Health Insurance Gap
Find out what a gap is in health insurance and how to avoid one on your policy here with Savvy.
Fact checked
When looking at health insurance policies, you may have seen the phrase ‘gap payments’ or ‘no-gap service,’ and wondered what this means. You can find out all about gap payments, what they are, who charges them and what this means for out-of-pocket expenses here with Savvy.
What is a health insurance gap in Australia?
A health insurance gap refers to the difference between the fee charged by a medical practitioner for a particular service and the amount covered by Medicare. The Medicare Benefits Schedule (MBS) sets a fee for each medical service which is covered by Medicare. This fee is often lower than what medical practitioners actually charge, meaning patients may have to pay the difference, or ‘gap,' between the MBS fee and the actual fee charged by the practitioner out of pocket.
What is no-gap health insurance?
No-gap health insurance is a type of policy that covers the full cost of medical treatment without any out-of-pocket expenses or additional charges. Such policies aim to eliminate the gap between the medical fees charged by healthcare providers and the amount covered by Medicare, but whether they cover part or all of the gap will depend on the level of cover you choose to buy.
No-gap health insurance policies are offered by many of the top private health insurance providers in Australia. For instance, no-gap hospital cover may cover the costs of hospital accommodation, theatre fees, doctor’s or surgeon’s fees and other in-hospital medical services. However, it's important to note that there may still be some out-of-pocket expenses for certain medical procedures, such as specialist consultations and diagnostic tests which are provided to you as an outpatient. In addition, you may still have to pay the excess amount you opted for when you bought your health insurance policy to be able to make a claim on your policy.
No-gap extras cover is usually only provided for basic medical treatments which aren’t covered by Medicare, such as physiotherapy, optical and dental. Some extras policies may offer no-gap treatments through healthcare providers which are affiliated with the health fund. This means if you want to get a teeth clean with no gap, for example, you may have to visit a dentist who is affiliated with your particular health fund and offers no-gap dental treatment for that fund’s members.
How can I get health treatment with no gap payments?
Getting health treatment with no gap payments can be a challenge, but it isn’t impossible. Some of the ways to do so include:
- Bulk billing – one way to get health treatment with no gap payments is to find a medical practice that offers bulk billing. Bulk billing means that the medical practitioner bills Medicare directly for their services and you don't have to pay anything out of pocket. To find a medical practice which offers bulk billing, you can search online or ask your private health insurer for a list of participating providers. Many medical practices will also display a sign or sticker indicating that they offer bulk billing. When you make an appointment, be sure to ask if bulk billing is available for your particular treatment.
- Use your health fund-approved provider – another way to avoid gap payments is to choose medical practitioners who participate in your private health insurer's ‘no gap’ or ‘known gap’ schemes. These schemes are designed to reduce or eliminate out-of-pocket expenses for patients, as the insurer and medical practitioner have agreed on a set fee for a particular service.
- Compare prices – a third method to reduce gap payments is to compare prices and fees charged by different medical practitioners. This can help you find a practitioner who only charges the MBS fee for a particular service, which can eliminate the gap payment.
It's important to check your private health insurance policy to see what level of cover you have, and whether there are any exclusions or waiting periods which could impact your ability to claim for a particular treatment.
More of your frequently asked questions about health insurance gaps
Helpful health insurance guides
Compare health insurance policies online
Disclaimer:
Savvy is partnered with Compare Club Australia Pty Ltd (AFS representative number 001279036) of Alternative Media Pty Ltd (AFS License number 486326) to provide readers with a variety of health insurance policies to compare. Savvy earns a commission from Compare Club each time a customer buys a health insurance policy via our website. We don’t arrange for products to be purchased from these brands directly, as all purchases are conducted via Compare Club.
Savvy’s comparison service is provided by Compare Club. Compare Club compares selected products from a panel of trusted insurers and does not compare all products in the market.
Any advice presented above or on other pages is general in nature and doesn’t consider your personal or business objectives, needs or finances. It’s always important to consider whether advice is suitable for you before purchasing an insurance policy.
For any further information on the variety of insurers compared by Compare Club or how their business works, you can read their Financial Services Guide.