When a hospital or healthcare provider charges more for a treatment or service than what is covered by Medicare and your private health insurance, the amount left to pay is known as “the gap”. A gap payment is an out-of-pocket expense that you usually need to pay yourself, unless you get gap cover insurance.
Gap cover is insurance that protects you from out-of-pocket expenses and it’s usually offered in some form by most insurers. It’s available in three levels of protection:
- Partial gap cover. Partial gap protection covers some of the gap, but not all, meaning you must pay the rest.
- Known gap cover. Known gap protection covers each treatment up to a maximum capped amount, with any remaining gap payable by you. The advantage is that you know what your out-of-pocket expenses will be before receiving treatment.
- Full gap cover. Full gap protection covers 100% of any fees in excess of the Medicare Benefits Schedule (MBS).
Gap cover only covers treatments and services provided by a doctor or a hospital that participates in your insurer’s gap cover scheme, so it’s important to find out if they do or are willing to do so before you receive any treatment. If the doctor or hospital is registered with your insurer, they will bill the insurer directly for the treatment. However, if there is a gap to be paid by you, they must notify you and obtain your consent prior to treatment.
These health insurers all offer some form of gap cover. Remember, ask the insurer before you receive treatment to make sure your doctor is participating in the fund's gap scheme.
To get gap cover, your insurer needs to have an arrangement with a gap cover doctor, meaning, the doctor, provider or hospital needs to have agreed to participate in the insurer's gap cover scheme.
You can often find out if your doctor or provider has an arrangement with your insurer via the Government's private health website. It provides you with a link to your insurer's gap cover information, including what doctors are participating.
If you can't find information about a gap cover doctor, call your health fund or ask the doctor's office when making an appointment for treatment. If you don't do this, and it turns out the doctor charges above the MBS fee and is not associated with your health fund, you'll have to pay much of the bill yourself.
Here's why there's a medical gap: Medicare pays 75% of the MBS fee for treatment you receive as a private patient. Your private health insurer pays the remaining 25%. But medical practitioners don't need to adhere to the MBS fee, so many often charge more.
This means that while you may be covered for 100% of the MBS fee costs, you'll sometimes still be hit out of pocket if the doctor decides to charge a higher fee.
Here's 5 ways you can avoid or at least limit your out-of-pocket medical expenses:
Choose a health fund that provides 100% gap cover. If this is unaffordable for you, at the very least opt for known gap cover, so you can budget for any expenses you will have to pay.
Choose a policy that doesn't include excesses or co-payments.
Make sure your doctor or hospital participates in your health fund's gap cover scheme or is at least willing to do so.
Before your hospital treatment, find out what fees are charged by other medical practitioners such as your anaesthetist and check whether they are registered with your health fund.
Only seek treatment from health care providers who charge the MBS scheduled fee.
Unless you get a private health insurance policy that includes gap cover, then private health insurance can't cover the gap — you'll still have some out-of-pocket expenses.
That's because private health insurance is set up to pay the 25% of the MBS fee that remains once Medicare has covered 75%. If a medical specialist charges more than the MBS fee, you'll have to pick up the bill yourself, unless you get gap cover.
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