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What is the gap and gap cover?

The gap is the difference between the fee charged by the hospital or the amount the doctor charges for services in hospital and the amount covered by Medicare and your private health insurer.

The gap occurs for 3 reasons 
  • You have chosen hospital insurance with an excess, co-payments, exclusions or other benefit limitations 
  • You have chosen hospital accommodation that is not included in your health insurance or a hospital that does not have an agreement with your private health insurer
  • Your doctor’s fee is more than the MBS fee, this is called the medical gap

The medical gap occurs because Medicare pays 75% of the MBS fee for in-hospital doctor’s services, a private health insurer will cover 25% of the MBS fee, but the doctor's fee is more than the MBS fee. Most private health insurers offer gap cover schemes to provide benefits to cover some or all of the gap between the MBS fee and the fee charged by the doctor.

These gap cover schemes vary, inquire about how they work and assess their fit to your needs and expectations.

A gap scheme may 
  • require doctors to register with the fund for you to be able to claim benefits for the services they provide to you. This may restrict your choice of doctor to those registered with the fund, or you may have to persuade your doctor to register and accept any conditions the fund requires them to meet for you to be able to claim your benefits
  • depend on the doctor’s willingness to participate in the fund’s gap scheme for you to be paid benefits. The doctor may be able to decide on a case by case basis whether to participate
  • allow you complete freedom to choose your doctor and always pay a benefit but only provide cover up to a market rate or customary amount charged by doctors

To claim benefits under a gap scheme it is most efficient for you or your doctor to submit your medical claims directly to the health fund.