What is a Medical Gap?

A Medical Gap is the difference between what your doctor charges to treat you as a private patient and the amount Medicare gives you for the service your doctor provided.

How a Medical Gap works

If your doctor charges above the Medicare Benefit Schedule (MBS) fee, you may have to pay the extra amount. This extra amount is called the ‘Medical Gap’.

If you decide to be treated as a private patient, the doctors and other healthcare providers are entitled to charge you a fee for their services.

These fees are your medical fees. They are different from other fees you are charged for your stay as a private patient in a hospital, including theatre, accommodation and meals.

When you are admitted to hospital as a private patient, Medicare pays 75% of the MBS fee for each MBS item.

Your health insurer pays the remaining 25% as long as your Hospital Cover includes that treatment.

Nevertheless, doctors and other healthcare providers are allowed to charge more than the MBS fee. This means there is no cap on the amount they can charge you.

If your doctor charges above the MBS fee, you may have to pay the Medical Gap.

Always check with your doctor what their fees are.

Also check with your health insurer how much it pays for the particular treatment you are receiving. Otherwise, you will pay significant out-of-pocket costs.

Example of a Medical Gap