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When you are treated by your Doctor in hospital, Medicare pays 75% of the Government Schedule fee and Transport Health pays the remaining 25%. However, some doctors charge above the government schedule fee and you are usually required to pay the difference. This out-of-pocket cost is referred to as “the gap”.
Transport Health’s Access Gap cover seeks to reduce or eliminate ‘the gap’, resulting in no or less out-of-pocket costs to you. Transport Health Access Gap has its own schedule of fees which are generally higher than the current government schedule of fees. If your doctor chooses to charge using our schedule of fees, there may be no out-of-pocket cost to you or, alternatively, your doctor may choose to charge a co-payment, which is an agreed amount doctors can charge above the fee set in our schedule. This co-payment will be known as an out-of pocket cost for you. Usually when a doctor charges a co-payment they should inform your prior to treatment.
It is important to be aware that your doctor can choose to participate in Access Gap on a patient by patient basis, so you should check with your Doctor whether they will participate. Also be aware that more than one doctor may be involved in your treatment.
Participating doctors will generally send their accounts direct to Transport Health. If the doctor does send you an account, you need to submit it directly to Transport Health and not to Medicare.
Please contact our Office on 1300 806 808 if you have any further queries.
acupunctureAcupuncture is a family of procedures involving the stimulation of anatomical locations on or in the skin by a variety of techniques. The most thoroughly studied mechanism of stimulation of acupuncture points employs penetration of the skin by thin, solid, metallic needles, which are manipulated manually or by electrical stimulation.
adult dependantPersons are considered dependants of the contributor in the following instances:
- Unmarried children between the age of 21-25 and are not full- time students and not eligible for cover under the family membership as detailed under the definition of “dependant children”
- Singles up to the age of 25 and not living in a de facto relationship
agreement private hospital
Transport Health has negotiated set benefit arrangements with 98% of private hospitals and day facility hospitals throughout Australia, eliminating or minimising out-of-pocket expenses for members according to their level of cover. Product excesses and/or co-payments still apply.
To find an agreement hospital, please use the hospital finder.
assisted reproductive services
Assisted reproductive services includes, but is not limited to:
- Vasectomy and reversals
Australian Government Rebate on Private Health Insurance
The amount of Australian Government Rebate you can claim is dependent on your income. The rebate percentage entitlement will depend on your nominated income tier.
A 30% Australian Government Rebate is available to singles earning less than $88,000 and families, couples (including de facto) and single parents earning less than $176,000. Those members over 65 may receive a higher rebate. For families with children the income threshold increases by $1,500 for each child after the first.
A 20% Australian Government Rebate is available to singles earning between $88,001 - $102,000 and families, couples (including de facto) and single parents earning between $176,001 - $204,000. Those members over 65 may receive a higher rebate. For families with children the income threshold increases by $1,500 for each child after the first.
A 10% Australian Government Rebate is available to singles earning between $102,001 - $136,000 and families, couples (including de facto) and single parents earning between $204,001 - $272,000. Those members over 65 may receive a higher rebate. For families with children the income threshold increases by $1,500 for each child after the first.
No Australian Government Rebate is available on premiums to singles earning over $136,001 and families, couples (including de facto) and single parents earning over $272,001.
* The Income Tiers are indexed annually.
The ATO will determine the amount of your Australian Government private health insurance rebate when you lodge your income tax return. Please take care when choosing your applicable Tier. Should your taxable income change throughout a tax year, you should contact Transport Health to nominate your new Tier. If you do not contact the fund, your rebate will be adjusted on your next income tax return. The ATO advise that there are no penalties for making an incorrect Tier nomination. The income test for both the Medicare Levy Surcharge and entitlement to the Australian Government Rebate is called income for (Medicare Levy) surcharge purposes. Further details can be found at www.ato.gov.au.
benefit limitation periods
Benefit Limitation Periods are a feature of some Hospital covers – They are initial periods of membership during which only minimal benefits are paid for some types of treatment. Benefit limitation periods will not apply to you if you are transferring from another Hospital product with Transport Health or another Fund.
