Australia's health system offers a comprehensive range of public and privately funded health services. You can choose whether to have Medicare cover only or a combination of Medicare and private health cover.

Here we explain the Australian health system and help you make decisions about how best to meet your health cover needs. The information in this section is general information only. It does not specifically relate to Super Members Health Plan. You can click on the heading below and go directly to the section you are interested in.

General information
What Medicare provides
When you are a private patient in a hospital
What private health insurance covers
Surcharges and Incentives
Lifetime Health Cover
Federal Government 30% Rebate on private health insurance
Medicare Levy Surcharge (MLS)
About private health cover
Membership
If you are already ill
Waiting periods
Pre-existing ailment or illness
New-borns
Transferring between funds
Suspending your membership
Notifying members of changes to fund rules
Paying your contributions
Unpaid contributions
Canceling your membership
Benefits you will receive
Time limit
Ineligible claims
Patients' Hospital Charter
Private Health Insurance Ombudsman
Types of private health cover
Hospital Cover
Ancillary Cover
Common terms used by private health funds

General information

Health care can be expensive. As the basis of Australia's health care system, Medicare covers many health care costs. Private health cover, like the Super Members Health Plan, provides additional cover for services not covered by Medicare.

What Medicare provides

Australia's Medicare system is available to all permanent Australian residents. The system has three parts: hospital, medical and pharmaceutical.

Hospital

If you choose to be a Medicare (public) patient, you can be treated, at no charge, in a public (Government owned) hospital by a doctor appointed by the hospital. You cannot choose your own doctor.

Medical

In hospital - under Medicare, you can be treated in a public hospital, at no charge, by a doctor appointed by the hospital. If you elect to be a private patient Medicare will cover you for 75% of the Government Scheduled (MBS) Fee for medical costs associated with being a private patient in a hospital.

Out of hospital - Medicare will reimburse 85% of the MBS Fee for your treatment. If your doctor direct bills Medicare, you will not have to pay anything.

Pharmaceutical

Under the Pharmaceutical Benefits Scheme (PBS) you pay only part of the cost of most prescription medicines purchased at pharmacies. The rest of the cost is covered by the PBS. The Government decides how much you pay towards the cost of PBS medicines.

When you are a private patient in a hospital

As a private patient - whether you are insured or not - you have the right to choose your own doctor, and decide whether you will go to a public or a private hospital that your doctor attends. You may also have more choice as to when you are admitted to hospital and avoid hospital waiting lists for non-emergency procedures.

When you are a private patient, in either a public or private hospital, you will be charged for the hospital accommodation and the medical and other services you receive. Private health cover, such as the Super Members Health Plan, may cover these charges.

When you are a private patient treated in a hospital, whether public or private, Medicare will refund 75% of the MBS Fee for your medical practitioners' services including doctors/specialists fees, pathology, radiology/imaging fees etc.

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As a private patient in either a public or private hospital you may need to pay some or all of the costs for a range of services such as:

• hospital accommodation
• theatre fees
• intensive care
• drugs, dressings and other consumables
• prostheses (surgically implanted)
• diagnostic tests
• pharmaceuticals and
• doctors' services.

Treatment as a private patient in a private hospital can be very expensive. Private health cover, such as the Super Members Health Plan, will cover some or all of these costs.

What private health insurance covers

If you have private health cover, you are covered against some or all of the costs of being a private patient in either a public or private hospital.

Alternatively, you can still choose to be treated as a public patient in a public hospital at no charge. (under Medicare)

There are many private health cover policies to choose from. These policies will cover either some or all of the cost of your hospital care and allow you to choose your own doctor or specialist.

As a privately insured patient you may insure against some or all of the costs of health services not covered by Medicare, such as:

• hospital expenses (theatre fees or accommodation) in either a public or private hospital
• some or all of the medical costs Medicare does not cover
• dental treatment
• ambulance
• chiropractic treatment; home nursing
• podiatry; physiotherapy, occupational,
• speech and eye therapy
• glasses and contact lenses
• prostheses and
• other ancillary services.

