Glossary

Accident

An unforeseen event, occurring by chance and caused by an external force or object, resulting in involuntary injury to the body requiring immediate treatment.

Accident does not include any unforeseen conditions the onset of which is due to medical causes nor does it include pre-existing conditions, falling pregnant or accidents arising from surgical procedures.

Adult Dependant

A child of the policy holder or their partner, who:

a) is not married or in a de-facto relationship,

b) is between 21 and 30 years old (inclusive), and

c) is not a Student Dependant

Please note that only some Medibank covers allow the addition of an Adult Dependant.

Ambulance

A road vehicle, boat or aircraft operated by a service approved by Medibank and equipped for the transport and/or paramedical treatment of a person requiring medical attention.

Annual limit

An annual limit is the maximum amount of benefits we pay towards services and/or items within a calendar year. A combined limit is an annual limit that applies to a group of services and/or items. Where the annual limit increases, it will increase on 1 January each year, up to the maximum limit. The first increase will be applied only after you’ve served one full calendar year of membership.

Appendicitis treatment

Admission to hospital for an inflamed appendix (appendicitis). It includes admission to hospital with suspected appendicitis and may include surgery to remove the appendix (appendectomy).

Assisted reproductive services (clinical category)

Hospital treatment for fertility treatments or procedures.

For example: retrieval of eggs or sperm, In vitro Fertilisation (IVF), and Gamete Intra-fallopian Transfer (GIFT).

Back, neck and spine (clinical category)

Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion.

For example: sciatica, prolapsed or herniated disc, spinal disc replacement and spine curvature disorders such as scoliosis, kyphosis and lordosis.

Benefit

The amount of money we contribute towards the cost of an item or service included under a member's cover. The benefit we pay for services or items is likely to be less than your annual limit and less than your provider’s charge, which means you may have out-of-pocket expenses to pay.

Benefit replacement period (BRP)

This is the period of time you need to wait from the date of purchase of an item before you can receive another benefit to replace it. This is separate to a waiting period.

CPAP-type device

An external device used to increase the flow or pressure of air that is available for respiration. These devices include Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) or similar devices, as approved by Medibank from time to time.

Calendar year

The period from 1 January to 31 December.

Cataracts (clinical category)

Hospital treatment for surgery to remove a cataract and replace with an artificial lens.

Chemotherapy, radiotherapy and immunotherapy for cancer (clinical category)

Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours. Surgical treatment of cancer is listed separately under each body system.

Chemotherapy and radiotherapy for cancer

Chemotherapy involves the administration of medication to kill cancer cells and to treat cancer. Radiation treatment uses high doses of radiation to destroy cancerous tumours, usually at one specific site in the body.

Child

Child means one of the following:

a) a natural child,

b) an adopted child,

c) a foster child,

d) a step-child, or

e) a child being cared for under guardianship arrangements approved by Medibank from time to time.

Child Dependant

A child of the policy holder or their partner, who:

a) is not married or in a de-facto relationship, and

b) is less than 21 years old.

Chiropractic

Chiropractic treatment involves the manipulation or adjustment of the spine and the diagnosis and management of spinal health related problems and is intended to treat conditions such as back or neck pain and injuries, headaches/migraines and joint problems to promote mobility.

It includes consultations and x-rays. Benefits are payable for one-on-one sessions only. Where x-rays are provided under a person’s cover, the practitioner must be licensed to provide them. 

The provider must be an AHPRA registered health practitioner. The peak body for Chiropractors is the Australian Chiropractors Association (ACA).

Clearance certificate

See: Transfer certificate.

Colonoscopy

A procedure to examine the lining of the large bowel (colon). It is used to screen, investigate and/or treat the cause of abdominal pain, bleeding, irregular bowel habit, remove polyps or detect cancer. Where a colonoscopy procedure is included under a cover, it must be performed in-hospital for benefits to be payable.

Commonwealth Medicare Benefits Schedule (CMBS)

See: Medicare Benefit Schedule (MBS).

Condition

An actual or perceived stated of health for which treatment is sought. It includes but is not limited to states variously described as; abnormality, ailment, disability, disease, disorder, health problem, illness, impairment, impediment, infirmity, injury, malady, sickness or unwellness.

Default benefit

See: Minimum benefit.

Dental surgery (clinical category)

Hospital treatment for surgery to the teeth and gums.

For example: surgery to remove wisdom teeth, and dental implant surgery.

Dependant

Is a person who is included under an eligible membership who is either :

a) a Child Dependant,

b) a Student Dependant, or

c) an Adult Dependant.

Diabetes management (excluding insulin pumps) (clinical category)

Hospital treatment for the investigation and management of diabetes.

