What is the gap?

Find out how you can minimise or eliminate out-of-pocket expenses with our unique medical gap cover scheme.

The gap is the difference between the fees charged by the hospital and doctors for your hospital stay, and the amount covered by Medicare and your private health insurer. It is the amount you have to pay towards your treatment. It is sometimes called your out-of-pocket expenses.

The gap occurs for 4 reasons:

1. your hospital insurance includes an excess, exclusions or benefit restrictions
2. the hospital you chose doesn't have an agreement with Doctors’ Health Fund
3. your doctor’s fee is more than the Access Gap Cover schedule or the AMA list of medical services and fees depending on your level of cover
4. you have incurred inpatient charges for items not covered under our health insurance hospital policies such as newspapers and telephone calls.

Doctors’ Health Fund provides benefits for some or all of the gap between the Medicare benefit and the fees charged by the hospital and doctors, depending on your level of cover.

It’s important to discuss with your doctor how much your gap will be, prior to admission.

Doctors' Health Fund medical gap

You can minimise or eliminate your out-of-pocket expenses with either of our medical gap covers.

Unique AMA-level benefits for Top Cover Gold

Our premium hospital cover, Top Cover Gold, pays a medical benefit up to the AMA list of medical services and fees where Medicare provides a benefit, meaning you will:

• have no out-of-pocket expenses if your doctor charges the AMA list of medical services and fees or less
• need to pay the difference if your doctor charges you above the AMA list of medical services and fees.

Access Gap Cover for Prime Choice Gold and Smart Starter Bronze

Our Prime Choice Gold and Smart Starter Bronze Plus hospital covers pay benefits according to the Access Gap Cover schedule. Doctors need to opt in to Access Gap Cover and then choose whether to charge no gap or a known gap (not exceeding $500 per treating practitioner per episode or $800 for management of labour and delivery of a baby).

They can also choose to opt in and out of Access Gap Cover per episode so make sure you check with your treating practitioner each time you are admitted to hospital. An episode is the period from admission to discharge, for one care type (for example, acute care or rehabilitation).

When your medical costs are covered by Access Gap Cover, your treating practitioner should not charge you additional costs such as booking fees or administrative fees.

Example: different medical benefit outcomes under each gap cover scheme for a knee reconstruction, item 49542 as of March 2026

Pathology and radiology – contracted no-gap cover

Our no-gap contractual arrangements with most pathology and radiology providers apply to all our hospital insurance products.

You will not have to pay for services by these contracted providers.