Nursing Home Type Patients

If you are in hospital for more than 35 days in succession you will be regarded as a Nursing Home Type Patient (NHTP) unless your doctor specifies otherwise (ie. your doctor completes a 3B certificate confirming that you continue to require acute care). Generally, all NHTPs have to pay part of the cost of hospital accommodation. The National Health Act 1953 does not allow health funds to insure for this part of the cost.

Ambulance cover

Medicare does not cover the cost of emergency ambulance services. If you want cover for such a service, you must arrange it yourself. You can arrange ambulance cover from the ambulance authority in your State.

Health funds may pay or reimburse you for all or part of your annual subscription to your State ambulance authority or the costs associated with transportation. If you take out a hospital insurance policy in New South Wales or the ACT, you will find your health fund premium includes this cover.

Health fund arrangements to cover gap

Health funds are able to negotiate agreements with hospitals and doctors so that you can know beforehand what costs (if any) you have to pay. Some health funds will give you full cover against the costs of hospital and medical charges. Others, for which you will pay lower premiums, will require you to meet part of the costs.

Hospitals, which have agreements with health funds, submit to the fund a single account for hospital services provided. Doctors who have agreements with health funds also usually forward all accounts to the fund. If you have a policy that requires you to pay part of the hospital or medical costs, the hospital or doctor will bill you directly. Hospitals and doctors with agreements with your health fund must, whenever possible, inform you before providing a medical service in hospital, of any amount you will have to pay. Your health fund can advise you which hospitals and doctors are covered under its gap arrangements.

If you have any problems or complaints that cannot be resolved satisfactorily with your health fund, you can have the problem fully examined by the Private Health Insurance Ombudsman. You should always try to resolve the problem with your fund before going to the Ombudsman.

Surcharges and Incentives

Lifetime Health Cover

Lifetime Health Cover is a Government initiative that recognises the length of time a person has had hospital cover with a registered health fund. People who take out hospital cover earlier in life and maintain their hospital cover will pay lower premiums throughout their life compared to someone who joins when they're older.

Lifetime Health Cover commenced on 1 July 2000.

To lock in the lowest premiums for life under Lifetime Health Cover, a person needs to take out hospital cover with a registered fund before their 31st birthday. If a person does not have hospital cover on their 31st birthday and decides to take out hospital cover later in life, they will pay a 2% loading on top of their premium for every year they are aged over 30. For example, someone who first takes out hospital cover at age 40 will pay 20% more than someone who first took out hospital cover at age 30.

People who were born on or before 1 July 1934 are exempt from Lifetime Health Cover and are able to join a health fund at any time in the future and pay the same premium as someone who takes out cover at age 30.

For more information about Lifetime Health Cover ring the Private Health Insurance Information Line on 1800 676 296, visit the Commonwealth Department of Health and Aged Care web site at http://www.health.gov.au or call the Super Members Health Plan Hotline on 1300 136 650.

Federal Government 30% Rebate on private health insurance

The Australian Government introduced the Federal Government 30% Rebate initiative on 1 January 1999. For every dollar that you contribute to your private health insurance premium, the Government will give you back 30 cents.

All Australians who are eligible for Medicare and who are members of a registered health fund are eligible for the rebate - no matter what your level of cover, income or type of membership.

How to claim the Rebate

In order to claim the Rebate, your health insurance policy must be with a registered health fund. In addition, all of the people covered by the policy must be eligible to claim benefits under Medicare.

There are three ways to claim the 30% Rebate:

1. Ask your health fund to provide the Rebate as a premium reduction.
2. Receive a direct payment from the Government through your local Medicare office.
3. Claim it back on your tax return, using a statement your health fund will provide at the end of the financial year.

If your employer has paid your premium on your behalf, you are entitled to claim the 30% Rebate.

For more information

You can seek further information on any aspect of the Federal Government 30% Rebate by calling the Private Health Insurance Information Line on 1800 676 296, visit the Commonwealth Department of Health and Aged Care web site at http://www.health.gov.au or call the Super Members Health Plan on 1300 136 650.

