We are committed to the purpose of striving for better health outcomes for our private health insurance members. As part of this commitment, GapCover aims to reduce or eliminate the out-of-pocket medical expenses paid by our members when they have a hospital stay.
How it works
The ‘gap' is the difference between the fees charged by you and the Medicare Benefits Schedule (MBS) fees for the services you provide to our members. This difference can leave our members with out-of-pocket expenses. With GapCover, you can help close this gap.
Please be aware that some levels of cover have excluded services. GapCover will not apply for an excluded service.
For all information about GapCover please see the GapCover provider guide.
Known gap
As long as your fees do not exceed the relevant amount in the GapCover Schedule of Benefits, the account will be paid in full and there will be ‘no gap' for our members.
However, you may wish to charge a Known Gap (an out-of-pocket expense that the member pays). This is any amount you charge that exceeds the amount shown in the GapCover Schedule of Benefits, up to a maximum of $500 per claiming provider (ie. per doctor's account).
If you submit an account where the Known Gap exceeds $500 per claiming provider, the benefit payable for that claim will be reduced to the MBS fee. In other words, the claim cannot be paid as a GapCover claim.
If the gap amount is to be charged to our member you must have obtained Informed Financial Consent (IFC).
Example:
As you can see from the following example, the out-of-pocket cost can be significantly reduced for our member when you choose to participate in GapCover.
| Doctor's total charge | $800 |
| GapCover Schedule fee The higher fee that will be paid up to for treatment covered by GapCover. |
$600 |
| MBS fee for all items | $400 |
Medicare pays |
We pay |
Member pays |
$300 75% of the MBS fee |
$100 25% of the MBS fee + $200 The difference between the MBS Schedule fee and the GapCover Schedule fee |
$200 The difference between the GapCover Schedule fee and the Doctor's charge |
In this case, Medicare will pay 75% of the $400 MBS fee. We will pay the remaining 25% of the MBS fee plus an extra $200 up to the GapCover Schedule fee of $600. The out-of-pocket cost for the member is $200.
This treatment can be covered under GapCover because the doctor has charged the agreed GapCover fee and the out-of-pocket for the member is less than $500 per claiming provider.