The government calls this Gap Cover.
Access Gap is a scheme that aims to reduce the difference between the Medicare fee and what specialists charge. Specialists can choose to take part in Access Gap on a case-by-case basis, and if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be.
An unforeseen event which causes injury and needs hospitalisation.
Accommodation covers a bed and meals in hospital. It also includes in-hospital services like nursing and is separate to your doctors’ bills.
The age-based discount is a discount for under 30s on selected hospital covers. It is available on Peoplecare’s Basic Plus Hospital and Bronze Plus Hospital covers.
The discount ranges from 2% to 10%, depending on your age. The younger you are, the greater your discount.
What's even better is that you can keep this discount on your policy until you turn 41. That’s more than a decade worth of savings.
Read more to learn how the discount works in detail.
We have agreements with most private hospitals in Australia. If you’re admitted to one of the few private hospitals that we don’t have an agreement with, you could have large out-of-pocket expenses.
You can search our agreement hospital list here, and we recommend that you call us if you’re planning a hospital admission to discuss exactly what you’ll be covered for.
Also called extras cover or general treatment.
Cover for services that aren’t covered by Medicare or done in hospital. Things like dental, optical, physio and chiro.
The most we’ll pay in a financial year for a specific extras service. Our annual limits refresh on 1 July each year.
Check your extras limits at any time via Online Member Services or on our mobile app.
A Government rebate to help with the cost of private health insurance. It’s income tested and is applied to both hospital and extras cover. If you have a Lifetime Health Cover loading, the Rebate isn’t applied to that portion of your payments. The Rebate you get is based on the age of the oldest person of your membership, your taxable household income (for Medicare Levy Surcharge purposes), CPI (inflation) and average health fund industry premium increases.
What we pay back for a health treatment or service.
A chronic disease is one that’s long-lasting and impacts on your quality of life. Some of the most common chronic diseases are cardiovascular disease, diabetes, mental health, cancer and osteoarthritis.
AKA Transfer Certificate.
All hospital covers in Australia must list what hospital services they cover across 38 clinical categories. The 38 clinical categories standardise the minimum requirements of a Basic, Bronze, Silver and Gold hospital cover. Private health insurance reforms: Gold/Silver/Bronze/Basic product tiers (PDF) on health.gov.au.
Private health insurance in Australia is 'community-rated', which means that everyone can buy the same product at the same price. A health fund can’t refuse to insure you, or refuse to sell you any current policy you want to buy. There are some exceptions to this – for example, you’ll pay a higher premium if you have a Lifetime Health Cover loading.
Changed your mind about your cover? No worries! Just let us know within 30 days of joining or upgrading your cover and you'll get a full refund of any premiums paid (as long as you haven't made any claims in that time, of course).
This is the date we use when we process your claim. This is the date you received the goods or service you are claiming. This date will be listed on your invoice for the service received.
AKA day facility. A private hospital or facility where patients are admitted, treated and sent home on the same day.
The Government’s set rates for public and private hospital accommodation. If you’re admitted to a private hospital for a restricted service, we’ll only be able to pay the default private rate (which is only a small amount of the cost of a private hospital stay). This means you’ll have big out-of-pocket costs. The same goes if you’re admitted to a hospital that doesn’t have an agreement with us – we’ll only be able to pay the default rates.
A child between 21 and 30 (inclusive) who resides with the policy holder and isn’t married or in a de facto relationship.
These are other services provided while you’re in hospital. Things like medications, bandages and crutches.
Elective surgery is planned surgery that isn't urgent (non life-threatening, for instance) and can be booked in advance after seeing a specialist.
An online system that hospitals can use to confirm your membership details and benefits before you’re admitted to hospital. This system is available online 24 hours a day, 7 days a week.
Urgent treatment that occurs in a 24-hour emergency department, generally at public hospitals.
How does an excess work?
The higher the excess, the lower your premium. You only pay the excess if you go to hospital.
With Peoplecare hospital covers you pay:
- Half the excess for same-day admission in hospital (e.g. $375 if you have a $750 excess)
- Full excess for an overnight stay or longer (e.g. $750 if you have a $750 excess)
- No excess for kids under 21 on a family hospital cover if they go to hospital
The maximum excess per financial year no matter how many times you go to hospital:
- Single covers – the full excess amount (e.g. $750 if you have a $750 excess)
- Couple and family covers – double the excess amount (e.g. $1500 if you have a $750 excess)
Something you’re not covered for on your hospital cover.
AKA ancillary or general treatment. Cover for services that aren’t covered by Medicare or done in hospital. Things like dental, optical, physio and chiro.
Private health insurer (like us!).
AKA out-of-pocket cost.
The amount you pay when your doctor or hospital charges more than what Medicare and your health fund can pay.
