Out-of-pocket costs
What you need to know about hospital out‑of‑pocket costs, why they may apply, and tips to help minimise what you might need to pay.
What are out-of-pocket costs?
An out-of-pocket cost, also known as a gap, is the amount you pay for medical or hospital services after Medicare and your private health insurer have paid their share.
The Medical Costs Finder provided by the Australian Government outlines typical fee ranges for common private procedures across Australia, giving people a sense of the likely out‑of‑pocket costs.
Why might I have out-of-pocket costs as a private patient?
Hospital procedures often involve several specialists (for example, surgery often involves an anaesthetist and a surgeon). Each specialist sets their own fees. If a specialist charges more than the Medicare Benefits Schedule (MBS) fee, you’ll pay the difference unless they participate in Access Gap Cover where you may have no out-of-pocket costs (No Gap) or a limited, pre‑agreed amount (Known Gap).
An excess is the amount you need to pay towards a hospital admission as a private patient. Many of GMHBA’s hospital covers include an excess, which helps members share some of the cost of hospital admissions in return for lower premiums (the amount you pay each fortnight, month or year for your policy). When an excess applies, it will be capped, so you only pay the maximum excess once per person per calendar year.
Diagnostics such as blood tests, scans, X-rays, and ultrasounds are medical costs, so the cost is shared between Medicare and GMHBA. You may be charged out-of-pocket costs if providers charge more than the Medicare Benefits Schedule (MBS) fee. These bills often arrive after your hospital admission and are sent direct to you, so you may need to complete a two-way claim with Medicare.
Pharmaceuticals supplied as part of hospital treatment are included in the admission for participating private hospitals, however you may be billed if you are supplied with discharge drugs (medications dispensed by the hospital to take home) or regular medications that are not related to your admission.
GMHBA will pay the minimum default benefit as prescribed by the government approved prescribed list of medical devices and human tissue products list.
Keep in mind that extras like TV hire, phone calls, parking and take-home aids (e.g. crutches) may come with additional charges, it's worth checking with the hospital in advance. These aren't covered under your hospital cover.
How to minimise out-of-pocket costs
You can take steps to help reduce your out-of-pockets:
- Checking your level of cover by reviewing your fact sheet in your member area so you know what’s included and what isn’t.
- Choosing specialists who participate in Access Gap Cover, which may reduce or eliminate out-of-pocket costs.
- Asking your specialist for a detailed cost estimate (also known as Informed Financial Consent) before agreeing to any treatment.
- Confirming your excess so you know exactly what you’ll need to pay on admission.
- Reviewing any waiting periods to avoid unexpected charges.
- Contacting GMHBA for a cover review - we can explain your benefits, the costs your likely to pay, and what questions to ask your providers.