Medicare Levy Surcharge (MLS)

The Medicare Levy Surcharge has been in place since 1 July 1997 with the aim of encouraging those on higher incomes to take out private hospital cover, and where possible, to use the private health facilities to reduce the demand on the public system.

The Medicare Levy Surcharge is an additional 1% surcharge of taxable income imposed on those in higher incomes, who are eligible for Medicare but who do not have an appropriate level of hospital insurance with a registered health fund. The Medicare Levy Surcharge is in addition to the normal 1.5% Medicare Levy.

Who must pay the Medicare Levy Surcharge?

You have to pay the Surcharge if you are a high-income earner and you do not have a private hospital insurance policy with a low front-end deductible.

High-income is defined as:

• a single person with an annual taxable income (including Recordable Fringe Benefits) greater than $50,000 or
• a family or couple with a combined taxable income (including Recordable Fringe Benefits) greater than $100,000.

The family income threshold increases by $1,500 for each dependent child after the first.

A Low Front End Deductible (or excess) is defined as equal to or less than:

· $500 per annum for single policies; or
· $1,000 per annum for families/couples.

You must also pay the Medicare Levy Surcharge if you are a prescribed person* with a taxable income over the threshold, and have any dependants who are not prescribed persons and who are not covered by a low front-end deductible hospital insurance policy with a registered health fund

* Generally, you will know if you are a prescribed person. If you need more information on prescribed persons, call the Australian Taxation Office (ATO) Help line on 13 28 61.

Your dependents in relation to the Medicare Levy Surcharge

Providing you contribute to their maintenance (including child support payments), your dependants are:

your spouse
- any of your children who are under 16 years of age, or
- any of your student children who are under 25 years of age.

You do not have to pay the Surcharge if:

- your taxable income is below the income threshold;
- your taxable income is over the income threshold and you have hospital insurance for you and all of your dependants with a low front-end deductible with a registered health fund;
- you are normally exempt from the Medicare Levy because you are a prescribed person* and you do not have any dependants. Your taxable income is not considered in this case.
- you are a high income earner who had already purchased a hospital insurance product with a front-end deductible greater than $500 for singles or $1,000 for families/couples, on or before 24 May 2000. In this case you will continue to be exempt from the Surcharge while ever you maintain continuous membership to the same hospital table.

Notes about the Surcharge

To be exempt from the Surcharge, your hospital cover must be held with a registered health benefits organisation (health fund) that covers some or all of the fees and charges for a stay in hospital. Ancillary or Extras cover does not constitute private patient hospital cover for the purposes of the Surcharge.

Low Front End Deductible

Your front end deductible (also known as excess) must be equal to or less than $500 per annum for single policies or $1,000 per annum for families/couples to be considered a Low Front End Deductible.

For more information

For more information about the Medicare Levy Surcharge, contact the Australian Taxation Office (ATO) by:

- calling the A Fax From Tax line 13 28 60
- calling the ATO Help line 13 28 62
- visiting the ATO Internet Home Page http://www.ato.gov.au

About private health cover

Private health insurance is provided through organisations registered under the National Health Act 1953. The financial performance of registered health funds is independently monitored to ensure solvency and capital adequacy requirements are met.

A health insurance fund is registered either as:

- an "open membership" organisation (anyone can apply to join); or
- a "restricted membership" organisation (available only through specific employment groups, professional associations or unions).

Health funds follow a principle known as 'community rating'. Under this principle the premiums charged by the funds do not vary according to your age (other than age at entry), sex, state of health or the size of your family. For example, a single, healthy 20-year-old and a single, unwell 60-year-old will both pay the same premium for the same cover, (Refer to Lifetime Cover). However, the cost of premiums for similar cover may vary between funds.

Private health insurance is different from trauma and disability insurance. These insurances are 'risk-rated' rather than community-rated and generally offer lump-sum payments in the event of specific illness or loss. They are not a substitute for registered health insurance.

Super Members Health Plan is underwritten by GMHBA Limited, a registered "open membership" organisation.

