HCi Factsheet

Keeping health insurance simple!

What is the (medical) gap?

January 2022

If you are going to be admitted into hospital, you are likely to hear about “gap fees” (also known as patient payments or out-of-pocket expenses), and it’s important to understand what this means.

What is the gap?

There are fees charged for surgeons, pathology, anaesthetists and other expenses as a private patient.

Medicare card sitting on a calculator and various notes of Australian currency

Medicare pays a set amount for each procedure as listed in the Australian Medical Benefits Schedule (MBS). As an inpatient, Medicare will pay 75% of the MBS cost. The remaining 25% is paid by your health insurance if you are covered, or by you.

Your doctor may charge more than the MBS cost. The gap between the MBS and the doctor’s charges has to be met by you, and cannot be claimed against health insurance.

How can you reduce the gap?

While paying for our health is worthwhile, there are ways to reduce the gap and minimise your expenses.

Most of us are not used to ‘shopping around’ for medical providers, but you certainly can and may find it saves you money. Research has shown there is not a direct relationship between higher medical costs and better providers, so don’t feel you have to pay a larger gap to be well cared for.

At HCi, we have relationships with a number of doctors around the country who charge a lower gap for our members. Some doctors will not charge you a gap at all, while others will ensure you know the gap ahead of time and will not change that cost. To find a relevant doctor in your area, please call us or look at the list on our website.

Remember that you are entitled to ask your doctor about costs, including asking your GP to refer you to a non-gap specialist or surgeon.

HCi used its best endeavours to ensure this information was accurate at the time of publication. From time to time, circumstances relating to the subject matter may change which may impact the accuracy of the information. This information is also general in nature and does not take into account any specific health or financial situation. Before making any decisions in relation to this information, you should consider your own financial and health situation and seek professional advice. Health Care Insurance Ltd ABN 43 009 579 088. A Registered Private Health Insurer.

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