For example: stabilisation of hypo- or hyper- glycaemia, contour problems due to insulin injections.

Dialysis for chronic kidney failure (clinical category)

Hospital treatment for dialysis treatment for chronic kidney failure.

For example: peritoneal dialysis and haemodialysis.

Dietetics

Dietetics applies nutritional principles to the planning and preparation of food to maintain health and treat disease. It's purpose is to promote good health through proper eating and development of modified diets. It includes consultations with a registered dietician where they have a Medicare provider number. Any consumables are not claimable. The peak body for Dietitians is the Dietitians Association of Australia (DAA).

Ear, nose and throat (clinical category)

Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck.

For example: damaged ear drum, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer.

Equivalent cover

The Medibank product we consider to be most similar in coverage to a member's previous cover.

Excess

This is the amount you pay towards your hospital admission (same-day or overnight) before we pay any benefits. The excess applies per member, per calendar year and it doesn’t apply to child, student or adult dependants on a family membership. Some hospitals may require you to pay the excess at the time of admission.

Excluded service

A service that we don't pay benefits towards, including hospital accommodation or in-hospital medical service like specialists' fees.

Exercise physiology

Exercise physiology involves the design, implementation and supervision of exercise programs for the prevention and management of illness and injury and aims to assist the body’s recovery from illness or injury.

Extras benefits

See: Benefits.

Family membership

A membership that includes the policy holder, their partner and one or more dependants.

Fertility treatment

Treatment in hospital to facilitate the implantation of a viable embryo in order to achieve pregnancy. It includes retrieval and implantation of eggs and collection of semen. In Vitro Fertilisation (IVF) treatment and Gamete Intra Fallopian Transfer (GIFT) are two of the most common procedures. Benefits are only payable for parts of the treatment where a member is admitted to hospital.

Financial year

The period from 1 July to 30 June.

Health cover account (HCA)

A notification sent to members to inform them of their cover date paid to (DPT), when their next payment is due, the amount they should pay and available methods of payment.

Hearing aids

An external device fitted to the ear. The device must operate independently of any other audio equipment and improve hearing ability. It includes the purchase of In the ear (ITE), In the canal (ITC) and Behind the ear (BTE) hearing aids as well as the repair of hearing aids.

Where a government subsidy is available, it must be claimed prior to any health insurance benefit and the account must be paid in full. It does not include benefits for batteries.

Heart and vascular system (clinical category)

Hospital treatment for the investigation and treatment of the heart, heart-related conditions and vascular system.

 For example: heart failure and heart attack, monitoring of heart conditions, varicose veins and removal of plaque from arterial walls.

Male reproductive system (clinical category)

Hospital treatment for the investigation and treatment of the male reproductive system including the prostate. For example: male sterilisation, circumcision and prostate cancer.

Major eye surgery

Surgery to treat conditions and disorders associated with the eye. This includes cataract surgery as well as surgery to the cornea, retina, eyelid, tear duct and muscles of the eye, however does NOT include laser eye surgery for the correction or improvement of vision instead of wearing glasses or contact lens.

Medically necessary

Surgery or treatment that if not performed, could adversely affect the patient’s condition and is undertaken in accordance with accepted standards of medical practice, appropriate to the treatment, diagnosis and care required for the particular condition, illness or injury.

Medicare

The basis of Australia's public health care system that provides free or subsidised medical treatment to eligible persons, including as a public patient in a public hospital. More information on the Medicare services can be found on their website.

Medicare Benefits Schedule (MBS)

A list of medical services for which Medicare pays a benefit and the rules that apply to the payment of those benefits. Each service has a fee that has been set by the Australian Government for the purpose of calculating the Medicare benefit payable for that service. Also known as the Commonwealth Medicare Benefits Schedule (CMBS).

Medicare eligibility

The level of coverage a person is entitled to receive under Medicare. It determines the type of health insurance cover most appropriate to supplement any existing entitlements. Levels of Medicare eligibility are:
• Full Medicare (Green card)
• Interim Medicare (Blue card)
• Reciprocal Medicare (Yellow card); or
• No Medicare.

Medicare levy surcharge (MLS)

An additional surcharge, on top of the Medicare levy, which Australian taxpayers are charged if they earn above a certain income threshold and do not hold residential hospital cover. For more information or to see if this applies to you visit the ATO's website.

Member

A person who is insured under a Medibank membership.

Membership

Means being insured under a policy with Medibank through the payment of Premiums in line with our Fund rules.

Membership category

The category to which a membership belongs. Also known as the membership scale. Medibank offers the following membership categories:

Single membership – covers the Policy holder.
Couple membership – covers the Policy holder and their partner.
Single parent family membership – covers the Policy holder and any of their child dependants and/or student dependants.
Family membership – covers the Policy holder, their partner and any of their child dependants and/or student dependants.

