If you’re going to hospital, chances are that you will hear a lot of jargon. We’ve collected some important terms you might need to understand, or questions you might need answers to, and tried to explain them in plain English.
Things you need to know
A waiting period is a period of time that you may need to have your private health insurance before you can use it for various treatments or services. If you upgrade your cover, you may also need to wait a period of time before being able to access any extra benefits you got from upgrading.
If you’re not sure if you’ve served your waiting period, it’s always best to check with your insurer before the treatment or service to make sure you’re covered.
The following standard waiting periods apply for hospital cover:
- Palliative care, psychiatric and rehabilitation services – two months
- Pre-existing conditions, ailments or illnesses – 12 months
- Pregnancy (including childbirth) – 12 months
- All other treatments included in your cover – two months
- Treatment resulting from an Accident sustained after joining– no waiting period
If you need psychiatric services, in certain circumstances, you might be able to upgrade your cover without a waiting period, once in your whole lifetime.
Waiting periods are in place to protect both customers and health insurers. By having a ‘waiting period’, people are not able to make a large claim shortly after joining, and then drop insurance straight after.
It makes it fairer, because the price of each type of cover changes based on the claims for all customers in a state on a particular type of cover.
If you’re swapping to an equal level of cover, by law, you won’t have to wait again. This is important because it protects your choices. You need to be able to weigh up your choices, without being penalised.
It’s called ‘continuity of cover’, and it means:
- If you switch to an equal level of cover at another insurer, you maintain your cover, without serving waiting periods again. Some health insurers will allow a small period of time between the end of your old policy, and the start of your new one, but this varies. It’s worth checking this with your new insurer.
- If there are any higher benefits, or new services included in your new cover, you will generally serve waiting periods for those things only. Any limits you’ve used at your old insurer also count to your new limits.
- You can still access your previous level of cover while waiting for higher cover to kick in.
The Private Health Insurance Act 2007 says that a person has a pre-existing condition if:
- In the opinion of a medical practitioner appointed by your health insurer, you had signs or symptoms of an illness or condition, at any time in the six months before you took out your policy (ending on the day you took it out).
A doctor appointed by your insurer decides whether your condition is pre-existing, not you or your doctor. The insurer’s doctor must consider your treating doctors’ opinions on the signs and symptoms of your condition, but doesn’t have to agree with them.
If you’re unhappy with your health insurer’s decision, or how they have handled your assessment, it’s always best to contact them, and follow any complaints handling processes that they have. If you can’t resolve it, you can discuss your complaint with the Private Health Insurance Ombudsman.
If your insurer’s doctor has assessed your condition and decides it was pre-existing, generally you won’t be covered for any treatment for it for the first twelve months of starting, or upgrading your policy. The exceptions to this are if it’s for psychiatric treatment, rehabilitation or palliative care, which you’ll generally wait two months before being covered for.
If you need psychiatric services, in certain circumstances, you might be able to upgrade your cover without a waiting period, once in your whole lifetime.
Yes. The choice is completely yours.
Here are some things you might consider in choosing a specialist.
Administration Fees
According to Australasian Royal College of Surgeons, ‘booking’ or ‘administration’ fees to see a specialist are unethical.
If you’re charged a fee like this, ask your doctor:
- What is the fee for?
- How does it apply to my care?
If the answer isn’t clear, you could refuse to pay the fee, and discuss it with your health insurer.
Paying for multiple tests and consultations for the same thing
To diagnose your health condition, your GP or specialist may order a range of tests. It’s worth asking what each test is for, and what it will cost.
It’s worth discussing this with your GP or specialist, and making sure you understand the benefits and costs of each test or treatment they suggest for you.
What is a General Practitioner (GP)?
GPs are usually your first point of contact when you need to get your health condition assessed. They focus on treating the body as a whole, and play a key role in diagnosing, treating and helping you manage your condition. Where necessary, they may refer you to a specialist.
What is a specialist?
A medical specialist is a doctor who has a high level of education and training in a specific area of medicine, for example, a cardiologist specialises in treating heart conditions.
Your GP might think you need further tests, or to see a specialist, to diagnose or further treat your condition. Here are 5 important things to remember about referrals:
- You can ask your doctor to refer you to a specific specialist.
- You can ask your doctor to refer you without naming a specialist. This is called an open referral. It means you can go to any relevant specialist with that referral.
- A referral covers your initial appointment and ongoing treatment with that specialist, unless you’re referred back to your GP. This means you’ll need a new referral. You’ll also need a new referral if:
- you have a new or unrelated condition, even to see the same specialist
- you want a second opinion from another specialist.
