Hospital out-of-pocket guide

Hospital cover helps pay for your treatment, services and accommodation while you’re admitted to hospital as a private patient. It can give you more control over your care if you need to go to hospital – such as the choice to be treated in a public or private hospital, picking your doctor and potentially shorter wait times for elective surgery if you choose to be treated in a private hospital.

When you’re admitted to hospital as a private patient, your health insurer will pay benefits towards your hospital costs (accommodation, theatre fees, items like dressings and bandages) and both Medicare and your health insurer will pay benefits for medical costs (fees charged by the medical specialists involved in your treatment, including anaesthetists, and services such as radiology and pathology).

To be covered, you’ll need the clinical category for your treatment included on your cover and to have served relevant waiting periods before your admission.

Find out more about using your hospital cover.  

Typical costs shown in this guide are based on historical claims data for GMHBA Limited members who have undergone this procedure as a private patient in a private hospital. We analyse claims paid during the reporting period and show a typical range of costs experienced by members.

This is a guide only and not a quote or guaranteed cost. Actual costs can vary depending on factors such as your specialist's fees, the hospital you attend, whether Access Gap Cover is used, your level of cover and any additional services required.

We recommend confirming all expected costs with your specialist, hospital and GMHBA before admission.  

The guide reflects a range of costs experienced by GMHBA members in the past. Your quote is personalised to your treatment and may differ for several reasons, including:

• The fees charged by your specialist and other doctors involved in your care
• The hospital where your procedure takes place
• Whether Access Gap Cover applies
• Your level of cover and any applicable excess or co-payment
• Additional tests, services or treatments you may need.

For the most accurate information, ask your specialist for a written estimate of costs and contact GMHBA to check your cover and benefits before your admission.

A medical gap (or out-of-pocket cost) occurs if your doctor charges more than the Medicare Benefits Schedule (MBS) fee for your hospital treatment. This relates to the medical costs for your admission. 

For inpatient specialist services, Medicare pays 75% of the MBS fee and your health insurer generally pays the remaining 25%.

If your doctor charges above the MBS fee and there is a medical gap, you may need to pay the difference.

Access Gap Cover can help reduce or eliminate these costs.

If your procedure is planned, there are steps you can take to minimise potential out-of-pocket costs:

• Check your cover early
• Explore your treatment options (private or public health system, seek a second opinion)
• Make sure your hospital is one of GMHBA’s participating private hospitals
• Ask your specialist(s) for a written estimate/quote of their fees and MBS item numbers, and whether they will use Access Gap Cover for your billing
• Contact GMHBA before going to hospital.

The Australian Health Service Alliance (AHSA) Access Gap Cover scheme is a billing system designed to reduce or eliminate the gap for inpatient medical fees.

Specialist doctors who are registered for, and choose to use, the Access Gap Cover scheme get a higher benefit from GMHBA (more than the standard 25% of the scheduled fee), in exchange for limiting the gap they charge to our members.

There are two scenarios for how GMHBA members may be billed when their specialist doctor uses the Access Gap Cover scheme:

• No gap – $0 to pay following the procedure
• Known gap – a maximum gap of $500 ($800 for obstetrics) to pay per doctor, per procedure.

If your doctor chooses not to participate in Access Gap Cover for the billing of your procedure, you’ll still be covered by Medicare and GMHBA for the scheduled fee, but will need to pay any gap.

Not always. If your specialist uses Access Gap Cover, you may have:

• No gap – no out-of-pocket cost for their inpatient medical services, or a
• Known gap – a capped out-of-pocket amount agreed under the scheme.

Other out-of-pocket costs, such as your hospital excess or co-payment (if applicable) or services not covered by your admission, may still apply.

Before your procedure, ask your specialist whether they will use Access Gap Cover for the billing of your treatment and request a written estimate of any costs you may need to pay.

Before your procedure, it's a good idea to ask your specialist for:

• A written estimate of their fees
• An outline of expected out-of-pocket costs
• The Medicare Benefits Schedule (MBS) item numbers for your treatment
• Whether they will use Access Gap Cover for the billing of your treatment
• Whether any other doctors will be involved in your care (such as an anaesthetist or assistant surgeon) and their likely fees
• Details of the hospital where the procedure will be performed.

Having this information can help you better understand your expected costs and allows GMHBA to provide more information about your cover and benefits before your admission.