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accident |
An accident is an unplanned or unforeseen event, resulting in bodily injury, requiring immediate medical
treatment in hospital. If you have an accident, you’ll be covered for hospital services normally excluded
or restricted on your nib health cover, provided the service is undertaken during the first admission to
hospital. This admission must be within 24 hours of the accident. For any subsequent hospital admissions
resulting from the accident, exclusions or restrictions under your cover will apply. |
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accommodation |
Includes the hospital bed, patient meals and nursing care in a hospital. It does
not include treatment by health professionals such as doctors. |
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admission |
To get treatment for an illness or condition as a private patient in a registered
public, private or day hospital you must be admitted by a medical practitioner.
Treatment in the emergency room of a private hospital is not an admission. |
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annual benefit limits |
This is the maximum amount NIB will pay, and/or the number of times you can claim,
for each extras service over a certain period of time. Most limits are for a calendar
year. At the beginning of each calendar year, your annual benefit limits are renewed
allowing you to claim again. |
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antenatal |
Classes - childbirth education classes that are run by a midwife or physiotherapist
(in private practice) prior to the birth of the baby. Antenatal classes teach breathing
and birthing techniques to help during childbirth.
Visits - a consultation between an expectant mother and her midwife (in private
practice) where for example, the mother has her blood pressure checked and the babies
heart rate is monitored. |
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artificial aids |
An aid/appliance (e.g. nebuliser, blood glucose monitor, wheelchair) or prosthesis
(e.g. mammary prosthesis following mastectomy, wig required as a result of medical
treatment). An extensive list of items covered is available by calling 13 14 63
or emailing us. Items must
be ordered by a medical practitioner (doctor). No cover for items supplied by a
public hospital. |
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benefit |
Benefits are the dollar amount NIB pays when you make a claim for an item or service
covered by your NIB Health Cover. How much you get depends on the type of cover
you have, what your doctor, hospital or provider charges and your choice of doctor,
hospital or provider. |
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calendar year |
January 1 to December 31. |
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contributor |
The person who first applied for the membership is known as the contributor and
in whose name the NIB membership is taken out. All correspondence relating to your
NIB membership is addressed to the contributor. |
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dietetics |
Service provided by a registered dietician. Does not include membership in diet
clubs/programs e.g. Weight Watchers. |
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endodontia |
The treatment and prevention of disease in the tooth pulp. Includes root canal therapy. |
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excess
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An excess is the amount you elect to pay towards your hospital stay, before we pay
a benefit. It's one of the things you can't claim back. Selecting an excess means
your contributions are lower.
The excess is only payable if you, or someone on your membership, go to hospital
- it does not apply to extras cover.
Depending on your health cover, you'll have to pay the excess each time you are
admitted to hospital. But we "cap" it to a set amount per year. The amount varies
depending on your health cover.
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exclusions |
Some procedures are excluded from some hospital covers - which means you won't be
covered in a public or private hospital and won't receive a payment from NIB for
that procedure. |
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extras |
Extras are the out of hospital services included in your NIB Health Cover. Depending
on your health cover, these include things like dental, physio, chiro, glasses and
frames, remedial massage, acupuncture and natural therapies. |
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Federal Government Rebate |
The Federal Government Rebate gives
you a 30%, 35% or 40% saving on your health cover contributions. All Australians
eligible for Medicare, regardless of income or level of cover, are entitled to receive
the 30% Rebate. Eligibility to receive the 35% and 40% Rebate is determined by the
age of the oldest person to be covered by the membership. The Federal Government
Rebate is not means tested or capped. |
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gap |
The Federal Government has a schedule of fees for medical services. This is called
the Medicare Benefits Schedule (MBS). Using the MBS Medicare pays 75% of the fee
for a medical service provided in hospital to a privately insured patient and NIB
covers the remaining 25% provided the procedure is not excluded from on your cover.
If Medicare does not pay a benefit an NIB benefit is not payable. The 'gap' occurs
when doctors charge in excess of the MBS. The
NIB MediGap Scheme aims to eliminate these gap payments. |
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home nursing |
Service provided by a registered general trained nurse in a private practice for
the treatment of illness, disease, incapacity, or disability when the patient is
totally dependent on nursing care. Does not include services such as Mothercraft,
Tresillian or Karitane nursing or a nurse-housekeeper during recovery after illness.
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Medicare Benefits Schedule Fee (MBS) |
The MBS is the amount set by the Federal Government for the purpose of paying Medicare
benefits. Medicare will pay 75% of the MBS Fee for medical services rendered for
hospital in-patient services. NIB will pay the other 25%, known as the 'gap' (providing
the procedure is not excluded on your cover). If your doctor/specialist does not
use the NIB MediGap scheme, you
will have to pay the amount by which your doctor's charges exceed the schedule fee. |
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NIB agreement private hospital |
An NIB agreement private hospital
is one which has negotiated charge agreements. Subject to your type of cover, this
provides for in-patient accommodation fees including bed fees, theatre and labour
ward, intensive and coronary care. Members who choose to use a non-agreement private
hospital will incur out-of-pocket expenses for most hospital related services. Before
receiving hospital treatment email
us or call 13 14 63 to confirm your benefit entitlements. |
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NIB member |
NIB members are all persons covered under your NIB Membership. |
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NIB membership |
The relationship between a member and NIB once NIB Health Cover is taken out is
called an NIB Membership. |
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NIB recognised provider |
Benefits are paid for services by
providers recognised by NIB. The providers must be in private practice and
services performed in their own consulting rooms. Providers are required to meet
certain criteria in order to be recognised by NIB e.g. professional qualifications,
membership of a professional association recognised by NIB, holders of a provider
number issued by the Federal Government. It is recommended that members
contact us before undergoing treatment to determine if their provider is
recognised by NIB.