We also provide an option for families with adult dependants, where, for an additional cost, some covers can be extended to also include an adult dependant/s.

Not all membership categories are available on all covers.

Membership scale

See: Membership category.

MembershipBonus

A feature included on some covers which can be used for:
- benefits for approved health related items,
- a top up towards extras benefits where the member has an out-of-pocket expense, or
- towards a hospital excess.

Members’ Choice hospital

See: Members' Choice Providers.

Members’ Choice network

The collective term for all Medibank Members’ Choice providers.

Members’ Choice provider

One of the following:
a) an extras provider Medibank has negotiated with so you won’t be charged more than the maximum agreed price, or
b) a hospital Medibank has an agreement with to help minimise members' out-of-pocket expenses

Members’ Choice hospitals/extras providers are subject to change. Search for a current Members' Choice provider online.

Mental Health Waiver

The Mental Health Waiver allows members who have served their two month waiting period for Restricted (Limited) in-hospital psychiatric treatment to upgrade to a cover with Included in-hospital psychiatric treatment and elect to have the two month waiting period for those higher benefits waived

Members can elect to use their waiver at the point of upgrading or after upgrading, prior to serving the two month waiting period for Included psychiatric treatment.  Members need to have held Hospital cover without a break of more than two months to be eligible to use the waiver.

The waiver only applies to the two month waiting period for the higher Included benefits for in-hospital psychiatric treatment. All other applicable waiting periods will continue to apply. 

Members will only be able to use the Mental Health Waiver once in their lifetime.

Minimum benefit

An amount set by the Australian Government as the minimum amount that a health fund must contribute towards hospital accommodation charges for an Included or Restricted service or treatment. Also known as a default benefit. Where a minimum benefit applies a member may have significant out-of-pocket expenses.

Miscarriage and termination of pregnancy (clinical category)

Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.

Obstetrics-related admissions

Services and treatment provided in hospital that deal with the care of women during pregnancy, childbirth and following delivery. It includes delivery of the baby and complications of pregnancy. This does not include any treatment that the baby may require. 

Occupational therapy

Occupational therapy helps people develop, recover, or maintain their daily living and work skills where they have a physical, mental or developmental condition. Its purpose is to enable people to participate more fully in the activities of everyday life.

Benefits are payable for consultations only and providers must have a Medicare provider number. The peak body for occupational therapist is Occupational Therapy Australia.

Orthodontics

The dental specialty concerned with the diagnosis, prevention and treatment of any abnormalities associated with the developing dentofacial structures. It aims to assist with the correction and alignment of the teeth and jaw. It generally involves the use of braces, removable appliances, functional appliances or headgear.

Orthodontics service descriptions are derived from the Australian Dental Association Schedule of Dental Services and Glossary which is widely accepted by the health insurance industry as the basis for the numerical coding (itemisation) of dental services for the purpose of paying benefits.

Orthoptics

See: Eye therapy.

Osteopathy

It involves stretching and the manipulation of bones and muscles in order to treat conditions such as back or neck pain and injuries, headaches/migraines and joint problems to promote mobility.

Benefits are payable for consultations only and providers must be an AHPRAregistered health practitioner. The peak body for osteopaths is the Australian Osteopathic Association (AOA).

Out-of-pocket expense

An Out-of-Pocket Expense (previously known as the ‘gap’) is a difference between the fee charged by a provider (a surgeon, dentist, or physiotherapist etc.) and the benefit Medibank will pay for the service. The term ‘gap’ will continue to be used for our GapCover scheme.

PackageBonus

A feature included on some covers which can be used for:
- benefits for approved health related items;
- a top up towards extras benefits where the member has an out-of-pocket expense; or
- towards a hospital excess.

Pain management (clinical category)

Hospital treatment for pain management that does not require the insertion or surgical management of a device.

For example: treatment of nerve pain and chest pain due to cancer by injection of a nerve block.

Pain management with device (clinical category)

Hospital treatment for the implantation, replacement or other surgical management of a device required for the treatment of pain.

For example: treatment of nerve pain, back pain, and pain caused by coronary heart disease with a device (for example an infusion pump or neurostimulator).

Palliative care (clinical category)

Hospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain.

Partner

A person who lives with the policy holder in a marital or de-facto relationship.

Per-Day Payment

A Per-Day Payment is a daily amount that you contribute towards your accommodation costs when admitted to hospital, and is separate to any applicable excess. The amount payable is determined by the cover held and is payable directly to the hospital.

