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    Access Gap Cover Scheme (AGC) is a billing scheme that aims to reduce or eliminate out-of-pocket expenses to members for doctor and specialist services received in hospital. Doctors may choose to participate in AGC on a patient by patient basis, so you should discuss this with your doctor.

    Accident is an injury inflicted as a result of unintentional, unexpected actions or events caused by an external force that requires immediate inpatient hospital treatment by a registered Medical Practitioner or Dentist, but excludes pregnancy. If ongoing treatment is required past the initial inpatient admission, this treatment will no longer continue to be classed as an ‘accident’.

    Accommodation means accommodation charges for inpatient services in hospital. This covers meals and a bed in hospital, and includes hospital provided services including nursing care. It does not include treatment by doctors and other health professionals.

    Agreement Private Hospital means a hospital with which Teachers Health Fund has an agreement regarding accommodation, theatre fees and other hospital charges.

    Bariatric surgery (weight-loss surgery) includes a variety of procedures performed on people who are obese including gastric banding.

    Benefit means a benefit payable under the Teachers Health Fund Rules and includes access to service to be provided directly to the Insured Member in lieu of a payment.

    Boarder Fees means the fee charged by a hospital for the accommodation of an individual assisting with the care of a member who is undergoing inpatient treatment, for example a parent staying with a child who is in hospital.

    Certified Age of Entry (CAE) is the age a person is assigned when first purchasing Hospital cover, as relevant to Lifetime Health Cover.

    Calendar Year means the time from 1 January to 31 December inclusive, in a given year.

    Clearance Certificate  is a certificate issued by a fund when a member terminates a policy or wishes to transfer to another fund.

    It is a record of your private health insurance cover including details about:

    • Type of cover
    • Level of cover
    • Join and cancellation dates
    • Waiting periods served
    • Certified Age of Entry (CAE)
    • A history of recent claims

    Continuity refers to the transfer of waiting periods between policies, including internal transfers between products and between funds.

    Cosmetic Surgery means surgical procedures that are listed in the Plastic and Reconstructive Section of the Medicare Benefits Schedule (MBS) that do not meet the eligibility conditions for the payment of Medicare benefits, or surgical procedures of a plastic or reconstructive nature that are not listed in the MBS.

    Dependant Child means a child, Adopted Child, Stepchild or Foster Child

    Emergency Ambulance means an ambulance service that consists of transporting a seriously ill person to a hospital by a State Government Ambulance Service or by a private ambulance service recognised by Teachers Health Fund in order to receive urgently needed treatment. This includes transportation from the scene of an accident or the scene of a medical event such as a heart attack or stroke, but does not include transportation to hospital for the routine management of an ongoing medical condition or transportation between Hospitals.

    Excess means an amount of a benefit that a policy holder agrees to forgo, in return for a lower premium. Applies to Private Hospital Saver and CoreElect cover.

    Extended Family Cover (EFC) means a policy that covers the Primary Member, their partner and the dependant children of the Primary Member, of which at least one person is a dependant aged between 21-25 and not a student dependant.

    Extended Family Cover – Single Parent means a Policy that covers the Primary Member and the dependant children of the Primary Member, of which at least 1 person is a dependant aged between 21-25 and not a student dependant.

    Federal Government Private Health Insurance Rebate or Rebate means the incentive rebate offered by the Federal Government to reduce Premiums of private health insurers to encourage permanent residents in Australia to take out private health insurance. The rebate applies to both Hospital and Extras cover.

    Gap means the difference between what a doctor charges and what Medicare and the fund (combined) will pay for an inpatient service.

    HICAPS means Health Industry Claims and Payment Service which is an EFTPOS type service used at the point of sale/services that allows Teachers Health Fund members to claim benefits with the Teachers Health Fund Member card. Only available for some services, and where the provider has access to the HICAPS system.

    Hospital means a facility registered under relevant state or territory legislation and issued with a commonwealth provider number, includes: same day hospitals, private hospitals, or public hospitals, or any other premises declared by the Minister to be a hospital. These may include, but are not limited to, facilities that are not in a normal hospital environment, such as ‘hospital in the home’ arrangements.

    Hospital Pharmaceuticals means any drug or medicine listed in the PBS that is dispensed to a hospital patient and is part of the episode of care the hospital treatment provided.

