If your specialist decides to charge more than the Medicare Benefit Schedule fee (the set government fee), you will be left with an out of pocket expense, commonly referred to as the ‘gap’. GapCover is a scheme designed to help eliminate or reduce your out-of-pocket expenses for in-hospital specialists’ charges.
How it works
- Specialists can choose whether or not to participate in GapCover for part or all of your treatment. If you are being treated by more than one doctor (e.g. surgeon and anaesthetist), participation is at each individual doctor’s discretion. So it’s important to ask your doctor(s) if they’ll do so before each claim forming part of your treatment.
- GapCover doesn’t apply to diagnostic services such as blood tests, x-rays and ultrasounds, out-of-hospital medical services and services not included on your policy. GapCover also doesn’t apply to things like excess payments and co-payments. You may still have out-of-pocket expenses.
- If your specialist chooses to participate in GapCover, the maximum out-of-pocket medical expense you’ll pay is $500 per doctor’s account for each hospital stay.
- GapCover is available on most Hospital covers in relation to eligible services. However, it does not apply to Public Hospital covers. Out of pocket costs may still apply.
- If your specialist chooses not to participate in GapCover then you will need to pay the balance after we have paid the ahm benefit for the doctor’s account.
What should you do?
- Before you consent to any treatment, ask your specialist/s if they’ll participate in GapCover for all claims as part of your treatment to help reduce your out-of-pocket expenses. To find a doctor that participates in GapCover, use our find a doctor search tool.
- Prior to going to hospital ask each of your specialists and your hospital for a breakdown of all the costs in writing. This is known as Informed Financial Consent. It should list the fees for each specialist involved in your treatment – your surgeon, assistant surgeon, and anaesthetist – and any other related costs.
For more information about GapCover, check the Member Guide.