NIB encourages providers to offer high-quality products and services at competitive
prices to members. NIB neither takes nor assumes any responsibility for the product
and/or service provided. Members should rely on their own enquiries and seek any
assurance or warranties directly from the provider of the service or product. NIB
benefits are limited to one benefit per patient, per provider, per day. If a provider
performs multiple visits/services within one consultation, the treatment that attracts
the higher benefit will be paid. Where multiple visits/services are performed on
the same day at different times by the same provider then only one visit/service
is payable (e.g. morning and afternoon visit/service).
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nursing home type benefit |
A Nursing home type benefit is a benefit set by the Federal Government for a patient
who is in hospital, but not in need of medical treatment, while awaiting a nursing
home placement. Where a member is classified as a nursing home type patient they
will be required to contribute a daily co-payment towards the cost of their hospital
stay (co-payments are also determined by the Federal Government). |
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obstetrics |
Medical care dealing with childbirth; including prenatal and postnatal care. |
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optical |
Contact lenses and glasses, prescribed to correct a sight defect. All claims
must contain clinically relevant prescriptions. The script must be lodged with the
claim. Add-ons including tinting, hardening and coating are not covered. The benefit
for contact lenses and disposable contact lenses will vary according to the type
of lens (item number). |
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out-of-pocket expenses |
Some charges and fees aren't covered by NIB. For example, NIB won't pay for medical
fees above the MBS fee (where doctors don't participate in NIB MediGap), any hospital
excess, or some personal and take home items like toiletries, newspapers and STD
and mobile phone calls provided in hospital. These are billed to you by your doctors
and the hospital.
NIB can tell you what you are covered for, but you should ask your hospital and
your doctors what your out of pocket expenses might be.
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out-patient |
Patients that don't require admission or an overnight stay in a hospital are outpatients.
NIB doesn't cover out-patient treatment. |
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paramedical services |
Paramedical services are services received in hospital including pharmacy, physiotherapy,
hydrotherapy and occupational therapy. |
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partner |
A partner (or spouse) means a person (of the same or opposite sex) who lives with
a contributing member in a marital or de-facto relationship. |
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partner authority |
The member (the person applying for membership) has the option of giving their partner,
as nominated on the membership application, authority to operate the membership.
This enables the partner to make claims on behalf of all people covered by the membership
and make changes to or enquiries about the membership.
Without partner authority
a partner is only permitted to sign and receive claim benefits for themselves. |
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periodontia |
Treatment of gums and gum disease. |
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Pharmaceutical Benefit Scheme (PBS) |
Many medicines cost much more than the price you pay - some cost hundreds of dollars
- but the Federal Government pays most of it for you. The government does this through
the Pharmaceutical Benefits Scheme (PBS). This is available to Australian residents
and eligible visitors from countries with reciprocal arrangements with Australia.
The name of PBS drugs appears in the Schedule of Pharmaceutical Benefits. For more
information about PBS, go to www.health.gov.au |
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Pharmaceutical Benefit Scheme (PBS) charge |
The maximum amount set by the Federal Government that a consumer pays towards the
cost of a PBS drug. The PBS charge is reviewed annually by the government. |
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pharmaceutical prescriptions |
NIB will pay a Pharmaceutical Prescriptions benefit when:
- the drug is only available on prescription; and
- the drug is listed on the Australian Register of Therapeutic Goods (ARTG); and
- the name of the drug does not appear in the Schedule of Pharmaceutical Benefits
The amount members will be paid will depend on their cover. A Pharmaceutical Prescriptions
benefit will not be paid if the drug is:
- listed as a contraceptive
- mixed to form a compound drug
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pre-existing condition |
A pre-existing condition is where the signs or symptoms of an illness or condition
were evident (whether or not diagnosed by a doctor) at any time during the 6 months
prior to joining a health fund, or upgrading to a higher level of cover. |
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private practice |
A practice (whether sole, partnership or group) which receives its entire income from
the fees charged to its patients without subsidy or funding from any public sector body. |
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prostheses |
A prosthesis is a surgically implanted item like an artificial knee or hip joint.
Some government approved, surgically implanted prosthetic items are on a 'no gap'
list, while others are not fully covered and you may have an out-of-pocket expense.
NIB recommends that you contact the hospital or your doctor to discuss any out-of-pockets
that may be incurred if you are to undergo a surgical procedure that requires a
prosthesis. |
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provider |
A professional or organisation that provides a health service, like hospitals,
doctors, dentists, acupuncturists and others. |
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public hospital benefit |
The amount of benefit payable to a member, determined by the Federal Government
as the minimum amount health funds must pay for accommodation costs. Public Hospital
Benefits will cover you in a shared ward of a public hospital but are nowhere near
sufficient for hospital services in a private room of a public hospital (generally
around 50% of the cost) or for hospital services in a private hospital (generally
between 5% and 30% of the cost). Public Hospital Benefits do not provide any benefits
for labour wards or theatre fees and some other services in a private hospital.
Public Hospital Benefits vary by State, the type of hospital and type of treatment
provided. Contact NIB if you
would like to know the benefits that may apply to your treatment. |
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restriction |
Some hospital covers have procedures that are restricted - that means NIB will only
pay a Public Hospital Benefit. You will incur considerable out of pocket expenses
if you choose to be treated for a restricted procedure in a private room of a public
hospital or in a private hospital. |
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student dependants |
Student Dependants are young people who are aged 21 to 25, are studying full time
and are not married or in a de facto relationship and are listed on your NIB membership.
Student Dependants must be studying at TAFE, university or college of advanced education
or business college. Student Dependants will not be covered if they stop studying
during the year. |
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waiting period |
The time you have to be in your level of health cover before NIB will pay benefits
for services included on your NIB Health Cover. |