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Understanding Health Insurance Gap Payments in Australia
Even with private health insurance and Medicare combined, you may still face an out-of-pocket "gap" payment if your doctor charges more than the combined Medicare and health fund benefit.
How the Gap Is Calculated
Medicare typically covers 75% of the Medicare Benefits Schedule (MBS) fee for in-hospital treatment. Your health fund covers the remaining 25% (under standard "no gap" or "known gap" arrangements) - but if your doctor charges above the MBS fee, you may owe the difference.
Gap Cover Schemes
- No Gap: You pay nothing out of pocket - doctor accepts the combined Medicare + fund benefit as full payment
- Known Gap: A capped, pre-disclosed gap amount (often under $500)
- Informed Financial Consent: Doctors must disclose expected out-of-pocket costs before treatment
Estimates only. Always request a written quote and informed financial consent from your specialist before treatment.