Medical Gap Scheme
- What is the medical gap?
- Under what circumstances is the Medical Gap Scheme available?
- How does the Medical Gap Scheme work?
- How do I access the Medical Gap Scheme?
- How do I find an Medical Gap Scheme specialist?
- What are the benefits of the Medical Gap Scheme?
- What should I do if I'm going to hospital?
- If a doctor is registered, can I be sure he or she will participate?
- Will my family doctor know which specialists are registered in the Medical Gap Scheme?
- What happens to the doctor's invoice?
- What if my doctor wants to offer me the Medical Gap Scheme, but isn't registered with MBF?
What is the medical gap?
For in-patient hospital treatment, the 'medical gap' is the amount above the Medicare Benefits Schedule Fee that some doctors charge for medical services. Traditionally, the 'medical gap' was not covered by health funds.
Under what circumstances is the Medical Gap Scheme available?
The Medical Gap Scheme is available to members who:
- Are financial members that contribute to an MBF hospital cover
- Do not have the service excluded under their hospital cover
- Have served all applicable waiting periods
- Are a patient as defined by section 3 (1) of the Health insurance Act 1973
- Receive services that are eligible for Medicare benefits
- Receive cosmetic surgery only in situations where it is clinically necessary
- Cannot claim compensation, damages or benefits from another source e.g. Workers' Compensation.
How does Medical Gap Scheme work?
If you have in-patient hospital medical treatment, your doctors can choose to participate in the Medical Gap Scheme. When they do, your doctor agrees with MBF on charging a certain amount for services and also agrees to bill us directly. When they 'opt in', in most cases you will have no 'medical gap' to pay for the treatment provided by the doctors that have opted in. And, if there's a gap you should be advised by the doctor(s) of that amount before your treatment.
In some instances a participating doctor can charge you a 'known gap'. A known gap is an amount above the Medical Gap Scheme benefit. These are also capped at maximum amounts providing you certainty regarding any possible out of pocket expenses. Doctors are independent of MBF and, as a result, we cannot guarantee participating doctors in every area.How do I access the Medical Gap Scheme?
Access to the Medical Gap Scheme is included in all levels of MBF hospital cover. There is no need to buy any additional products.
Ask doctors involved in your hospital care if they are registered as Medical Gap Scheme providers and they are willing to participate for your services. When they do, doctors will bill us directly.How do I find a Medical Gap specialist?
Your general practitioner is in the best position to refer you to a specialist that will meet your clinical needs. You should then ask the specialist whether they will accept as full payment the Medical Gap Scheme benefits for your in-patient hospital services.
If your doctor does not appear on the Find a Medical Gap Specialist search tool, ask them if they participate in the Medical Gap Scheme for your treatment.
You can also click on the following link to find out if your radiology or pathology provider has entered into an arrangement with MBF.
Alternatively, call MBF on 131 137 for more information on registered Medical Gap Scheme specialists.
What are the benefits of the Medical Gap Scheme?
- Peace of mind. In most instances you will enjoy the financial certainty of 'no gaps' for medical services received in-hospital where your doctor opts in for your treatment.
- Simplified claims process. You do not have to make a claim - the doctor bills us directly.
- Value for money. You get even more from your private health cover.
What should I do if I'm going to hospital?
Call us before you go to hospital and we'll confirm whether your doctors are registered in the Medical Gap Scheme. If they are, ask each of them if they will use the Medical Gap Scheme for your in-hospital service.
Remember, you can also ask your GP to refer you to a specialist offering the financial certainty of our Medical Gap Scheme.If a doctor is registered, can I be sure he or she will give me 'no gaps'?
No. As doctors can choose to participate and charge the Medical Gap Scheme benefits on a patient-by-patient basis, we cannot guarantee that the doctor will participate in each and every instance. You will still need to ask them.
Will my family doctor know which specialists offer 'no gaps'?
Your family doctor is the best person to refer you to an appropriate specialist for the health care you require. If they do not know if the specialist you are being referred to is registered in the Medical Gap Scheme you can contact MBF on 131 137. In most cases, we can confirm whether the specialist you have been referred to is registered.
If your specialist is registered, you will then need to ask if they will accept the Medical Gap Scheme benefits as full payment for your treatment. Doctors are not obliged to use the scheme for every patient.
What happens to the doctor's invoice?
Your participating s doctor should send the invoice directly to MBF. If however, they have sent the invoice to you (with the Medical Gap Scheme claim form attached), forward it on to MBF immediately, not Medicare and do not pay the account. We will arrange for the Medicare portion to be paid on your behalf. The whole amount is then sent to your doctor and we will send you a statement showing what we have paid. In most cases you should not have to pay anything to a participating doctor for your in-hospital treatment.
What if my doctor wants to offer me the Medical Gap Scheme, but isn't registered with MBF?
It is easy for your doctor to register. They can download the application form from one of our special provider (doctor) websites or even register online. Contact points for providers:
Websites: http://provider.mbf.com.au or www.bupaproviders.com.au
Email: eprovops@bupa.com.au
Phone: 1800 111 623