On some tables Transport Health applies BLP’s to palliative care for the first 12 months of membership if previously uninsured. BLP means benefits are restricted to basic cover. Basic cover provides public hospital cover as a private patient in a shared ward, with your own choice of doctor. Treatments for these services are not recommended in a private hospital under these covers. Please contact the Fund for further information on these benefits within the first 12 months of cover.
benefit replacement periods
A benefit replacement period is the period of time you will need to wait after claiming an item before you can receive further benefits to replace the item.
i.e. if you received a claim benefit for a full set of dentures on 1/7/2011 you would not be eligible to claim on dentures again until after 1/7/2014.
Period before replacement can be claimed
Dentures – Full
Dentures – Upper/Lower/Partial
broader health cover
Broader Health Cover is an initiative designed to utilise non-hospital forms of treatment, including early release and preventative health care.
chiropracticChiropractic employs manipulation and adjustment of body structures, such as the spinal column, so that pressure on nerves coming from the spinal cord may be relieved. This treatment based on the concept that the nervous system coordinates all of the body's functions, and that disease results from a lack of normal nerve function. Chiropractic treatment has been shown to be effective in treating muscle spasms of the back and neck, tension headaches, and some sorts of leg pain.
Co-payments under Top Hospital cover are an amount payable by the member and applicable to each hospital admission during a calendar year. Top Hospital with Co-payment has a daily co-payment of $100 per night, capped at $500 per person, per calendar year. This is also capped annually at $500 per person to a maximum of $1000 per couple / family per calendar year. Co-payments do not apply to same day accommodation.
Healthy Choice Hospital has a daily co-payment of $100 for overnight accommodation capped at $500 per person with a family maximum of $1000 in any calendar year. There is also a daily co-payment of $150 for day stays / day procedures excluding in-patient dental treatment.
Benefits are only payable for cosmetic surgery or services where it is required for a medical purpose and for which Medicare benefits are payable.
CPAP stands for "Continuous Positive Airway Pressure".
Benefits can only be claimed from either a hospital or extras table but not from both. Benefits are payable for replacement parts i.e. masks.
dependant childrenPersons are considered dependants of the member in the following instances:
- Unmarried children up to the age of 21
- Unmarried children between the ages of 21 and 25, who are full-time students in an approved apprenticeship / study course
The Excess is an amount payable by the Member on making a claim, and applicable only once in the calendar year.
The excess, as in Top Hospital with Excess cover, is $250 per person, on the first overnight admission, per calendar year. A single membership has a maximum excess of $250 annually. A family membership has an excess of $250 up to a family maximum of $500, for overnight admissions, per calendar year.
Young Singles Cover has a $250 excess payable on overnight and/or day stays per admission. This excess is capped annually at $500. Young Couples cover has a $250 excess payable on overnight and/or ay stays per admission. This excess is capped annually at $500 per person, per calendar year.
An excluded service is one on which benefits will not be paid by Transport Health.
Transport Health does not pay benefits for hospital treatment of any of these conditions when you elect to be treated as a private patient. You re, however, covered by the public system under your Medicare entitlement, only when treated as a public patient by hospital appointed doctors in a public hospital.
extras coverExtras cover is a form of health insurance which allows a member to claim back some or all of the cost of non-hospital treatment, such as dental, physiotherapy, chiropractic and osteopathy.
Under all hospital covers, medical benefits are paid in accordance with the Medicare Benefits Schedule Fee for inpatient medical treatment. Medicare will cover 75% of schedule fee and Transport Health will pay the remaining 25% of the schedule fee up to the Medicare Benefits Schedule (MBS).
If a doctor charges more than the MBS this is known as the ‘gap’ and is payable by the member.
"General" dental usually refers to preventative dentistry and the normal maintenance required to sustain oral and dental health.
Usually this includes regular check-ups, hygeineist, fillings etc.
GIFTStands for in gamete intrafallopian transfer, which is when a mixture of sperm and eggs are placed directly into the fallopian tuves using laparoscopy.
Hospital cover is a type of health insurance which covers a member for the cost of treatment in hospital, should they require it.
The price of hospital cover is based on the level of care covered, and on whether services are excluded from the policy. For example, Basic Hospital Cover covers only treatment in public hospitals as a private patient, whereas comprehensive plans cover treatment in private hospitals. Mid-range plans often exclude certain expensive treatments in order to reduce the cost of the member's premium, or offer restricted benefits on some services.
