Closing the gap

How the gap is covered

The amount of benefit that health funds can provide you with depends on the type of treatment (or service) you have received. In some cases, your health fund may not cover the whole cost of your treatment. If this is the case, you will need to pay the remaining amount (the gap).


Medical services provided by doctors in hospital

If you receive doctors' services in hospital as a private patient, Medicare will cover 75 per cent of the Government's set fee for doctors' charges (this is often referred to as the 'schedule fee') and your health fund will cover the remaining 25 per cent of that schedule fee.

The Government determines the set fee on the basis of what is considered a fair and reasonable price for a particular service. However, the Government does not control doctors' fees and your doctor may charge more than the set fee.

The 'medical gap' arises where doctors charge in excess of the schedule fee. It is the difference between fees charged by doctors for medical services in hospital, and the combined health insurance benefit and Medicare benefit.

Doctors' charges above the set fee may only be covered by health funds where an agreement or gap cover scheme exists, involving the fund, doctors and/or hospital. Without such regulatory measures in place there could be an uncontrolled escalation of medical charges.

Where an agreement or scheme is in place, you will have either no out-of-pocket expenses (this is referred to as "no gap") for doctors' services provided in hospital, or you will know in advance what costs you will bear (this is referred to as a "known gap").

If you want a health insurance policy that covers all or part of the medical gap, you should check whether your health fund offers this kind of product and, if so, which doctors participate in its agreements or gap cover schemes.

It is important to contact your health fund and doctor before admission to hospital treatment to find out if you may be required to pay any out-of-pocket expenses. You may wish to ask your GP to refer you to a specialist who offers no gap, or a known gap, for the medical services he/she provides in hospital. If you are referred to a specialist and are not happy with the costs they indicate, consider asking your GP to refer you to another specialist.

Search for Health Care Providers participating in the Access Gap Scheme

Non-medical services provided in hospital

If you enter hospital as a private patient, in addition to the fees charged by doctors for medical services provided in hospital, you may also be required to pay the difference between what the hospital charges for non-medical services (such as accommodation) and the amount of benefit your fund pays.

Most funds have agreements with various hospitals under which all or most of your non-medical costs for in-hospital treatment will be covered. You should check with your fund to find out which hospitals it has such agreements with.

Out-of-hospital medical treatment

For medical services provided outside hospital (for example, visits to a specialist in their rooms) Medicare will cover 85 per cent of the Government set fee. You must pay the remainder of the doctor's fee.

Health funds are not permitted to provide any benefits for medical treatment provided outside of hospital for which a Medicare benefit is payable.

 

Information on this page was provided by www.health.gov.au

(c) Commonwealth of Australia