If your medical practitioner (such as your doctor, specialist or anaesthetist) charges more than the Medicare Benefits Schedule (MBS) fee, you may have to pay the difference (gap) to the doctor. Fortunately, HBF has fully covered arrangements with more doctors in WA than any other major Western Australian private insurer. This means that more often than not, you won't have an out-of-pocket expense.
You should always call us or speak to your doctor to check what arrangement they have with HBF and what, if any, gap you'll have to pay. HBF may cover all, some, or none of this gap, depending on the agreement we have with the doctor. The doctor will fall into one of three categories.
Fully covered - These practitioners are fully covered by Medicare and your HBF insurance, so you won't have anything to pay.
Known-gap - These practioners have agreed to charge a fixed amount above the MBS fee. HBF will cover some of this gap, but there may also be an out-of-pocket expense. However, for some procedures, ‘known-gap’ doctors might choose to charge above the agreed amount, in which case you will only be covered up to the MBS fee. So ‘known gap’ practitioners should provide you with details of out-of-pocket expenses in writing prior to the procedure. You’ll need to agree to these charges before your surgery, which is known as giving your ‘informed financial consent’.
No agreement – These doctors choose not to participate in any form of gap cover. If you use a ‘no agreement’ provider, you’ll have to pay all costs that are charged above the MBS fee.
Many surgeons work with a preferred anaesthetist and may also use an assistant. Be sure to speak with your doctor before your procedure to find out if anyone else will be involved in your surgery. You should then check with us about whether these supporting medical practitioners will be covered. It’s also a good idea to check whether your doctor and associates will invoice you directly or submit an account to HBF, so that you know what to expect after your hospital stay.
Please note, plastic and reconstructive items are generally only covered up to the MBS regardless of the doctor’s agreement.
How do I find out if my doctor is covered by HBF's medical gap?
We can tell you if your medical practitioner is 'fully covered' or 'known gap covered' by HBF. Simply call us on 133 423, visit an HBF branch BEFORE your hospital stay, or use our online map to search for a fully covered medical practitioner.
How do we decide if a medical practitioner is covered by our medical gap arrangements?
We advise medical practitioners' of the amount we can afford to pay under our medical gap scheme. It is then up to each individual medical practitioner to decide whether they wish to participate, and if they would like to be a 'fully covered' or 'known gap' covered provider.
Why can't HBF fully cover every medical practitioner?
The fees that medical practitioners' charge can vary significantly. As a not for profit fund, we cannot afford to cover the range of fees charged by every medical practitioner without having to significantly increase health insurance premiums.
Need more information?
To find out more about our medical gap cover, how to save on out-of-pocket hospital expenses, or for information to help you prepare for your hospital stay, please refer to How does gap saver work?.