What is the Medical Gap Scheme?

Medical Gap Scheme is designed to assist you financially when you need private treatment, adding further value to your medical insurance.

The Medical Gap occurs when a doctor charges a fee higher than the Medicare Benefit Schedule (MBS) - the MBS is a listing (or schedule) of the Medicare services subsidized by the Australian Government.

How to avoid paying the Medical Gap

If you require a medical procedure, speak with your doctor prior to treatment and ask if they participate in your funds Medical Gap cover scheme. The doctor has 3 options:

  1. Participate in 'No Gap' cover - no extra out-of-pocket expenses for you
  2. If your doctor agrees to participate in a ‘No Gap’ scheme. You will have no gap (out of pocket) payment to make to the doctor. This is because the doctor has accepted the terms of the ‘No Gap’ scheme offered by your health fund.

  3. Participate in Known Gap cover - capped out-of-pocket expenses for you
  4. If your doctor agrees to participate in a ‘Known Gap’ scheme, you will be charged a known gap for each* procedure that the doctor performs.
    The doctor must provide you with details of the out of pocket expense in writing prior to the procedure, this is referred to as “informed financial consent”

    * N.B. It should be known that the doctor is entitled to charge a ‘Known Gap’ for each additional procedure (item number) that is necessary whilst performing a procedure or surgery.

  5. Not participate in Gap cover - you will incur all out-of-pocket expenses
  6. If your doctor chooses not to participate in any form of Gap cover, you will incur all costs that are charged over the MBS scheduled fee.

Miscellaneous information regarding Medical Gap Schemes.

Not all funds offer both a No Gap or Known Gap scheme. There are funds who only have a No Gap scheme.

For the consumer to obtain optimum benefit from the Medical Gap Schemes, it is necessary for all those who are involved in the procedure to participate in the Gap Scheme e.g. Anaesthetist, assistant surgeon etc.

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