In the Australian health insurance industry the difference in the amount your insurance covers and what a medical practitioner charges falls into the hands of the individual to pay. This is referred to as ‘Gap’ or in other countries ‘co-payments’.
The Medicare Benefits Schedule (MBS) outlines schedules fees for different medical procedures, 75% of this rate is covered by Medicare (government) and the remaining 25% by your health fund. Gap occurs when health professionals charge more than the scheduled fee for procedures, leaving the patient out of pocket.
When does gap occur?
- - If you have an arrangement with your health fund in return for lower premiums
- - If your procedure is one not covered by your policy
- - When your hospital does not have an agreement with your health insurance provider
- - When your medical professional charges more than the fee described in the MBS
How to avoid Gap
- - Find a health insurance policy that pays the gap
- - Find out from doctors and other treating medical professionals if they charge a higher than scheduled fee prior to treatment
- - Only use hospitals that have an agreement with your health fund
Studies have found that as many as 1 in 6 people that have had medical procedures that incurred a gap where not of it and as a result were left with a large bill despite having a private health insurance policy.