For example, as a private patient in a hospital or a day surgery centre your doctor and any specialists who treat you will each raise a bill for their services. The Australian Government sets a schedule of fees for all medical treatments called the Medicare Benefits Schedule (MBS).
For items on the MBS, Medicare covers 75 per cent, while your health cover picks up the remaining 25 per cent. However, some doctors and specialists charge more than the MBS fees, with the extra amount referred to as the ‘medical gap’ or your out-of-pocket cost.
We have Access Gap, a scheme to reduce your out-of-pocket doctor expenses. First you need to ask your doctor if they participate. If they do, we pay them more than the Medicare Benefit Schedule fee – resulting in lower or no out-of-pocket expenses for you.
AKA Access Gap or Medical Gap Cover. An arrangement that aims to reduce the difference between the Medicare fee and what doctors charge. Doctors can choose to take part in Access Gap on a case-by-case basis, and if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be.
Minor dental services like annual check-ups, cleaning and fluoride treatment. General dental includes diagnostic services, preventive treatment, extractions, oral surgery and fillings.
AKA ancillary or extras cover. Cover for services that aren’t covered by Medicare or done in hospital. Things like dental, optical, physio and chiro.
Health Industry Claims And Payment Service. This lets you claim on the spot at your provider using your health fund card.
Covers you as a private patient in a private or public hospital. It includes hospital accommodation as well as medical treatment received in hospital (i.e. as an in-patient).
A patient who is admitted to hospital (or a day surgery) for the day or overnight. Treatment that’s received in the emergency ward of a hospital without being officially admitted isn’t classed as in-patient and is covered by Medicare only.
IFC is being told what your out-of-pocket costs will be for a procedure. You should be told how much you will have to pay before you’re admitted to hospital (preferably in writing).
Hospital treatment for life-threatening conditions, injuries or complications. Intensive care is a type of special unit accommodation.
This is the code that identifies the treatment you’ve received and is needed to process your claims. The code is provided by Medicare, your dentist or other healthcare provider.
Fees for the delivery of a baby in a birthing suite.
Lifetime Health Cover is designed to get people to take out private hospital cover earlier in life. If you have private hospital cover by 1 July after your 31st birthday and keep it, you don’t have to worry about it. If you decide to get hospital cover later, you’ll pay 2% more for cover for every year you’re over 30. This is called your Lifetime Health Cover loading. LHC loadings stay on your cover for 10 years. Once you’ve had hospital cover for 10 years straight, the loading is removed.
The most you can claim for a service in a certain time.
Significant dental services, such as complex fillings, tooth extractions, crowns and bridges.
The medical devices or human tissue products that private health insurers pay are listed in the Prescribed List of Medical Devices and Human Tissue Products set out in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules, as in force from time to time.
We will pay the Government's set benefits on their Prescribed List of Medical Devices and Human Tissue Products for treatment that you are covered for as part of your hospital cover.
You are not covered for medical devices or human tissue products on services that are excluded on your hospital cover.
Fees for medical services while you’re in hospital. Things like doctor & specialist fees, radiology, pathology and anaesthetists.
AKA Access Gap or Gap Cover. Medical Gap aims to reduce the difference between the Medicare fee and what doctors charge. Doctors can choose to take part in Access Gap on a case-by-case basis, and if they take part you’ll either have no gap or be told exactly what your out-of-pocket costs will be.
A service provided by a doctor, specialist, radiologist, pathologist or anaesthetist.
A list of fees for medical services is set by the Government.
Medicare pays 75% of the MBS fee for in-hospital medical services and private health cover pays the other 25% (sometimes more if the doctor agrees).
Health funds can’t pay benefits for medical services outside of hospital (things like going to your GP), but Medicare pays 85% of the MBS fee for these. For GP appointments, Medicare pays 100% of the MBS fee.
The Medicare Levy Surcharge is paid by high income earners (that’s singles who earn over $97,000 and families that earn over $194,000 in the financial year) who don’t have private hospital cover.
The surcharge is between 1% and 1.5% (depending on your household income) and is paid on top of the 2% Medicare Levy paid by most Australian taxpayers.
The fee set by the Government for an individual item on the Medicare Benefits Schedule (MBS). Medicare pays 75% of the MBS fee for in-hospital medical services and private health cover pays the other 25% (sometimes more if the doctor agrees). Health funds can’t pay benefits for medical services like going to your GP or specialist consultations etc.
Management of pregnancy, labour, delivery and associated care in hospital.
Treatment or services received without being admitted to hospital. Things like visits to your GP and specialist appointments.
This is a Government subsidy that reduces the cost of some prescription medications. The PBS amount changes on 1 January every year and is $31.60 as at 1 January 2024. We’re only able to pay benefits on the cost of prescription medication that’s above the PBS amount.
