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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”.
The gap is an out-of-pocket expense that you must pay yourself, unless your policy includes 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:
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.
There are several circumstances in which a gap can occur, leaving you with an out-of-pocket expense to pay:
There are several ways you can avoid or at least limit your out-of-pocket medical expenses:
There are two main types of gaps: hospital gaps and medical gaps. Hospital gaps are the out-of-pocket expenses incurred while being treated in hospital and they include:
Medical gaps are the out-of-pocket expenses incurred for out-of-hospital treatments and services and they can include:
Prostheses are artificial replacements for human body parts such as eye lenses, artificial hips, pacemakers and heart valves. The Prostheses List is a list of surgically implanted prostheses that health funds are required to pay a benefit for when the procedure is covered by the MBS.
While health funds are required to pay for one prosthesis (known as a “no gap” prosthesis), if the prosthesis costs more than the prescribed amount on the Prostheses List, then you will be required to pay the gap between the amount on the list and the amount charged by the prosthesis supplier. It’s important to always speak to your insurer before having a procedure that involves a prosthesis to determine if there will be a gap to pay.
A gap cover doctor is one who has an arrangement with a health insurer and participates in their gap cover scheme. Medical practitioners have arrangements with various insurers, and in return for a greater volume of patients they agree to charge a set fee for their services.
You can find out which gap cover doctors are registered with your particular health fund by calling the health fund direct or asking the doctor’s office when making an appointment for treatment. It’s important to do this, as seeking treatment from a doctor who charges above the MBS fee and is not associated with your health fund could see you paying much of the bill yourself.
If, after treatment, you receive a bill that is much higher than you anticipated, there are several things you can do:
The short answer to this question is no. If a medical practitioner charges more for a treatment than the amount designated by the MBS, there will be a gap between what is being charged and what Medicare and your insurer will pay.
As this guide has shown, the only way to reduce or eliminate this gap is to have a policy that includes gap cover, ideally for 100% of costs, but at least with enough cover to substantially reduce your out-of-pocket expenses. The only other way to avoid paying a gap is to only seek treatment from health care providers who don’t charge above the MBS limit. However, doing this will severely restrict your choice of providers and defeat one of the main purposes of having private health insurance, which is to be able choose your own doctor.
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