site:

Health care complaints resolution bodies

State and territory complaints resolution bodies are all independent organisations dealing with complaints about health services (such as hospitals, medical centres and nursing homes) and individual health practitioners (such as doctors, nurses, dentists and counsellors).

NEW SOUTH WALES

Health Care Complaints Commission

Phone: [phone]
Toll free: 1800 043 159
TTY for hearing impaired: [phone]
Web site: 

VICTORIA

Office of the Health Services Commissioner

Phone: [phone]
Toll free: 1800 136 066
TTY for hearing impaired: 1300 550 275
Web site:  

QUEENSLAND

Health Rights Commission

Phone: [phone]
Toll free: 1800 077 308
TTY for hearing impaired: [phone]
Web site: 

AUSTRALIAN CAPITAL TERRITORY

Complaints Commissioner

Community and Health Services

Phone: [phone]
TTY for hearing impaired: [phone]
Web site: 

WESTERN AUSTRALIA

Office of Health Review

Phone: [phone]
Toll free: 1800 813 583
Web site: 

TASMANIA

Complaints Commissioner

Office of Health

Phone: [phone] or 1300 766 725
(for the cost of a local call in Australia)
Web site: 

NORTHERN TERRITORY

Health Complaints Commission

Phone: [phone]
Toll free: 1800 806 380
Web site: 

SOUTH AUSTRALIA

South Australian Health and Community Services Complaints Commissioner

Inquiry Service Mon-Thurs 10am-4pm
Phone: [phone]
Toll free: 1800 232 007
Reception: [phone]
Web site: 

Private Health Insurance
Administration Council

The Private Health Insurance Administration Council (PHIAC) is an independent statutory authority that regulates the private health insurance industry. In addition, PHIAC collects and disseminates financial and statistical data regarding health funds and collects and disseminates information about private health insurance to enable consumers to make
informed choices.

Suite 16, Level 1

31 Leichardt Street

KINGSTON ACT 2604

Phone: [phone]

Fax: [phone]
E-mail: [email protected]
Web site:

Department of Health and Ageing

Further information about private health
insurance is available from the Department of Health and Ageing.

Private Health Insurance Branch
MDP 86

Department of Health and Ageing

GPO Box 9848

CANBERRA ACT 2601

Phone: [phone]
(24-hour answering machine).

E-mail: [email protected] 

Web site:

Acute care: Short term care for an illness or health problem

Benefits: Money or services you may receive from your health fund.

Charter: A formal document detailing rights and privileges.

Co-payments: A co-payment is an agreed amount paid towards the total cost of each day spent in hospital. For example, you might agree to pay the first $50 for each day’s hospital admission.

Excess: An excess is an amount of money you pay towards the cost of hospital treatment, regardless of the number of days of hospitalisation. For example, your product has an excess of $300. This means if you go to hospital you pay the first $300 of hospital charges for your care.

Facility fee: The fee charged by some private hospitals for attendance at their emergency department, to offset the cost of establishing and running a high-cost facility.

Gap agreement: A contractual agreement under which health funds are permitted to pay benefits above the Medicare Benefits Schedule (MBS) fee for medical services provided to admitted patients.

Gap cover scheme: A scheme that allows a health fund to pay benefits above the MBS fee for admitted patients without the need for contracts.

Hospital costs: Costs associated with your stay in hospital, such as nursing and accommodation.

Lifetime Health Cover: Lifetime Health Cover is a system of private health insurance that was introduced on 1 July 2000. Under Lifetime Health Cover, health funds are required to charge members different premiums based on their “Lifetime Health Cover Age”. Generally, a person’s Lifetime Health Cover Age is their age on the 1 July before they purchase hospital cover for the first time. When you first take out hospital cover, for every year your Lifetime Health Cover Age is over 30, you will pay an additional 2% loading on top of your hospital cover premium. For example, someone who first takes out hospital cover when their Lifetime Health Cover

Age is 40 will pay 20% more than someone who first took out hospital cover when their Lifetime Health Cover Age was 30. People born on or before 1 July 1934 can join at any time and not have to pay the 2% increase.

Medical costs: Costs associated with the provision of medical services by a doctor.

Medicare: (see Schedule fee)

Out-of-pocket expenses:
The costs you have to pay for admitted hospital medical services and hospital services that are not covered by Medicare or your health fund.

Pre-existing condition: An illness or health problem you already have when you decide to take out or upgrade your hospital cover. Whether a condition is ’pre-existing’ is determined by a doctor appointed by the health fund.

Prostheses: Prostheses are the manufactured items and human tissue items that are surgically implanted during an admitted hospital medical procedure. These prostheses do not include items that are not permanently inserted into people, such as artificial limbs, external mammary prostheses or wigs.

Schedule fee: The government sets a schedule of medical fees - called the Medicare Benefits Schedule - based on a fair price and how much Australia can afford to pay for the total health system. Whether you are a member of a health fund or 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 admitted hospital medical services to private patients.  In the case of services incurred out of hospital, Medicare can reimburse doctors’ fees at either 85% or 100% of the MBS fee depending on whether you are treated by a GP or specialist.  Your doctor(s) can, however, choose to charge more than the scheduled fee.

Self-funded:  As a private patient you are responsible for paying hospital and medical fees connected with your treatment that are not covered by Medicare. You can either pay for costs out of your own pocket or have private health insurance. If you are self-funded you will be required to meet all costs not covered by Medicare. You will be eligible for a 75% rebate of the MBS  fee on services covered by Medicare. You will be responsible for paying all
other costs.

Waiting periods: When you take out private health insurance or upgrade your existing hospital cover, you may have to wait before you can claim for some services from your health fund.  For example, there is a 12-month waiting period on payment of hospital benefits for any pre-existing ailments and obstetric conditions.  Ask your health fund whether waiting periods will apply to your cover.