Membership

There are four categories of membership:

Single Membership provides cover only for the person named as the member on the application form (the contributor).
- Family Membership provides cover for the contributor, one other adult and one or more dependent children.
- Couple Membership provides cover for the contributor and one other person who is not a dependent child of the contributor.
- Single Parent Family Membership provides cover for the contributor and one or more dependent children.

'Dependent children' are defined as the contributor's unmarried dependent children, step children and foster children who are under 18 years of age. This age limit extends to 25 if the 'dependent child' is a full-time student, and depends on the contributor for maintenance and support.

Health funds are not required to offer all types of cover to all categories of membership.

If you are already ill

Even if you are already ill, all health funds must allow you to purchase any type of cover. However, standard waiting periods may apply before benefits are payable. If a fund refuses you membership you may appeal to the Minister for Health and Ageing.

Waiting periods

When you join a health fund or increase your level of cover, you may have to wait some time before your insurance becomes effective. This protects you and others in your fund by making sure no contributor makes a large claim shortly after joining a fund, and then drops their membership. This 'hit and run' behavior results in increased premiums for everyone. The Government sets the maximum time that health funds are able to make members wait until they can claim benefits for hospital treatment. These maximums are:

12 months for pre-existing ailments;
12 months for obstetric cases; and
2 months in all other circumstances.

The Government does not regulate waiting periods for benefits payable under ancillary tables. These waiting periods are set by individual health funds and you should make sure you are aware of ancillary benefit waiting periods that apply to your fund.

There is usually no waiting period if you need hospital or medical treatment because of an accident that happens after you join the fund.

Pre-existing ailment or illness

When you decide to take out or upgrade private health insurance, you may already be ill. You may have what is referred to as a pre-existing ailment. Under the National Health Act 1953, a health fund may impose a 12 month waiting period on benefits for hospital treatment where it should have been reasonably apparent to either the member or a medical practitioner that there was a pre-existing ailment in the six months prior to joining a hospital table or upgrading to a higher level of cover.

What is the exact definition of a pre-existing ailment?

A pre-existing ailment is an ailment, illness or condition, the signs or symptoms of which, in the opinion of a medical practitioner appointed by the health fund, existed at any time during the 6 months prior to the member joining a hospital table or upgrading to a higher level of cover.

What this means in real terms is that the sign or symptom of the pre-existing illness, ailment or condition should have been reasonably apparent or reasonably evident to the contributor; or there must be something that would have been apparent to a reasonable general practitioner on a routine external examination if the contributor had been examined.

In forming an opinion about whether or not an illness was pre-existing, the health fund-appointed medical practitioner who makes the decision must take into account information provided from your own doctor.

If you require hospital treatment, but you have less than 12 months membership on your current hospital table, a 12-month waiting period could apply if your condition was pre-existing.

The decision about whether your condition is pre-existing is made by your health fund. It is important to check this with your health fund prior to your admission to hospital.

Remember, your health fund will need at least a week or so to advise you about whether the pre-existing ailment 12 month waiting period applies.

New-borns

If you have a Single membership and are expecting a child, you may need to transfer to a Family Membership or a Single Parent Family membership. If you want the child to be insured from the time of birth, you may have to transfer to the new policy two months before your child is born. Ask your fund to explain its policy on new-borns.

Transferring between funds

You can transfer from one health fund to another, for the same or a lower level of benefits, without serving additional waiting periods.

The fund to which you transfer may impose waiting periods before you are eligible for any new or higher benefits on your new policy.

The fund to which you transfer must give you credit for the waiting periods you have already served.

Benefits paid by the previous fund may be taken into account by your new fund when it determines your annual benefit limits.

Transferring between funds will not affect your Lifetime Health Cover entitlements provided that you transfer from hospital cover with your existing health fund to hospital cover with the new health fund.

Suspending your membership

In fairness to you, most funds will let you waive, defer or suspend your membership if you are away from Australia for a period of time specified by your fund. Suspension may also be permitted under other conditions, such as periods of unemployment. Ask your fund what conditions apply.

