• Private Health Insurance System
• Understanding Healthcare Jargon
• Understanding Private Health Insurance Premiums
• Frequently Asked Questions
• The Gap – It is Your Right to Know
• Informed Financial Consent

The Gap – It is Your Right to Know

The gap is the difference between what your doctor charges and what Medicare and your health fund will pay for a particular service, which you must pay out of your own pocket. Some doctors have an arrangement with a health fund and don’t charge a gap fee, but whether or not you have to pay some of the costs will also depend on your level of cover.

Doctors’ fees

The Government sets a fee for every medical service in the Medicare Benefits Schedule (MBS). When you have hospital treatment as a private patient, Medicare will pay 75% of the MBS fee. Your private health insurer will pay 25%.

Gaps for doctors’ fees come about when your specialist, and/or the other doctors involved in your hospital care, charge more than the MBS fee. Your insurer can pay more than 25% of the MBS fee, if the doctor is prepared to use its “gap cover arrangements”. In this circumstance, you will either have no gap to pay, or you will be informed in advance about any gap. Many doctors are prepared to use gap cover arrangements.

Doctors can choose, on a case-by-case basis, whether they wish to use an insurer’s gap cover arrangements. If you doctor chooses not to use your insurer’s gap cover arrangements, you would be required to pay the gap between the MBS fee and the total charge out of your own pocket.

How can I find about about any gaps?

Many people with private health insurance are concerned about the gap. Right now, more than 83% of all privately insured medical services in hospital have no gap at all. But you still have the right to find out what gap, if any, there might be for your medical treatment.

• Before going to hospital as a private patient, you should ask the doctor for an estimate of his/her fees. You should also ask about any other doctors likely to be involved in your care (eg anaesthetist, assistant surgeon) and how to get information about their fees
• Check with your health insurer about how much is likely to be covered by your health insurance policy
• You should also check with your hospital about any likely out-of-pocket costs relating to your hospital accommodation

 We have produced a simple checklist to help you find out about any gaps, from your doctor, health fund and hospital.

So before you begin your treatment or hospital stay, you can feel confident in knowing whether there will be a gap and how much it will be. You can download a copy of the gap checklist  GapChecklist

 Some funds have specific information on their site, or you may have to contact them to obtain details of their gap cover arrangements.