Find a specialist and understand your costs
When you go to hospital, the doctors involved in your care can set their own fees. This means your costs can vary depending on who treats you and whether they participate in Gap Cover (also known as the Access Gap Cover Scheme) for your procedure.
Gap Cover can help reduce or remove the medical gap you pay for eligible inpatient specialist fees. You can use GMHBA’s find a provider tool to search for specialists who are registered to use Gap Cover. A specialist can choose whether to use Gap Cover for each patient and procedure, so it’s important to ask them about their fees before you go to hospital.
Need help? Contact us to understand your options.
Ask what you’ll need to pay
Before your treatment, ask your specialist for informed financial consent. This is a written estimate that explains the fees for your procedure and any medical gap or out-of-pocket costs you may need to pay.
It’s also a good idea to contact us before your treatment, so we can talk you through what may be covered and what costs may apply.
What is a medical gap?
A medical gap is the difference between what your specialist charges and what Medicare and GMHBA pay towards your inpatient medical fees.
For inpatient specialist services, Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee and your health insurer pays the remaining 25%. If your specialist charges more than this amount, the difference is the gap you may need to pay.
How Gap Cover can help
GMHBA provides Gap Cover through the Australian Health Service Alliance (AHSA) Access Gap Cover Scheme. It’s designed to help reduce or remove the medical gap for eligible services when you’re treated as a private patient in hospital.
If your specialist chooses to use Gap Cover, GMHBA can pay a higher benefit than the standard MBS amount. In return, your specialist agrees to limit the gap they charge you.
There are two ways Gap Cover can work:
- No Gap – you won’t pay a gap for that specialist’s fee.
- Known Gap – you’ll know the gap amount before treatment. The most you’ll pay is $500 per specialist, per hospital admission, or $800 for obstetrics services.
Check if your specialist offers Gap Cover
Even if your specialist has participated with Gap Cover before, they can decide whether to use it for your procedure. They may choose to use Gap Cover for some patients or procedures, but not for others.
That’s why it’s important to ask whether each specialist involved in your care will participate in Gap Cover for your procedure. Your senior surgeon should be able to advise this as part of informed financial consent.
You can also use GMHBA’s Find a Provider tool to see whether a specialist has participated in Gap Cover before. This can help you start the conversation about whether No Gap or Known Gap may be available before you go to hospital.