- It’s important to know when your referral expires, and to see a specialist within that timeframe.
GP referrals
Referrals from GPs last 12 months. If you need ongoing care, your GP can write a referral without an expiry date (called an ‘indefinite referral’), but they must specifically state on your referral that it is ‘indefinite’.
Specialist to Specialist Referrals
If your specialist refers you to another specialist, your referral lasts 3 months, unless you’re already admitted to hospital. If you’re already in hospital, they last 3 months, or until you’re able to leave (or be ‘discharged’ from) hospital, whichever is longer.
- Your health insurer might have agreements with specialists that can save you money on any fees you pay your specialist for treatment in hospital. This is called a ‘gap’ scheme, because it reduces the gap between what your doctor charges and what Medicare and your insurer pay for your treatment.
Find out more on your referral options.
‘Gaps’ or ‘out-of-pocket costs’ are the difference between what you’re charged and what Medicare and your insurer (if you have one) will pay for your treatment. Another way to think of it is ‘the amount you pay’.
Check out our top five tips on reducing your out of pocket costs .
A rebate is an amount paid back to you for a service. The Medicare rebate is the amount that has been set as an appropriate charge for that service, on a list called the Medicare Benefit Schedule (MBS).
Allied Health Providers (or Allied Health Professionals) are generally health professionals that aren’t doctors, nurses or medical professionals. They are usually university qualified, and focus on preventing, diagnosing and treating a range of conditions.
Some examples:
- Psychologists
- Occupational therapists
- Radiographers
- Pharmacists
- Podiatrists
In Australia, there are two main categories of hospital services that you can access: public and private, with several subsets that sit under each category.
Public Hospitals
| Hospital Type | What’s the difference? |
|---|---|
| Public Acute Hospitals | They focus on providing care for ‘acute’ health situations, over shorter periods, such as in an emergency, or surgery. They may also provide care over a longer term, for example, some types of rehabilitation. |
| Public Psychiatric Hospitals | They focus on caring for mental health conditions, sometimes for longer periods. |
Private Hospitals
| Hospital Type | What’s the difference? |
|---|---|
| Private ‘day’ facilities | They provide treatment that can be undertaken in a single day which will not require an overnight stay. |
| Overnight private hospitals | These hospitals provide treatment which may include elective surgery, psychiatric and/or rehabilitation treatment. Some private hospitals will have emergency departments. |
The Australian Medical Association (AMA) has created a list of fees that they think are appropriate for a doctor to charge for each medical service.
It’s important to remember that doctors can charge any fee they feel is reasonable.
Find out more about the AMA and their list of fees.
Acute care in hospital is healthcare which is mainly intended to:
- Diagnose a condition
- Relieve symptoms of an illness or injury
- Reduce how severe an illness or injury is
- Cure or treat an illness
- Manage labour (pregnancy)
- Where an illness or injury threatens your life, or your body functioning normally, acute care might be treatment to prevent an illness or injury from becoming worse
- Perform surgery
Acute care does not include:
- Mental health care, or
- Palliative care
Many health insurers make arrangements with specialists to reduce the ‘gap’ you pay in doctors’ fees. Remember, a ‘gap’ is the difference between what you’re charged, and what Medicare and your insurer pay for your treatment.
Some insurers call this a ‘Gap Scheme’, and others might call it something different like ‘Gap Cover’, or ‘MediGap’.
Where a specialist chooses to use your insurer’s medical gap scheme for your treatment, they agree only to charge up to a certain fee. Your insurer then pays a much higher amount than what they normally would, so that you pay less or nothing.
A specialist may be part of the scheme, but not use it for your treatment. They choose whether to use it for each course of treatment they provide.
If you’re a Bupa member, find out more about Bupa’s Medical Gap Scheme.
A medical registrar is a senior doctor who supervises residents, interns and students in a hospital.
They will usually have at least three years of experience in a public hospital.
These are the same as ‘Extras’ on your health insurance. Extras cover is only allowed to include treatments that are:
- For health conditions
- Not covered by Medicare
- Not hospital treatment
It’s a document from your health insurer that explains what ‘benefit’, or money has been paid toward your treatment.
‘Visiting Medical Officers’, are specialist doctors who see patients to provide input in a specific medical specialty, like orthopaedics, for example. They might also be called ‘senior consultants’.