You will not be paid benefits for services used while your membership is suspended. Similarly, the time for which your membership is suspended cannot count towards any waiting or qualifying periods.

Suspending your membership with the agreement of your health fund will not affect your Lifetime Health Cover entitlements.

When you start paying contributions again, your benefit entitlements will continue on a similar basis as before your membership was suspended.

Notifying members of changes to fund rules

Health funds change rules and premium prices from time to time. As a result, funds are required to tell their members, in writing, about any change that:

- adversely affects the scope, level or nature of benefits, or
- increases the cost of premiums.

Paying your contributions

Paying in advance

Generally, you must pay contributions at least one month in advance unless payments are made under a payroll deduction scheme or direct debit.

The maximum period for which you may pay in advance is usually 12 months.

Some funds such as the Super Members Health Plan offer a 'rate protection' policy under which, if you have paid in advance, you will not have to pay extra if rates are increased over the period for which you have paid.

For example, if you pay your premium in advance, say for 12 months, and there is a rate increase after four months, with rate protection, you will not have to pay the increased rate until your 12 months of cover ends.

When no 'rate protection' policy applies, the fund will ask you to pay the balance owing on the new rates, or reduce the length of time your payment covers. When you are advised of rate increases, check whether the increase will affect the length of time your advance payment covers.

Unpaid contributions

Your private insurance lapses - meaning you are not insured - if you are more than two months behind in paying your contributions.

Some funds may not accept payment of arrears in excess of two months. In such cases they may impose further waiting periods when you resume contributions.

Canceling your membership

If you decide to cancel your membership, your fund should pay back any contributions you have paid in advance. The fund may deduct a small administration charge.

Benefits you will receive

The amount of benefits you receive for hospital or medical treatment will depend on the type of cover you purchase, and whether you have chosen to contribute to the costs of your hospital treatment in exchange for paying a lower premium.

The amount of benefits you will receive also depends on the hospital and doctor you choose and whether they have an agreement with your fund.

When a fund has an agreement with your doctors and hospital, you are less likely to face out-of-pocket costs. If you elect to go to a hospital that does not have an agreement with your fund, you may face significant out-of-pocket costs.

You should ask your doctor well in advance of receiving treatment to give you an estimate of any amount you will have to pay for your doctor's services that is not covered by your health fund. You should also ask your hospital and health fund to inform you of any amount you will have to pay for your hospital charges.

You can ask any health fund about the hospitals and doctors with whom they have agreements.

Time limit

You should lodge a claim within two years of the date of the service however some funds may allow claims to be lodged after two years. Check with your fund.

The claim form must be signed by you or your spouse (in the case of memberships other than Single).

Ineligible claims

Benefits are generally not paid:

- if you will be paid compensation by a third party;
- for certain ancillary services provided by someone not recognised by your fund or if you are not covered for ancillary benefits;
- if you put false or inaccurate information on your claim form;
- if you are more than two months behind with your contributions;
- if you claimed benefits for services provided while your membership in the fund was suspended;
- if the service provider is directly related to you - that is, if he or she is your spouse, parent, child or sibling; or
- if your claim is made two or more years after the date of service.

Patients' Hospital Charter

To help you understand what you can expect from your health fund, doctor and hospital, a Private Patients' Hospital Charter is available. It will assist you with some of the important questions you may need to ask those involved with your health care.

Copies of the Charter are available from health funds, the Department of Health and Aged Care and the Private Health Insurance Administration Council (PHIAC).

Private Health Insurance Ombudsman

If you have a problem with your health insurance arrangements, you should first discuss it directly with your health fund.

If you are unable to reach a satisfactory agreement with your fund, contact the Private Health Insurance Ombudsman. Ring the toll-free Hotline on 1800 640 695.

Types of private health cover

There are two types of private health insurance cover available:

- hospital cover; and
- ancillary (or extras) cover.

While hospital cover helps with the cost of treatment by your doctor and other costs like hospital accommodation, ancillary cover provides benefits for services such as physiotherapy, dental and optical treatment.

