Mind the (medical) Gap!

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What is ‘the gap’ in healthcare costs?


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 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.

*This fact sheet is general information only. All private health insurance claims are subject to eligibility conditions, including your level of cover, completion of waiting periods, consideration of pre-existing conditions and any other restrictions relevant to your cover.

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