An elective procedure is surgical treatment in hospital that is medically necessary, and planned or pre-booked – so it’s not related to an emergency. A procedure could also be ‘semi-elective’. This means it could be necessary to save a patient’s life, but doesn’t need to happen immediately.
If you’ve ever needed treatment in hospital, you might have heard the words ‘inpatient’ or ‘outpatient’. The main time you’ll notice the difference is how you pay for treatment. The table below gives you a summary of the difference between inpatients and outpatients.
| Inpatient | Outpatient | |
|---|---|---|
| Definition | An inpatient is someone who has been ‘admitted’ to hospital for treatment as a doctor has assessed they need hospital care. At this point, you’ll usually have been assigned a bed in the ward, or a room. If you’re not sure whether you’re being admitted, check with your doctor. | An outpatient is someone receiving medical treatment who hasn’t been ‘admitted’ to hospital. |
| Examples |
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| Exceptions | Emergency room treatment. If you visit an emergency department for treatment, you can be ‘in’ hospital, without being admitted. | You could be admitted to hospital after receiving treatment in an emergency department. |
| Who pays for it | If you choose to be a public patient, Medicare does. As a private patient, your treatment is covered by a mix of:
|
Depending on your treatment and what you’re charged, Medicare might pay some or all the cost.
You pay the rest yourself. |
Informed Financial Consent means that:
- You’ve been informed about the costs you can expect, and what benefits you’re getting for that cost. Your doctor and hospital have a responsibility to give you all the information before you have your treatment
- You consent to them, knowing what you’re getting, and what you’ll need to pay
Your Informed Financial Consent should include:
- Information about your procedure, including the item number , and the fee for each item
- What you’ll pay for things like your accommodation, and use of the operating theatre
- What you’ll pay for each doctor, including your anaesthetist
- What you’ll pay for any prostheses you are having
- Your signature, or the signature of your guardian
Find out more about Informed Financial Consent.
Your doctor could also use the Australian Medical Association’s (AMA) Template to give you Informed Financial Consent.
Medicare is the way the government provides access to healthcare for the public. Most taxpayers pay a tax of 2% of their taxable income to help fund it. There are 2 versions of Medicare – ‘full’ Medicare, and ‘reciprocal’ Medicare.
Full Medicare is for:
- Australian citizens
- Permanent residents
- Some people in the process of applying for permanent residency
It covers:
- The cost of treatment as a public patient in a public hospital. This includes doctors’ services, hospital costs and more
- 75% of the fee on a government list (MBS) for doctors’ services in hospital if you’re a private patient
- All (what’s known as ‘bulk billing’) or some of the cost of going to a GP or specialist
- Some (but not all) tests and examinations your doctor orders for you, and
- Reduced cost on some prescription medications, if they are on a government list called the Pharmaceutical Benefits Scheme (PBS)
Reciprocal Medicare is for overseas visitors who are from certain countries that Australia has agreements with. It only covers some of the costs medically necessary healthcare that can’t wait until they return home.
Find out more about how the Australian Healthcare System works.
Find out more about Medicare
Medicare has a list of medical services that the government will either pay some or all of the cost of, called the Medicare Benefit Schedule. Each has a fee that the government thinks is appropriate to charge for that service, which is the amount Medicare will pay for that service. It’s important to remember that your doctor could charge more than the fee on this list.
A Medicare item number is the number on a list that Medicare gave your treatment, to identify it. You can use that number to check with Medicare, and/or your private health insurer what they will pay for your treatment.
- The prostheses are provided with a treatment that is included in your health insurance
- The treatment is provided as part of a hospital treatment, or part of a treatment you have instead of a hospital treatment (sometimes called ‘hospital substitute treatment’)
- Medicare pays money towards the treatment
The Pharmaceutical Benefits Scheme or ‘PBS’ is the system that the government uses to decide what medicines the government will pay some of the costs for, to help reduce the cost of some prescription medicines so that the cost is manageable for everyone.
For medicines on this list, the government sets an amount for people with Medicare to pay, and a lower amount for seniors and concession card holders to pay, called the ‘PBS co-payment’.
The government will pay anything above that amount, and you only pay the co-payment, if the medicine is on the PBS list, and it costs above the PBS co-payment.
You will pay the full cost of the medication, if:
- The medicine is put on the PBS list, and the cost of the medication is below the PBS co-payment, or
- The medicine is not on the PBS
Find out more about the PBS.