You are able to take out either one of these types of private health insurance cover on their own, or some health funds offer packaged products that provide cover for both hospital and ancillary services.

Hospital Cover

There are various types of private health insurance hospital cover that you can purchase. Some health fund policies will give you full cover against the costs of hospital and medical charges. Others, for which you will pay lower premiums, will require you to meet part of the costs.

You can elect to pay a lower premium in return for agreeing not to be covered for some conditions, or to only receive limited benefits for a certain condition, or to pay a set amount towards the cost of your hospital treatment.

You could elect to pay a lower premium and take out a hospital cover policy with one or more of the following features:

An exclusion for a particular condition or conditions
If your policy features an exclusion for a particular condition, you are not covered for treatment as a private patient in a public or private hospital for that condition. For example, if you purchase a private health insurance policy that excludes maternity, hip replacements and knee replacements, and you go into hospital as a private patient for one of these conditions, your health fund will not pay any benefits towards your hospital and medical costs.
If you are unsure which conditions are excluded on your policy you should ask your health fund.

A front-end deductible (also known as an excess)
An excess is an amount of money you agree to pay for a hospital stay before health fund benefits are payable. For example, if your policy has an excess of $200, you will be required to pay the first $200 of your hospital costs should you go to hospital as a private patient. An excess could apply every time that you go to hospital in a year, or it may be capped at a total amount that you will have to pay in a year. If you are unsure how the excess on your policy works you should ask your health fund.

A co-payment
With a co-payment, you agree to pay an agreed amount each time a service is provided. For example, a policy may have a co-payment clause that requires you to pay the first $50 for each day's hospital accommodation. If your policy has such a co-payment and you were in hospital for 5 days, you would have to pay $250 ($50 x 5). The total amount of co-payment you can pay in a year is sometimes limited to a set maximum amount.

Restricted benefits
If your policy has restricted benefits for some conditions you will be covered for treatment as a private patient in a public hospital for these conditions, but will face considerable out-of-pocket costs if you were to be treated in a private hospital for these conditions.

If you are unsure about whether restricted benefits apply to your policy you should ask your health fund.

Public hospital table
Some health funds offer policies that have restricted benefits for all conditions. This policy is sometimes called a public hospital table. Under this policy you will be covered for treatment as a private patient in a public hospital, but will face considerable out-of-pocket costs if you were to be treated in a private hospital.

Ancillary Cover

Ancillary cover is available for a range of non-hospital services such as physiotherapy, optical or dental treatment. Ancillary cover is usually available separately or as an add-on to hospital coverage.

Common terms used by private health funds

Accommodation

Accommodation covers meals and a bed in hospital, and includes all hospital-provided services including nursing care. It does not include treatment by doctors or other health professionals.

Ancillary services

Ancillary services are services, such as physiotherapy, speech pathology and podiatry, which are provided by health professionals.

Co-payment
A co-payment is where you agree to pay a set amount each time a service is provided. For example, a private health insurance policy may have a co-payment clause that requires you to pay the first $50 for each day's hospital accommodation.

Dependant

A dependant is defined by each health fund according to their rules.

Generally a dependant is:

- your spouse;
o any of your children who are under 18 years of age, and you contribute to their maintenance; or
- any of your student children who are under 25 years of age, and you contribute to their maintenance

Diagnostic tests

Diagnostic tests can include such things as x-rays and bloods tests.

Drugs, dressings and other consumables

Drugs, dressings and other consumables are additional services to support hospital treatment. For example, medications, bandages and crutches, prostheses (surgically implanted). These include such things as hip replacements, artificial lenses and heart valves.

Elective surgery

Elective surgery is treatment of a condition your doctor considers does not require immediate attention.

Emergency treatment

Emergency treatment occurs when the patient is treated by the medical practitioner within 30 minutes of presentation and the patient is in danger of suffering loss of life, limb, bodily function or mental stability; is in severe pain or is bleeding.

Excess

An excess is an amount that you agree to pay if admitted to hospital in exchange for lower premium costs. You may be required to pay an excess every time you go to hospital, or only the first time, depending on the private health insurance policy you take out. An excess is also known as a front-end deductible.