For example, if your medication costs $50, we’ll pay a benefit on the difference between the PBS amount and $50.
The ability to transfer between health funds without having to re-serve waiting periods.
A pre-existing condition is any aliment, illness, or condition that you had signs or symptoms of (in the opinion of a medical practitioner appointed by the health insurer) that existed at any time during the 6 months before you joined a hospital cover or upgraded to a higher hospital cover. 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 cover or upgrading to a higher hospital cover. This waiting period only applies to hospital cover, not extras cover.
Pre-existing condition restrictions don’t apply to the following services:
- Rehabilitation, hospital psychiatric services, palliative care have a 2-month waiting period
- Ambulance has a 1-day waiting period
Also called payment or rate, it's what you pay for health cover.
The Private Health Information Statement (PHIS) is a summary of the key features of your cover in the government’s standard format.
The PHIS is designed to help you understand what’s on your cover and compare your cover to others available using privatehealth.gov.au.
Learn more about how to read your PHIS.
PHIO is an independent service for health insurance problems and enquiries. The Ombudsman also publishes reports and information about private health insurance.
A hospital run as a commercial or charitable operation.
Being a private patient in a private hospital or day surgery lets you choose the doctors who treat you at a time that suits you (as long as the doctor you choose operates from the hospital or day surgery you'd like to be admitted to, and that the hospital or day surgery has the services you need). As a private patient in a private hospital, you might be charged for things like:
- care in intensive/critical care units
- doctors’ services (including diagnostic tests)
- operating theatre fees
- other health services (like physiotherapy)
- dressings, medications and other consumables
- medical devices and human tissue products.
Being a private patient in a public hospital lets you choose your doctor, as long as the doctor you choose operates from the hospital or public surgery you're being admitted to. As a private patient in a public hospital, you might be charged for things like:
- hospital accommodation
- doctors' services (including diagnostic tests)
- personal expenses, like TV hire and telephone calls
- medical devices and human tissue products.
A prosthesis is a surgically implanted device, human tissue item or other medical device, like heart pacemakers, hip and knee joints.
A person or business qualified to provide medical or healthcare services, like a clinic, dentist or therapist.
A registration number given to a provider by the organisation that they’re registered with. Providers are generally registered with either Medicare or the ARHG (Australian Regional Health Group).
On your invoice, you’ll find the Provider Number near the provider’s name and address. It’ll generally be a mix of letters and numbers and can be up to eight digits long.
For online claims, providers are only registered with Medicare and the Provider Number will be seven digits followed by one letter.
For manual claims, some services don’t have registered providers. If you can’t find the Provider Number on your invoice, just leave the field blank.
A hospital funded by the Government. Recognised public hospitals have access to the Medicare Benefits Schedule, the Pharmaceutical Benefits Scheme and private health insurance arrangements.
Public patients are treated in a public hospital under Medicare by a doctor chosen by the hospital.
AKA premium or membership payment.
What you pay for health cover.
Or in its full name, the Australian Government Rebate on Private Health Insurance.
It is a Government rebate to help with the cost of private health insurance (so that more people would take out private cover).
It’s income tested and is only applied to the standard cost of cover. If you have a Lifetime Health Cover loading, the Rebate isn’t applied to that portion of your payments.
The Rebate you get is based on the age of the oldest person of your cover, your taxable household income (for Medicare Levy Surcharge purposes), CPI (inflation) and average health fund industry increases in rates.
AKA restricted benefits. A restriction is a service that’s only paid at the default rate, rather than a private hospital rate. If you have restricted services on your cover and you're admitted to a private hospital for one of these services, we can only pay the default rate and you'll have large out-of-pocket costs.
Same day patients are admitted, treated and sent home on the same day.
A facility or unit dedicated to the treatment or care of patients with particularly complex conditions that need a high level of attention, like an intensive care unit.
If you’re having financial troubles or travelling overseas, you can ask us to suspend your health cover for an agreed length of time. If you suspend your health cover, you don’t have to pay your premiums, but can’t claim during this time.
Please contact the fund to see if you're eligible for suspension.
Following a suspension, it’s important to reactivate your membership within the agreed time or you’ll have to re-serve your waiting periods. If you earn over the Medicare Levy Surcharge income threshold, you’ll still have to your pay the surcharge for the time your cover is suspended. Also, your Lifetime Health Cover status won't change while your cover is suspended.
Costs for procedures performed in an operating room, including day surgery facilities.
AKA Clearance Certificate. You get this when you transfer from one health fund to another. It shows all the details of your last cover to help your new fund work out things like waiting periods, benefits and Lifetime Health Cover loading for your new cover.
How long you have to hold your cover before you can make a claim. Refer to your Cover Description or call us for more detail.