Lifetime Health Cover
If you are aged over 30 and you are taking out private hospital cover for the first time, you may have to pay an additional loading on top of your premium, known as Lifetime Health Cover. The loading increases 2% for every year where you are not covered, and will be applied to your premium for 10 years.
Your age Loading Your age Loading Your age Loading Your age Loading 30 0% 39 18% 48 36% 57 54% 31 2% 40 20% 49 38% 58 56% 32 4% 41 22% 50 40% 59 58% 33 6% 42 24% 51 42% 60 60% 34 8% 43 26% 52 44% 61 62% 35 10% 44 28% 53 46% 62 64% 36 12% 45 30% 54 48% 63 66% 37 14% 46 32% 55 50% 64 68% 38 16% 47 34% 56 52% 65+ 70%
After contributing to a hospital plan for 12 continuous months, you may cancel or cease your cover for a combined period of 1094 days without incurring a further penalty.
You can calculate your exact loading, taking into account all gaps in coverage and overseas absences, using the Department of Health and Ageing's Lifetime Health Calculator.
Limited benefits refers to a service which is covered by Transport Health but at a reduced rate.
Normally, services have limited benefits during the first few months of coverage, but in some cases benefits are reduced through the lifetime of the policy.
For hospital services with limited benefits, members are restricted to treatment in a public hospital as a private patient, and cannot claim for the cost of treatment in a private hospital.
loyalty rewardThe loyalty reward offers you the option, after 24 months continuous membership of Young Couples cover, to upgrade to a Top Cover plan for pregnancy and birth-related services with no further waiting periods applying.
major dentalMajor dental refers to restorative and cosmetic dentistry, including crowns, bridges, implants etc.
Medicare is the Australian Government's universal health insurance scheme, which covers all eligible citizens and residents for hospital treatment in public hospitals by hospital-appointed doctors.
Individuals with private hospital insurance are still entitled to receive treatment under Medicare through the public system.
medicare surcharge levy
The Medicare Levy surcharge will be income tested against three new income thresholds. Middle and higher income earners, who do not have the appropriate level of private patient hospital cover, will incur a Medicare levy surcharge on their income.
Base Tier* Tier 1* Tier 2* Tier 3* Singles $88,000 or less $88,001 - $102,000 $102,001 - $136,000 $136,001 or more Families $176,000 or less $176,001 - $204,000 $204,001 - $272,000 $272,001 or more
Medicare Levy Surcharge
Rate 0.0% 1.0% 1.25% 1.5%Further details about the Medicare levy surcharge and how the ATO define what is considered income for surcharge purposes can be found at: www.ato.gov.au/medicarelevysurcharge.Extras only Tables do not have an appropriate level of private patient hospital cover, and if your income is over a certain amount, the Medicare Levy Surcharge will apply. For further details please contact your Tax Agent or ATO website.Those members on above Base Tier incomes who suspend their membership whilst overseas may no longer be exempt from the Medicare Levy Surcharge for the period of suspension. Members should seek advice from their Tax Agent of the ATO in relation to their personal circumstances.
naturopathyNaturopathic medicine integrates traditional natural therapeutics - including botanical medicine, clinical nutrition, homeopathy, acupuncture, traditional oriental medicine, hydrotherapy, and naturopathic manipulative therapy - with modern scientific medical diagnostic science and standards of care.
When a newborn baby is in hospital with the mother a separate accommodation charge is not usually raised for the child during the hospital stay. Single cover should be changed to family or single parent family at least 3 months prior to the birth, however, single parent family or family cover is required to cover accommodation costs for:
• Newborns admitted to hospital and / or intensive care
• The second and later children of a multiple birth
non-agreement private hospital
A non-agreement hospital is a provider which does not have a contract with a health insurer outlining the agreed benefits which will be paid for treatment.
You should check with Transport Health before seeking treatment to ensure that your hospital or provider has an agreement with us, or you may be liable for additional costs.
For members with Extras cover, optical benefits are available from all Optical retailers in private practice who are registered with Transport Health. All eligible members can claim a benefit* on frames, prescription lenses and contact lenses.
A claim for services can usually be made on the spot at Optical Outlets around Australia. After your treatment, swipe your membership card and the claim will be processed automatically. There are no forms for you to complete and you'll only pay the balance of the account.