Federal Government's 30% Rebate

For every dollar that you contribute to you private health insurance premium, the Government will give you back 30 cents.

Front-end deductible

Gap

The term 'gap' generally means the difference in the amount that your doctor charges and the amount that is covered by Medicare and your health fund, i.e. the amount that you must pay for your medical services received in hospital. It can also refer to the difference between what your hospital charges and the amount that is covered by your health fund.

Intensive care

Intensive care is treatment for actual or potential life-threatening illnesses, injuries or complications.

Labour ward fees

Labour ward fees include costs for delivery of babies in a birthing suite.

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 the age they are when they first take out hospital cover. For every year you are aged over the age of 30 when you take out hospital cover, you will pay an additional 2% loading on top of your hospital cover premium. For example, someone who first takes out hospital cover at age 40 will pay 20% more than someone who first took out hospital cover at age 30.

Low Front End Deductible

Your front end deductible (also known as excess) must be equal to or less than $500 per annum for single policies or $1,000 per annum for families/couples to be considered a Low Front End Deductible.

MBS Fee (Medicare Benefits Schedule Fee or Government Scheduled Fee)

The Government sets a schedule of medical fees - called the Medicare Benefits Schedule. You can claim a rebate for medical fees whether you are a member of a health fund or not. The rebate is currently 75% of the MBS fee for in-hospital medical fees and 85% of the MBS fee for medical fees incurred out of hospital.

Medical expenses/charges

Medical expenses are charges for medical procedures performed during a hospital stay. This covers items such as surgeons' fees, obstetricians' fees, radiology, pathology and anesthetists. Medicare pays 75% of the MBS Fee for these services.

Medicare Levy Surcharge

Higher income individuals and families who do not have private hospital insurance cover will pay an extra 1% of their taxable income for the Medicare levy surcharge. This is in addition to the normal 1.5% Medicare levy.

Palliative care

Palliative care is provided when a patient's condition is terminal. Such care simply provides relief of suffering and any enhancement to quality of life that can be achieved.

Pre-existing ailment

A pre-existing ailment is an ailment, illness or condition, the signs or symptoms of which, in the opinion of a medical practitioner appointed by the health fund, existed at any time during the 6 months prior to the member joining a hospital table or upgrading to a higher level of cover.

Private patient in a public hospital

You are a private patient in a public hospital if you choose to be treated in a public hospital but retain the right to choose your own doctor. If you do so, you will be charged for hospital accommodation costs and doctors fees. Medicare pays 75% of the MBS Fee for your doctors' charges. If you have private health insurance, your health fund will pay at least the remaining 25% of the MBS fee for your doctor's charges and can pay more if the health fund has an agreement with your doctor. Your health fund will also cover some or all of your hospital accommodation costs.

Private patient in a private hospital

You must be a private patient to be treated in a private hospital. As a private patient in a private hospital you have the right to choose your own doctor, and you are responsible for costs associated with all hospital and doctors' services.

Medicare pays 75% of the MBS Fee for these doctors' charges. If you have private health insurance, your health fund will pay at least the remaining 25% of the MBS fee for your doctor's charges and can pay more if the health fund has an agreement with your doctor. Your health fund will also cover some or all of your hospital accommodation costs.

Prostheses (surgically implanted)

Prostheses include such things as hip replacements, artificial lenses and heart valves.

Psychiatric care

You are under psychiatric care if you have a disability and you are taking part in a program designed to improve your functions, retrain you in lost skills or help you to re-establish your place in society.

Public patient

You are a public patient if you choose to be treated in a public hospital under Medicare by a doctor appointed by the hospital.

Rehabilitation care

You are under rehabilitation care if you have a disability and you are taking part in a program designed to improve your physical functions, retrain you in lost skills or help you to re-establish your place in society.

Same-day patient

You are a same-day patient if you are admitted, treated and discharged on the same day.

Theatre fees

Theatre fees are costs for procedures performed in an operating room including those performed in day surgery facilities.

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