Member Onboarding

Hospital Out-of-Pockets Explained

Sometimes you’ll have to pay for part of a treatment out of your own pocket – discover when this happens and how to minimise the cost.

Is everything covered when I go to hospital or is there more to pay?

Depending on your level of cover and whether you’ve chosen to pay an excess or co-payment, you may need to pay part of your hospital bill out of your own pocket – this is called an ‘out-of-pocket’ expense.

A ‘gap’ is the most common type of out-of-pocket. A gap occurs when the total cost of your treatment is greater than the combined amount Medicare and your health fund pays towards that treatment. Gaps can occur when you go to hospital in two ways - Medical gap and hospital gap.

Medical gap

When you go to a private hospital as a private patient for treatment, your doctor or specialist’s bill is covered between Medicare and your health fund. Medicare pays for 75% of the medical practitioner’s bill and your health fund pays the remaining 25%, up to the price listed in the Medicare Benefits Schedule (MBS).

Medical gaps occur if your doctor or specialist charges more than the MBS. Doctors and specialists can charge as much as they want above the MBS fee, which can lead to significant out-of-pocket expenses when you go to hospital for treatment.

To help our members avoid medical gaps, HBF has fully covered or known gap arrangements with a large network of doctors and other specialists across Australia. If you choose to see a fully covered doctor or specialist, HBF will cover any additional costs the specialist charges above the MBS, meaning you won’t have anything to pay (apart from any excess or exclusions). If you choose to see a “known gap doctor”, HBF will cover a portion of the cost the specialist charges above the MBS, and you’ll only have to pay the remaining ‘known gap’.

Hospital gap

A hospital gap occurs if the cost of your stay in hospital (e.g. accommodation and theatre fees) is greater than the amount your health fund covers. To help members avoid the hospital gap, many health funds have arrangements with hospitals to fully or partially cover costs relating to hospital accommodation.

It’s important to note that even if your health fund has an arrangement with a hospital to cover costs, you will still need to pay any excess or co-payment you’ve agreed to on your policy.

To help you get the best value out of your hospital insurance, HBF has special arrangements with a large network of Member Plus private hospitals across Australia. At an HBF Member Plus hospital you’ll be fully covered for accommodation and theatre fees for services covered on your policy. That means you can limit or avoid the cost of your hospital stay by choosing treatment at an HBF Member Plus hospital.

What can I do to help cover costs when there’s an unavoidable gap?

To help members cover the cost of unavoidable gaps, HBF has GapSaver: a product you can add to your policy that helps cover out-of-pocket costs.

How does GapSaver work?

Think of GapSaver as a way of building up a pool of money you can dip into to cover eligible claims – the money you put into it (an additional contribution on top of your policy premium) accumulates over time and can be used to cover unexpected out-of-pocket costs. The best thing about GapSaver is the money you contribute never expires; it just accumulates year by year. You can use your GapSaver dollars to help cover the cost of hospital or extras services.

Depending on your income, you may be eligible to access the Australian Government rebate on private health insurance, which contributes up to 26.791% towards the cost of your GapSaver premiums – this means you could earn more GapSaver dollars than you pay in premiums.

You might also like