If you receive private medical services (from doctors and specialists) in hospital, Medicare and your health insurance will usually pay benefits towards these fees. These charges might include blood tests (pathology) and imaging (x-rays, scans etc) as well as surgery and other medical services you receive in hospital. The benefits you receive will be calculated as a percentage of the Medicare Benefit Schedule fee.
The Medicare Benefit Schedule (MBS) fee is determined by the Federal Government and is the basis on which Medicare and health funds calculate their benefits for medical services. So when Medicare or a health fund calculates a benefit for a medical service, it is calculated as a percentage of the MBS fee. Importantly, the MBS fee is not a ‘recommended’ fee and doctors and specialists are not compelled to charge the MBS fee. In fact many doctors and specialists charge significantly more than the MBS fee.
For private medical services you receive in hospital, Medicare will usually pay 75% of the Medicare Benefit Schedule (MBS) fee and your health insurance (hospital policy) will usually pay a standard benefit covering the remaining 25% of the schedule fee. In effect, you will usually be covered for 100% of the Medicare Benefit Schedule fee.
'Medical gap' is the term often used to describe that part of a doctor or specialists fee that is above the MBS fee – so it is not covered by the standard Medicare and health fund benefits. You may experience 'out of pocket expenses' when the fees charged by doctors for medical services in hospital exceed the combined Medicare and health insurance benefit.
Medical Gap Cover Schemes
In recent years, most funds have introduced Medical Gap Cover Schemes to help reduce or eliminate the Medical Gap. These often involve the health fund and doctor having an agreement or understanding in relation to fees and benefits available from your health insurance.
Where such a Medical Gap agreement or scheme is in place the health fund is permitted to provide a higher level of benefit and you will have either no ‘out of pocket’ expenses for doctors or specialists fees for in hospital services (a no gap scheme) or you will know in advance what costs you will incur (a known gap scheme).
Under No Gap Schemes, your doctors or specialists charges are fully covered by Medicare and your health fund – so you have nothing to pay. You should ask your doctor or specialist if they participate in a No or Known Medical Gap Scheme with your health fund.
Where your doctor or specialist agrees to participate in your health funds Known Gap Scheme, they will generally provide you with Informed Financial Consent – a form that sets out their fees, the Medicare and health fund benefits and the amount you are required to pay for your treatment or procedure. While Known Medical Gap Schemes often greatly reduce your out-of-pocket costs, you will still need to pay something towards your treatment. You should ask your doctor or specialist if they participate in a Known or No Medical Gap Scheme with your health fund.
You should ask your doctor or specialist before having a hospital procedure if a Medical Gap cost will apply. In some cases, where your doctor or specialist does not participate in a No or Known Gap Scheme with your health fund, they can reach a “one off” arrangement with your fund for no gap (or a reduced gap) to apply. You should speak with your fund before hospitalisation to see if this can be arranged.
Hospital Policies
Medical Gap cover is automatically included in most - but not all - hospital insurance policies at no extra cost. You should check with your health fund or contact us to confirm if your health insurance includes Medical Gap cover.
Health Link can help with Medical Gap Cover and Health Insurance
Health Link Consultants has access to a huge selection of policies from a range of health funds to ensure we can find the most appropriate and competitive cover for your needs.
Simply provide us with details of your health insurance needs using the online form or call us on (03) 9670 5555 or 1800 808 026. We’ll then review your situation and forward a policy recommendation to you. Best of all, Health Link’s health insurance review and personal recommendation service is available to you free of cost and without obligation.
More information about Medical Gap Cover
For more information about Medical Gap cover or any other health insurance related matter, contact Health Link Consultants on (03) 9670 5555 or 1800 808 026 – or contact us online.