Pharmaceutical Benefits Scheme (PBS)

The Pharmaceutical Benefits Scheme (PBS) is funded by the government and makes subsidised prescription medicines available to Australian residents. Residents eligible for the PBS contribute to the cost of subsidised medicines by paying a per day payment for each item set by the government.

Physiotherapy

Physiotherapy assesses, diagnoses, treats, and works to prevent disease and disability through physical means in order to help a person recover from injury, reduce pain and stiffness, and increase mobility.

It includes one-on-one and group physiotherapy consultations, clinical Pilates, hydrotherapy (group sessions only). 

The provider must be an AHPRA registered health practitioner. The peak body for physiotherapist is the Australian Physiotherapy Association (APA).

Plastic and reconstructive surgery (clinical category)

Hospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether acquired as a result of illness or accident, or congenital.

For example: burns requiring a graft, cleft palate, club foot and angioma.

Podiatric surgery (provided by a registered podiatric surgeon) (clinical category)

Hospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon, but limited to cover for:

• accommodation; and
• the cost of a prosthesis as listed in the prostheses list set out in the Private Health Insurance (Prostheses) Rules, as in force from time to time.

Podiatry

The diagnosis, treatment and prevention of conditions affecting the toe, foot and ankle in order to help members maintain good foot hygiene and posture. It may include the treatment of toe nail conditions, calluses and ulcers of the feet and assessment of gait to correct poor posture. The provider must be an AHPRAregistered health practitioner.

Policy holder

The main member on a Medibank membership who owns, and is responsible for the cover.

Pre-existing condition (PEC)

An ailment, illness or condition that in the opinion of a medical practitioner appointed by Medibank, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months prior to the day on which the person became insured under the policy or changed their cover.

Pregnancy and birth (clinical category)

Hospital treatment for investigation and treatment of conditions associated with pregnancy and child birth.

Premium

An amount of money that must be paid towards a membership for a specified period of cover.

Reciprocal health care agreement (RHCA)

An agreement between the Australian Government and certain overseas countries to provide visitors with access to subsidised health services for essential medical treatment. These arrangements vary from country to country. Additional information and confirmation of entitlements can be checked with Medicare. Holders of reciprocal Medicare entitlements are generally eligible to receive the AGR if they hold a Resident cover.

Rehabilitation (clinical category)

Hospital treatment for physical rehabilitation for a patient related to surgery or illness.

For example: inpatient and admitted day patient rehabilitation, stroke recovery, cardiac rehabilitation.

Removal of appendix

Surgery to remove an inflamed appendix (appendicitis). Also known as an appendectomy.

Removal of tonsils and adenoids

Surgery to remove tonsils and/or adenoids.

Renal dialysis

Treatment aimed at assisting or replacing the function of the kidneys. It can include both haemodialysis (circulating the blood through a machine) and peritoneal dialysis (infusing and draining a sterile solution into the abdomen). Where included under a person's cover, treatment must be provided in hospital for benefits to be payable.

Resident cover

A type of cover designed for residents of Australia who are entitled to full Medicare benefits.

Similar cover

See: Equivalent cover.

Single membership

A membership that includes one member, known as the policy holder.

Single parent family membership

A membership that includes the policy holder and one or more dependants.

Skin (clinical category)

Hospital treatment for the investigation and treatment of skin, skin-related conditions and nails. The removal of foreign bodies is also included. Plastic surgery that is medically necessary and relating to the treatment of a skin-related condition is also included.

For example: melanoma, minor wound repair and abscesses.

Sleep studies (clinical category)

Hospital treatment for the investigation of sleep patterns and anomalies.

For example: sleep apnoea and snoring.

Speech Therapy

Speech therapy diagnoses, manages and treats individuals who are unable to communicate effectively or who have difficulty with feeding or swallowing. It's purpose is to assist people who have communication disabilities. Speech pathologists also assist with a variety of conditions associated with feeding, swallowing or breathing problems Benefits are only payable for consultations and providers must have a Medicare provider number. Speech Pathology Australia (SPA) is the peak body.

Spinal fusion

Surgery to join two or more vertebrae in the spinal column. Spinal fusion often involves a bone graft and may involve the insertion of screws, rods or cages to hold the fused joints in place.

It may include surgical treatment of conditions such as chronic low back pain, spondylolisthesis, spondylosis and degeneration of the spine, but does not include the treatment of developmental deformities such as scoliosis or kyphosis.

State of residence

The State or Territory in which the policy holder resides.

Student Dependant

A child of the policy holder or partner who:

a) is not married or in a de-facto relationship,

b) is 21-30 years old (inclusive), and

c) is undertaking full-time education as determined by Medibank at an Australian educational institution.