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Access Gap Cover
Emergency Services Health’s scheme to eliminate or reduce out-of-pocket expenses for medical services (doctors, diagnostic imaging/radiology, and pathology) during hospital stays. The Australian Health Service Alliance has recently written to Australian medical practitioners advising them about the launch of Emergency Services Health and our participation in Access Gap Cover. If the medical practice is not yet aware of us, or has not received their notification, ask them to contact our office on 1300 703 703, we are here to help.
Accident & Emergency Facility Fee
A fee charged to patients by private hospitals for the treatment in an accident and emergency department. It is not covered by Medicare or private health insurance.
The maximum benefit payable for services received during any calendar year for particular services or groups of services per person unless stated otherwise. The Annual Maximums start new on the 1st of January each year (orthodontics maximum is determined by length of membership based on anniversary year).
The amount payable by Emergency Services Health to you, or on your behalf to a service provider in respect of a claim made relating to the provision of health services, treatment, care, or goods by a recognised provider.
From January 1 to December 31.
A request submitted by a member to Emergency Services Health for the payment of benefits for hospital treatment, in-patient medical treatment or extras treatment. All claims must be made within two years of receiving treatment.
A Contributor in Emergency Services Health Fund Rules refers to the person who is registered as the Contributor of the policy, in which the policy holds their name as the authorising contact, recipient for all written and/or electronic communications and is responsible for premiums of the policy.
A co-payment is an amount that a member agrees to pay towards the cost of each day spent in hospital. Emergency Services Health does not have co-payments on its hospital coverage. However, if you transfer to Emergency Services Health and your previous cover had a co-payment component, you’ll be required to serve waiting periods in relation to the co-payment and you may be required to pay the co-payment if you receive hospital treatment during the waiting periods.
Emergency Services Health’s literature refers to four different types of dependents: spouse/partner, child, student and non-student dependents. Our Fund Rules refer to the Contributor and dependents. Dependents may be a spouse/partner of the Contributor and any child dependent of the Contributor or of the spouse/partner.
A child dependent is a person who is a child of the Contributor or spouse/partner of the Contributor, does not have a partner and is either under 21 years of age, or is a student dependent or is a child non-student dependent.
A student dependent means under all policies, a person who is a child of the Contributor and/or their spouse/partner who is over 21 years of age but under 25 years of age, who is considered to be a full time student of a school, college, university or other tertiary institution recognised by Emergency Services Health.
A child non-student dependent is a person who is a child of the Contributor or the spouse/partner of the Contributor and is aged 21 years but under 25 years. Child non-student dependents can only be included in the Lifelong Combined product at the Single Parent Family Plus or Family Plus rates.
In all cases a child is taken to include a natural child, adopted child, foster child or a child who is a legal ward of the Contributor or their spouse/partner. A child ceases to be eligible as a dependent if married or in a de facto relationship.
An excess is an amount that a member agrees to pay upfront before a health insurance benefit is paid towards hospital accommodation as set out under a health insurance policy, similar to a motor insurance policy. Emergency Services Health does not have excesses on any of its hospital products. However, during waiting periods you may be required to pay an excess if you were subject to one under your previous policy.
Generally refers to non-hospital and non-medical health services such as dental, optical, or physiotherapy. Also sometimes referred to as Ancillary cover or General Treatment.
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This most commonly refers to the difference between the Medicare Benefits Schedule Fee for a medical service and the amount covered by Medicare. It can also refer to the uninsured difference between the fee charged for a service and the benefit paid by Emergency Services Health (and Medicare if applicable), in effect your out-of-pocket cost. It can also refer to the uninsured difference between the fee charged for a service and the benefit paid by Emergency Services Health (and Medicare if applicable), in effect your out-of-pocket cost.
Accommodation included in your hospital cover generally includes all in-hospital services such as meals, bed and nursing care. Accommodation does not include take home or personal items, e.g. toiletries, television, hairdressing, manicure etc
A person who has been admitted to a hospital. This does not include a person being treated in the out-patient or accident & emergency sections of a hospital.
The maximum cumulative total benefit limits payable in the lifetime of the member on a particular service. Where lifetime limits apply, any benefits paid by your previous private health insurer are treated as part of this Lifetime Limit.
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Medicare Benefits Schedule (MBS)
A list of medical services and fees recognised by the Australian Government.
The use of the words “membership” and “member” in this website relates to the policyholder (Contributor) and all dependents under the policy of the Emergency Services Health insurance. It does not imply member voting rights as described in the constitution of Emergency Services Health Pty Ltd ABN 98 131 093 877.
When a member is not up-to-date with policy payments, the membership will be in arrears and no benefits will be paid to or on behalf of the member. The policy may be cancelled by Emergency Services Health if in arrears greater than two months.
Emergency Services Health operates on a not-for-profit basis. This means we do not pay dividends to shareholders, and any surpluses are retained to benefit members.
The portion of charges you incur that is not covered by Medicare or health fund benefits.
A person receiving treatment at a hospital but not admitted to hospital.
Specialised health care to support and comfort people with life-limiting illnesses.
Pharmaceutical Benefits Scheme (PBS)
An Australian Government subsidy scheme that lowers the cost of prescription medicine. Health funds are not permitted to pay benefits towards medicines that receive a government subsidy except when they are supplied while an in-patient of a hospital.
Emergency Services Health’s reference to a policyholder refers to the contributor of the policy (not everyone covered under the policy).
This refers to a health insurance policy with Emergency Services Health and the treatment you’re insured for in exchange for a set premium. The policy is governed by the Fund Rules of Emergency Services Health.
Where signs or symptoms of an ailment, illness or condition (in the opinion of a medical practitioner appointed by us) existed at any time during the six months before you purchased your policy or upgraded to a higher level of cover.
The amount you pay for your hospital, extras or combined cover policy. You must pay the premium that applies to your policy in the state in which you live. This means that if you move states, different premiums will apply.
Prostheses include screws and plates, intraocular lenses, replacement joints, cardiac stents, defibrillators and other devices that are surgically implanted during your stay in hospital.
An individual or institution that provides preventive, curative, palliative or rehabilitative health care services to individuals, families or communities.
Recognised health providers
Recognised health providers are those who are in private practice in Australia and recognised by us. We only pay benefits for services by these providers. If you wish to ensure that your provider is covered please speak to us prior to treatment.
Restricted Membership Access
Emergency Services Health is a restricted membership private health insurer, meaning that people must meet certain criteria to be eligible to become a member, i.e. the general public cannot join.
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Standard Information Statements (SIS)
SIS are available on all private health insurance products in Australia. These are designed to assist you in reviewing and comparing different health insurance policies.
This is a Federal Government initiative and all health insurers are required to provide such statements by law. Emergency Services Health SIS are available on request.
For further information on SIS and other detailed information on private health insurance in Australia visit the Federal Government's private health website.
State of Residence
The state or territory where the Contributor of the policy lives.
Suspension of Private Health Cover
Under certain circumstances, such as travelling overseas, members may suspend the payment of their premiums for an agreed period of time (conditions apply).
A ‘waiting period’ in the context of private health insurance means the period of time from the commencement of cover or increase in cover, to when the benefit or new benefit can be claimed by the member under their chosen cover (excludes accidents).