What is Medical Gap Cover?

A schedule of fees has been set by the Federal Government for eligible services by doctors in a hospital or day surgery. Medicare pays 75% of this schedule fee for in-patient medical treatment and GMHBA pays the other 25% up to 100% of the Medical Benefit Schedule (MBS) fee.

GMHBA’s medical gap cover is a billing system that provides higher benefits than the scheduled fee which will reduce or even eliminate your out-of-pocket costs for doctor or specialist fees when treated in hospital.

What is a scheduled fee (MBS)?

The Federal Government has created a schedule of fees (Medicare Benefits Schedule) set for eligible services by doctors in a hospital or day surgery. Medicare pays 75% of this scheduled fee for in-patient medical treatments and GMHBA pays the other 25%, up to 100% of the Medical Benefit Schedule (MBS) fee.

Gold, Silver and Bronze Hospital

In the event that your doctor chooses to use GMHBA’s medical gap cover and where the actual fee for the anticipated service is greater than the MBS fee, an additional medical gap benefit will be paid equal to 20% of the MBS fee for each service*.

GMHBA's medical gap cover options

If your doctor or specialist is one of more than 14,000 who choose to participate in GMHBA's medical gap cover system, two options are available for our Hospital products:

Option 1 - Known Gap

Your doctor chooses to use GMHBA's medical gap cover system - and charge a known patient gap. To participate, your doctor must inform you in writing of the cost of the anticipated services, the Medicare and GMHBA benefits and the patient gap before any treatment commences. They must bill us direct for the GMHBA and Medicare benefits. We'll arrange to pay these benefits direct to your doctor and all you’ll need to pay is the known gap.

Option 2 - No Gap

If your doctor chooses to use our medical gap cover and not charge a patient gap, your GMHBA benefit and the Medicare benefit will fully cover the doctor's charges. In these instances, your doctor will bill us direct and you'll pay nothing.

Multiple doctors

If other doctors are involved in your treatment (such as anaesthetists) you should ask GMHBA, your doctor or the other medical professionals if they will be using GMHBA’s medical gap cover system. If they choose not to, you will still receive a combined Medicare and GMHBA benefit of up to 100% of the MBS fee and (if applicable) any GMHBA member ‘Connect Rewards Plus’ dollars you may have accrued for medical out of pocket costs that exist. The participation in GMHBA’s medical gap cover by any medical practitioner is not a recommendation or endorsement by GMHBA of that practitioner.

Gold Hospital Cover with Gap Saver

GMHBA’s Gold Hospital Cover with Gap Saver option provides medical gap cover regardless of whether your doctor participates or not. Where the actual fee for the anticipated service is greater than the MBS fee, an additional medical gap benefit will be paid for you*, which in most cases will be in excess of 20% of the MBS fee for each service, as paid under our other covers. The additional medical gap benefit under the Gap Saver option will vary by eligible service, please contact GMHBA prior to treatment to determine your additional medical gap cover benefit.

* Additional medical gap benefits may not be payable towards the cost of imaging or pathology services. Please contact GMHBA on 1300 44 64 22 for details.