What’s the difference between medical or hospital gap?
The term ‘medical gap’ refers to the amount above the Medicare Benefits Schedule that some medical practitioners charge for medical services. This expense is not typically covered by health funds and includes day surgery or hospital procedures.
Some funds have an agreement with certain doctors that may cover some or all of the doctor’s fee for hospital treatments. If your health fund doesn’t have an agreement with your chosen doctor you may have to contribute an amount towards the bill out of your own pocket.
The term ‘hospital gap’ refers to the out-of-pocket expenses you may face for your hospital accommodation. Many hospitals have agreements with health insurance funds to cover the full or partial costs of your hospital accommodation.
If you choose to go to a hospital that doesn’t have an agreement with your health fund, you may have to pay a significant bill for your treatment.
If you opt for health insurance excess or a co-payment policy, you’ll have to pay an agreed amount towards the cost of your treatment. That applies even if your hospital has an agreement with your health fund.
Understanding the Medicare Benefits Scheme
To gain a better understanding of Access Gap Cover and related benefits, it pays to know the basics of the Medicare Benefits Schedule (MBS).
The MBS is an extensive list of medical procedures that are covered by Medicare and private health insurance hospital cover.
Regardless of whether you receive treatment at a public or private hospital, your private health insurance and Medicare will typically only cover the MBS cost. If you have private health cover, Medicare will contribute 75% to the MBS amount for your treatments and your fund will pay the remaining 25%.
If you don’t have a health insurance policy, Medicare will pay 100% of the MBS amount.
When your doctor charges an amount above the MBS for the treatment, you’ll be paying the gap. With Access Gap cover, this out-of-pocket expense may be reduced, and in some cases, covered entirely. Without private health cover, you’ll have to fund the medical gap entirely out of your own pocket.