Medical gap
You might have heard of the Medicare Benefit Schedule (MBS). This is a list of the medical
procedures Medicare covers, as well as what they’ll pay towards treatment.
When you are admitted to hospital as a private patient, your specialist’s bills will be covered
up to the MBS fee. Medicare will cover 75% of the MBS fee, while we will cover the remaining
25%. An out-of-pocket expense occurs when there is a difference between your specialist’s fees
and the combined benefit provided from Medicare and HBF.
We have a number of arrangements in place with specialists that can help eliminate or reduce
these out-of-pocket expenses for you:
1. Fully covered*:
If your specialist participates in a Full Cover arrangement, they will only charge up to an
agreed fee and we will pay an additional amount
above the MBS, unless your procedure is on the HBF Limited Surgical Items List*, leaving you
with no out-of-pocket expense for your inpatient services.
2. Known gap*:
If your specialist participates in a Known Gap arrangement, they have the option to opt-in or
opt-out of the arrangement on a case by case basis. If they choose to opt-in,
your specialist will only charge up to an agreed fee and we will pay an additional amount above
the MBS, unless your procedure is on the HBF Limited Surgical Items List*, minimising or
eliminating your out-of-pocket expense.
3. Opt out or no agreement:
If your specialist chooses to opt-out of the arrangement or are not registered to participate in
an arrangement, their in-patient services will be covered up to the MBS fee. You will need to
pay the difference between the MBS fee and the specialist’ fees (this is your out-of-pocket
expense).
*HBF has a “HBF Limited Surgical Items List” (HBF List), which is subject to change from time to
time. Where
your treatment involves an item on the HBF List, HBF will not pay a benefit greater than the
Medicare Benefit Schedule (MBS)
fee for that item and any services you receive from an anaesthetist associated with that item.
As such, out-of-pocket costs may apply. This applies regardless of whether your chosen provider
is a full cover or known gap.
Save with HBF Member Plus
HBF has fully covered and known gap arrangements with a large network of doctors and specialists
across Australia. We call these doctors and specialists Member Plus providers. The arrangements
we have with Member Plus providers help our members avoid or limit medical gaps.
Medical cost breakdown
Medicare Benefits Schedule (MBS) fee
Paid by HBF
You pay
Paid by HBF
Paid by Medicare