    Informed Financial Consent means the procedures that hospitals and doctors have in place to inform a patient, in writing, of the hospitals and doctors charges, health fund benefits and out-of-pocket costs (where applicable) that exist in respect of medical and hospital treatment.

    Inpatient means a person who has been admitted to hospital.

    Lifetime Health Cover (LHC) means a Federal Government initiative; a policy that applies to everyone born after 1 July 1935, that sets a premium rating for life when an adult first takes out private health insurance. For each year an adult remains uninsured after the age of 31, there is a penalty increase of 2% on top of the general premium. Applies to hospital cover only; does not apply to extras cover.

    Lifetime Limit means benefits paid under categories with a lifetime limit will take into account any amount already paid for that type of service, including under other policies with other funds. The total benefit paid will not exceed the limit claimable under the current policy.

    Medical Practitioner means a person registered or licensed as a medical practitioner under a law of a State that provides for the registration or licensing of medical practitioners but does not include a person so registered or licensed:

    • whose registration, or licence to practise, as a medical practitioner in any State has been suspended, or cancelled, following an inquiry relating to his or her conduct; and
    • who has not, after that suspension or cancellation, again been authorised to register or practise as a medical practitioner in that State.

    Medicare Benefits Schedule (MBS) or Schedule Fee is a list of 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 Federal Government for the purpose of calculating the Medicare benefit payable for that service.

    Medicare Safety Net provides families and individuals with financial assistance for high out-of-pocket costs for out-of-hospital Medicare Benefits Schedule (MBS) services. Once you meet a Medicare Safety Net threshold, you may be eligible for additional Medicare benefits for out-of-hospital MBS services for the rest of the calendar year.

    Medicare Levy Surcharge (MLS) means a tax paid over and above the 1.5% levy all taxpayers are charged. It applies to singles without a level of hospital cover that exempts them from the levy and who earn over $70,000. MLS also applies to couples earning a combined income over $140,000 (increases by $1,500 for each child after the first) who do not have a level of hospital cover that exempts them from the levy. (All Teachers Health Fund of hospital products will exempt those covered by a policy from the MLS.)

    Members or Insured persons means all people covered by a policy, including the policy holder, spouse, dependent children and student dependents.

    Outpatient means a patient who undergoes minor surgery or medical treatment in a same day hospital facility, private hospital or dental clinic, but is not formally admitted as an inpatient.

    Per admission means a period where a member is admitted to hospital for treatment as an inpatient.

    Pharmaceuticals means a substance which:

    • has been prescribed by a Medical Practitioner or a dentist; and
    • has been supplied by a pharmacist in private practice or a Medical Practitioner; and
    • can only be supplied on prescription under applicable State law; but does not include substance which:

    a.  is available under the Pharmaceutical Benefits Scheme in any formulation, presentation, strength, pack size with or without repeat dispensing or combination of the preceding regardless of whether of such availability is subject to the Specified Purpose, Authority Required, Pensioner Concession or Special Patient Contribution conditions of that scheme; or

    b.  was prescribed in the absence of illness or disease or for enhancement of sporting or employment performance.

    Pharmaceutical Benefits Scheme (PBS) gives all Australian residents and eligible overseas visitors access to prescription medicine in a way that is affordable, reliable and timely. Through the PBS, the Australian Government subsidises the cost of prescription medicine.

    Policy means rules, conditions and benefits relating to or provided by or under any product of Teachers Health Fund.

    Policy holder means the person in whose name the membership is held and who is responsible for the payment of premiums.

    Portability is the term used to describe entitlements for policy holders to transfer from one health fund to another without the imposition of new waiting periods, or with reduced waiting periods where the waiting period has been served in part; does not necessarily include additional benefits available due to years of service.

    Pre-existing condition A pre-existing condition is an illness, ailment or condition where the signs or symptoms existed at any time during the six months before taking out private health insurance or transferring to a higher level of cover. This rule applies to new members to private health insurance and existing members who are upgrading their level of cover.

    Pregnancy and birth related services means any type of treatment related to the management of a pregnancy by a certified medical practitioner, including but not limited to management of labour and delivery and complications arising from the condition of being pregnant.

    Private Health Insurance Ombudsman (PHIO) is an independent and free service for consumers with private health insurance problems, enquiries and complaints.

