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 and GMHBA pays the other 25% up to 100% of the Medical Benefit Schedule (MBS) fee. It is also sometimes referred to as the Medicare Schedule fee.
GMHBA's medical gap cover is a billing system for participating doctors or specialists to use when they treat members in hospital. Medical gap cover is included at no extra cost to members of all the hospital covers GMHBA offers. If your doctor chooses to use GMHBA's medical gap cover, a higher benefit than the scheduled fee will usually be available from GMHBA, which will reduce or even eliminate your out-of-pocket costs.
Medical Gap Cover – Everyday Hospital Range (Gold, Silver, Bronze)
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.
Additional medical gap benefits are not payable towards the cost of imaging or pathology services within the Everyday Hospital Range.
Medical Gap Cover – Premium Hospital range (Gold Plus, Silver Plus)
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, that in most cases will be in excess of 20% of the MBS fee for each service, as paid under our Everyday Hospital Range.
As the additional medical gap benefit will vary by eligible service, please contact GMHBA prior to treatment to determine your additional medical gap cover benefit.
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:
- 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. GMHBA will pay all benefits direct to your doctor.
Multiple doctors
If others 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'll still receive a combined Medicare and GMHBA benefit of up to 100% of the Medicare Schedule Fee and any Connect Rewards Plus dollars you may have accrued for medical out of pocket costs that exist.
Ask your doctor before treatment begins if they have chosen to participate in GMHBA's medical gap cover system. Otherwise, visit a branch or call 1300 4 GMHBA (46422) and ask us.
In an emergency
In the case of an emergency, it may not be possible for a participating doctor to advise you of their fees in advance. Please contact us should this occur.