What is Medical Gap?

When you are treated in a private hospital, you usually get a bill from the hospital, and then the doctors, surgeons, anaethetists etc send you a bill separately.

Medicare and your health insurer pay a refund on these doctors accounts based on the "Medicare Benefits Schedule" (MBS). That's a fancy name for a list of all the different procedures that a doctor can perform in hospital, and how much Medicare believes is fair to charge for each one.

When a doctor's bill is received, Medicare pay a refund of 75% of the MBS. Your health insurer then pays an extra 25% of the MBS. So all up, 100% of the MBS is covered.

There's no rule that says a doctor has to charge exactly what Medicare think is fair and some choose to charge more. That's called the ‘known gap’ and can leave patients financially out of pocket. Your doctor should discuss this with you so there are no nasty surprises.

An example of this is if the MBS for a procedure is $100 and your doctor charges $120, Medicare pays $75, your health insurer pays $25 and you would need to pay the extra $20.

In short, Medical Gap is the difference between what your doctor charges and what’s covered by Medicare and your hospital cover.

What is Gap Cover?

Some health insurance products offer ‘Gap Cover’. This means that your health fund will pay more than the normal 25% of the MBS fee, leaving you less out of pocket.

What is Frank's Gap Cover?

All of Frank's hospital covers come with Gap Cover. If your doctor charges more than the MBS, Frank will cover you for up to 20% above the MBS (so you get up to 120% of the MBS). There are two examples of how you might be billed by your provider

1. No Gap – if your Doctor charges up to 120% of the MBS there will be no out of pocket doctors’ fees for you to pay following the service.

2. Known Gap – anything that your doctor charges above 120% of the MBS will be an out of pocket cost payable by you. Your doctor should discuss this with you prior to your procedure

What is not covered by Gap Cover?

Frank's Gap Cover does not cover services provided by pathologists and radiologists, such as blood tests and imaging. Medicare and Frank will cover the MBS for these treatments and you’ll only have to pay a gap if your doctor charges higher than the MBS.