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Member Insider: Managing the ‘gap’

24 September, 2019
A doctor explaining about private health insurance to a patient

It can be a shock when you use your private health insurance policy and still face an unexpected medical bill. Isn't avoiding such costs the very reason you've been paying your health insurance premiums?

We understand gap fees are frustrating, however health funds have limited control over what a medical specialist can charge. While most medical specialists charge reasonable fees and offer their patients advice about costs in advance, there are some medical specialists who don’t.

What is the hospital and medical gap?

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. It is also known as the out-of-pocket expenses you may pay for your treatment.

Who decides what specialists charge?

In Australia, medical specialists are free to set their own prices. Their charges aren't regulated, as the Government is prohibited from regulating fees under the Commonwealth Constitution.

Why does a gap happen?

  • You may have chosen Hospital cover with an excess, exclusions or benefit restrictions, and not be fully covered for your planned procedure
  • You may have chosen a hospital that does not have an agreement with CBHS for that treatment. Always check with CBHS before your admission.
  • Your doctor doesn’t participate/bill you under the Access Gap Cover Scheme (AGC).
  • Your doctor’s fee is more than the Access Gap Schedule (AGC) or the Medicare Benefits Schedule Fee (MBS). More on these below.
  • You have incurred inpatient charges for items not covered under your CBHS Hospital cover, such as newspapers, phone calls or prescribed medication.

What is the Medicare Benefits Schedule Fee (MBS)?

The Australian Government sets a fee for a range of treatments, procedures, tests and so on, and these are listed on the Medicare Benefits Schedule (MBS).

Medicare will pay 75% of the MBS fee for treatment of admitted private patients in hospital.

What is the Access Gap Schedule (AGC)?

If your doctor charges above the MBS but under, or up to, the agreed 'no gap' threshold, you'll be covered and have no out-of-pocket costs. If they charge more than the 'no gap' threshold, you may have a ‘known’ gap. This usually limits your out-of-pocket costs. Here’s what you need to know about Access Gap Cover.

What can you do to avoid the gap?

The best defence against excessive out-of-pocket fees is understanding the system, asking questions and making sure you can give Informed Financial Consent (IFC). IFC is when your doctor/hospital provides you the breakdown of all expected costs that you may incur. IFC works best when doctors, hospitals and health insurers work together to provide information about the costs associated with treatment, and the private health insurance benefits payable, prior to your admission to hospital. Learn more about IFC here.

What questions should I ask my doctor about costs before I go to hospital?

  • What are their fees? Don’t be afraid to ask for this information in writing.
  • Will they will use CBHS Access Gap Scheme.?
  • Ask if the doctor can offer you a better price. Specialists may adjust their fees for patients who would struggle to cover the cost.
  • Feel free to get a second opinion and quote for a fee estimate.
  • What are the fees for any other doctors involved in your care in hospital? As well as the doctor who is performing the procedure, an anaesthetist, assistant surgeon, pathologist, consultant physician or radiologist may also be involved in your care. Each of these doctors will be in private practice and will charge a fee, and there might be an out-of-pocket cost to you.
  • Is your fee an estimate only? Remember, your doctor may only estimate the cost of your in-hospital or day surgery elective procedure in advance.
  • If the cost changes, when will they let me know?
  • What are the MBS item numbers for the services they are going to perform? (You can give this information to CBHS and we will give you an estimate of benefits.)
  • What if I need a prosthesis/implant? Prostheses include pacemakers, defibrillators, cardiac stents, joint replacements, intraocular lenses and other devices that are surgically implanted during a stay in hospital. Before surgery, your doctor will tell you if one is required, why you need it and whether it will cost you anything.


    Should I check with CBHS before I go to hospital?


  • Check with CBHS to confirm you are covered for the procedure and MBS item.
  • Check you have served any required waiting periods.
  • Check your chosen excess or co-payment, if any.
  • Ask us for a written quotation of benefits.

See more information on going to hospital.


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