There are five main types of costs you could experience in a hospital visit.
| Medical costs: | The fees charged by a surgeon, physician, anaesthetist, or other medical specialist when they are treating you in hospital. |
|---|---|
| Hospital costs: | Charges related to staying in the actual hospital such as the use of the bed, food and operating theatre, plus nursing and allied health services. |
| Pharmacy costs: | The cost of prescribed medication provided to you, or purchased by you, for treatment of your condition. This includes pharmaceuticals listed on the Australian Government’s Pharmaceutical Benefits Scheme Schedule (PBS), and, in some cases, non-PBS ‘High Cost Drugs’. |
| Prostheses costs: | The cost of things that are surgically implanted like artificial hips or knees or cardiac devices such as pacemakers, and stay implanted when you leave hospital. |
| Ambulance costs: | The costs associated with transport services (via air or road) from the place where you are treated, to the emergency department of a receiving hospital. Learn more about how Ambulance costs work. |
Learn more about who pays for these costs.
There are several different medical professionals involved in your hospital care. They will each have particular roles and responsibilities in providing healthcare, based on their medical specialty and experience.
Some types of doctors that might be involved in your care are:
- Student doctors, or medical students, who are still completing their medical degree.
- Interns, or doctors who have completed their study, and are spending time gaining experience in hospital
- Residents, which look after patients in a hospital ward. They will usually be training for their medical specialty
- Registrars are senior doctors who supervise students, interns and residents.
- ‘Visiting Medical Officers’, are specialist doctors who see patients to provide input in a specific medical specialty, like orthopaedics, for example. They might also be called ‘senior consultants’.
Learn more about other medical professionals and hospital staff who might help in providing you care.
An emergency department is part of a hospital that diagnoses and treats urgent health situations.
When you arrive at an emergency department, the staff will assess how urgent your situation is and prioritise care in order of how urgent your health situation is.
Find out more about what to expect in an emergency department.
Excesses
If you have private health insurance, an excess is a one-off payment you make if you need to go to hospital. You pay it before you go to hospital, and before your insurer covers the rest of the costs your policy includes.
This should be on the paperwork for your policy, and should have been agreed on before you took out your policy.
Things to check with your insurer:
- How many times per year is it paid per person?
Most excesses apply once per person per year. They may also then limit how many times excesses are paid for your whole policy per year. This could be calendar year, or depending when you join.
- If I transfer health insurers, do I need to pay it again?
Say you paid your excess after going to hospital in January, then changed insurers in March. If you need to go to hospital again that year, even though you’ve paid your excess with your old insurer, you may need to pay it again with your new insurer. If you know you need further hospital treatment, you could save money by considering this before you switch your cover.
- What happens if I change my cover to one with a higher excess?
You will usually need to pay the difference between your lower excess and your higher excess, the next time you are admitted to hospital. The table below gives an example of how this might work:
| Cover type | On cover with $250 Excess | Move to cover with $500 Excess in June |
|---|---|---|
| Hospital Admission Date | In April | In August of the same year |
| What you would pay | $250 Excess | You’d pay a $250 Excess (the difference between the excess on your old cover and your new cover). |
Co-payments
If you have private health insurance, a co-payment is a set amount you pay each day that you are in hospital, usually up to a maximum number of days. It usually applies every time you are admitted to hospital.
Things to check:
- How many times per year is it paid per person?
- If I transfer health insurers, do I need to pay it again?
- What happens if I change my cover to one with a higher excess?
- How many days I have to pay it?
Usually there will be a maximum number of days you need to pay a co-payment.
These work in a similar way to an excess on car insurance.
When you select your private hospital cover, you can choose whether you’d like to have an excess or co-payment on your policy. If you do have one, you’ll usually pay a lower price for your cover (often called a ‘premium’). That way, you only pay this amount should you need to go to hospital.
The short answer
No, health insurers in Australia can’t discriminate against you based on your age, gender, sexuality or your health status.
The long answer
Health insurers can’t discriminate against anyone because of a concept in Australian health insurance law called ‘community rating’.
Community rating is different from ‘risk rating’. Risk rating is a type of insurance rating that impacts pricing and benefits, based on a range of different factors that may increase your potential ‘risk’ for that insurer. For example, if you get car or life insurance.
In Australia, we don’t use this system for health insurance, we use community rating. This means:
- Equal access to and management of health insurance
- States are the ‘community’ within which each cover is ‘rated’ or priced. This means that price, what you get, and the limits you have for each type of cover can only vary between each state
- You can’t generally be refused health insurance
- Each type of cover must be available in all states and territories
- Discounts can’t be beyond 12%