    Private Hospital means:

    • a hospital that is approved as such under a law of the Commonwealth, or of a State or    Territory, or
    • any other hospital recognised by Teachers Health Fund as a private hospital for the purpose of paying benefits.

    Private Patient means an inpatient who is not a public patient.

    Public Hospital means a Hospital that is operated by a Australian State or Territory Government.

    Public Patient or Medicare Patient means an inpatient of a public hospital who receives treatment without charge.

    Recognised Provider is a qualified person who provides services that are eligible for benefits, recognised by Teachers Health Fund in a particular discipline, modality or calling as a provider for whose services, provided to an eligible member with cover for the provider’s services.

    Restricted service means a service or treatment in respect of which the benefit payable under a specified Hospital cover is subject to any applicable Fund rules. This means that you are only covered for a rate of a shared room of a public hospital for services that are restricted whilst in a private hospital.

    Savings Provision Entitlement (SPE) as it relates to the Federal Government 30% rebate: a provision to ensure that people remaining on a policy do not have their rebate reduced to 30% when an eligible person leaves the policy under certain circumstances.

    Single Parent Family Membership means a membership that includes two or more members with all but one of them being dependant children of the other member.

    Spouse of a person means the spouse recognised by law of that person and also includes a same sex partner or de facto spouse.

    Standard Information Statement (SIS) is a statement provided by a fund on request, available for each product that the fund makes available. The statements provide standard information on benefit entitlements, restrictions, and eligibility requirements to join a fund, if any.

    Student Dependent means a child, stepchild or foster child of the relevant Primary Member or the partner of that Primary Member, registered with Teachers Health Fund, who:

    • does not have a partner; and
    • is between 21 and 25 years of age (both inclusive);and is either:
    • a full-time student at a school, college, TAFE or university; or

    Teachers Health Centres offer Eyecare and Dental services.

    Transfer generally means the transfer of a policy holder or dependents from another health fund to Teachers Health Fund, or the change to another membership within Teachers Health Fund.

    Waiting Period is a period of time you need to wait after taking out your cover before you can receive benefits for services or items covered. This includes:

    Hospital waiting periods
    Pre-existing conditionsA pre-existing condition is an illness, ailment or condition where the signs or symptoms existed at any time during the six months before taking out private health insurance or transferring to a higher level of cover. This rule applies to new members to private health insurance and existing members who are upgrading their level of cover. If you are a new member to private health insurance you will have to wait 12 months before you can receive benefits for items or services related to a pre-existing condition.If you change to a higher level of cover, you may have to wait 12 months to receive benefits, including benefits for services not previously covered.A 12 month waiting period applies to all pre-existing conditions except pregnancy & birth related services, which is a 9 month waiting period and psychiatric, palliative care and rehabilitation, which is a two month waiting period. 12 months
    Pregnancy & birth related services 9 months
    Psychiatric, rehabilitation & palliative care 2 months
    All other hospital services 2 months
    Emergency Ambulance transport 1 day

    Extras waiting periods
    Orthodontia 24 months
    Wheelchair purchase
    Major dental 12 months
    Clinical psychology
    Healthy lifestyle
    Medical appliances
    Optical 6 months
    All other services 2 months
    Emergency Ambulance transport 1 day


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    Your Rebate

    All Australian residents, who are entitled to Medicare, are able to claim an income tested rebate on their private health insurance; would you like to apply your rebate?

    For individuals earning between $88,001 - $102,000 (or $176,001 - $204,000 for families*).
    *For families with children, the thresholds are increased by $1,500 for each child after the first.

    How rebate tiers workX

    Most Australians with private health insurance currently receive a rebate from the Australian Government to help cover the cost of their premiums. The private health insurance rebate is income tested. The table below details the different rebate amounts and Medicare Levy Surcharge levels.

    The rebate applies to hospital, general treatment and ambulance policies. It does not apply to overseas visitors cover. The rebate levels applicable for 1 July 2013 to 30 June 2014 are:

    < Age 6530%20%10%0%
    Age 65-6935%25%15%0%
    Age 70+40%30%20%0%

    Single parents and couples (including de facto couples) are subject to family tiers. For families with children, the thresholds are increased by $1,500 for each child after the first.