For those members forwarding a claim directly to Transport Health, a copy of the Optical prescription must accompany an Itemised account, together with a completed claim form. Members should note that Optical supplies and/or services received overseas or purchased from overseas including items sourced over the internet are not claimable.
* for eligible services up to your annual optical limit
orthodonticOrthodontics is the specialty of dentistry that is concerned with the treatment of malocclusions (improper bites), which may be a result of tooth irregularity, disproportionate jaw relationships, or both. Orthodontic treatment can focus on dental displacement only, or can deal with the control and modification of facial growth.
osteopathyA system of medicine based on the theory that disturbances in the musculoskeletal system affect other bodily parts, causing many disorders that can be corrected by various manipulative techniques in conjunction with conventional medical, surgical, pharmacological, and other therapeutic procedures.
out-of-pocket expenseAn out-of-pocket expense is a sum payable by the member where their insurance does not cover the full cost of their treatment. Out-of-pocket expenses can occur in either hospital or general treatment.
physiotherapyPhysiotherapy is a science-based healthcare profession which views movement as central to health and well-being. Physiotherapists aim to identify and make the most of movement ability by health promotion, preventive advice, treatment and rehabilitation. Core skills used include manual therapy, therapeutic exercise and the application of electrophysical modalities.
podiatryThe branch of medicine that deals with the diagnosis, treatment, and prevention of diseases of the human foot.
It is standard practice in the Health Insurance Industry to apply a 12 month waiting period before benefits are paid on any pre-existing conditions.
A pre-existing condition is defined by law as any ailment, illness or condition that you had signs or symptoms of during the six months before you joined a hospital table or upgraded to a higher hospital table. 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 table or upgrading to a higher hospital table.
If you knew you weren’t well, or had signs of an ailment that a doctor would have detected (if you had seen one) during the six months prior to joining the hospital table, then the ailment would be classed as pre-existing.
Transport Health will appoint a medical practitioner to determine whether you have a pre-existing condition based on your treating doctors’ information.
Transport Health has negotiated arrangements with health care providers to participate in programs that eliminate or minimise out-of-pocket expenses for some extras treatments like physiotherapy, chiropractic and osteopathy. Members can claim on their extras policy for treatment by any registered provider, however, by using a preferred provider out-of-pocket costs will be reduced or eliminated.
pregnancy & birth-related servicesPregnancy and related services includes, but is not limited to, antenatal and postnatal care and management of labour and delivery.
reflexologyReflexology is a therapeutic method of relieving pain by stimulating predefined pressure points on the feet and hands. This controlled pressure alleviates the source of the discomfort.
Removal of the rebate on Lifetime Health Cover LoadingLegislation currently before the Federal Parliament will mean that the Australian Government rebate on Private Health Insurance will no longer apply to the Lifetime Health Cover (LHC) component of hospital cover premiums effective 1 July 2013. The changes will realign arrangements under the Private Health Insurance Act 2007 so that all recipients of the rebate receive a comparable benefit relative to their premium, regardless of whether they have a LHC loading or not. Rebate recipients will be treated consistently subject to age and income.
A restricted benefit is where a form of treatment is covered but at a reduced level to other treatments on the same plan. For example, cover may be restricted to treatment as a public patient, or may be capped at a certain total cost. Access Gap cover is not normally available where benefits are restricted.
Restricted benefits usually refer to hospital insurance.
shiatsuShiatsu is a manipulative therapy developed in Japan and incorporating techniques of anma (Japanese traditional massage), acupressure, stretching, and Western massage. Shiatsu involves applying pressure to special points or areas on the body in order to maintain physical and mental well being, treat disease, or alleviate discomfort.
Benefits payable during the first 6 months of membership and after serving the specified waiting periods, cannot exceed 50% of the full annual benefit limit entitlement. If further treatment is required in the subsequent 6 months, members are entitled to the balance of the annual limit. The overall benefit payable over 12 months is equal to the normal quoted annual limit but this amount cannot be claimed totally within the first 6 months. Sub-limits do not apply to members who are transferring from other funds, providing they have held equivalent membership and served the required waiting periods.
In general, sub-limits apply to those who were previously uninsured. After 12 months of membership (or the stated waiting period for the service - whichever is the greater), members are entitled to unrestricted benefits as stipulated on the relevant plan's page.