Medical Gap Agreements

We have agreements in place with specialists across Australia to help members minimise or eliminate out-of-pocket costs. Learn more about our Medical Gap Agreements below.

To discuss your hospital cover call 133 423

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When you are admitted to hospital as a private patient, your specialist’s bills will be covered up to the Medicare Benefits Schedule (MBS) fee. Medicare will cover 75% of the MBS fee, while we will cover the remaining 25%. However, you may still incur an out-of-pocket cost if there’s a difference between your specialist’s fees and the combined benefit provided from Medicare and HBF.

That’s where Medical Gap Agreements come in. Our Medical Gap Agreements can help reduce these out-of-pocket costs for you.

Medical Gap Agreements

Full Cover

If your specialist participates in a Full Cover arrangement, they cannot charge fees that exceed the Full Cover Schedule. HBF will pay an additional amount over the MBS fee, leaving you with no out-of-pocket costs for your inpatient services.

Provider Choice

Provider Choice is a flexible arrangement that allows specialists to choose the level of out-of-pocket costs for their patients. If your specialist participates in the Provider Choice agreement, they can choose to bill in one of two ways:

  1. Opt-in:

    2. The specialist must choose to charge a fee that does not exceed the Provider Choice fee Schedule. This will result in an increased benefit from HBF and your specialist will not be able to charge you an out-of-pocket cost.

  2. Opt -out

    3. The specialist chooses to charge fees above the relevant Schedule, which means you will need to pay the difference between the MBS fee and the specialist’s charge. There is no limit to the specialist's fee and they can charge you what they believe is a reasonable amount.

By understanding which option your specialist has chosen and requesting a medical benefit quote from HBF before your hospital admission, you can better prepare for your treatment and avoid any unexpected costs.

Frequently Asked Questions

I will be receiving inpatient treatment, what will my out-of-pocket cost be?

Please contact your medical specialist and request an Informed Financial Consent (IFC). The IFC will confirm the MBS items and charges associated with your treatment. Once you have this information, contact us on 133 423 for a medical benefit quote.

What is Informed Financial Consent (IFC)?

Informed Financial Consent (IFC) is a quote by your specialist, which sets out any out-of-pocket costs you will be required to pay. If your specialist doesn’t provide this upfront, you are entitled to request one.

Understanding this information and knowing all the estimated costs of your procedure will allow you to provide informed financial consent for the costs of your treatment.

More information on IFC can be found on the Australian Medical Association (AMA) website.

What is the Medicare Benefits Schedule (MBS)?

The MBS is a list of fees for medical services set by the Australian Government for eligible hospital treatment as a private patient. For in-hospital medical services, Medicare pays 75% of the MBS fee and HBF pays the other 25%.

What is the Provider Choice schedule of fees?

Provider Choice arrangement includes a schedule of maximum fees that apply when they opt-in. Unless they opt-out a Provider Choice specialist must charge you no more than what is listed in the Provider Choice fee schedule and you will have no out-of-pocket costs from their inpatient treatment.

What is the main difference between Known Gap and Provider Choice?

While both agreements are opt-in/opt-out agreements, the new Provider Choice Agreement is a simplified version offering only two billing options. This means once your specialist opts in, you will be fully covered for your inpatient medical treatment.

Who chooses the Medical Gap Agreement my specialist is on?

HBF offers a choice of Medical Gap Agreements, and the specialist elects which agreement they wish to register for. If they choose to be a Full Cover specialist, they must provide all HBF members with a no-gap experience.

However, if they choose the Provider Choice agreement, they have the flexibility to opt-in or opt-out of the agreement on a case-by-case basis. This means that the out-of-pocket cost may vary from surgery to surgery or member to member.

How do I find a fully covered specialist?

You can find a list of our Full Cover medical specialists at hbf.com.au/health-insurance/find-a-provider.

I expect to have an inpatient procedure after 1 October 2023 – What do I need to do?

Please consult your specialist to-confirm charges and what your out-of-pocket costs are prior to any procedure scheduled from 1 October 2023.

As we work through these changes, you might notice some quotes are only valid until 30 September 2023. If you have a treatment date after 30 September 2023, please make contact. We will review your circumstances and confirm, if you need to seek further details from your specialist (such as requesting an updated Informed Financial Consent based on treatment after 1 October 2023).

What happens if my specialist selects the opt-in option under Provider Choice after 1 October 2023?

If your specialist opts-in to Provider Choice, they will charge you no more than the fee set out in the Provider Choice Schedule of Fees. By charging a set fee, we will fully cover the cost of your treatment.

What happens if my specialist selects the opt-out option under Provider Choice after 1 October 2023

If your specialist opts-out of Provider Choice, the amount you need to contribute to the cost of the treatment will depend on the amount they charge. There is no limit to this amount and your specialist will charge what they believe is a reasonable amount. HBF will pay the specialist up to the MBS fee and the outstanding amount will be your out-of-pocket cost.

My Known Gap / Provider Choice specialist has told me they will not continue with any HBF Medical Gap Agreement – What does this mean?

This means your out-of-pocket costs for your treatment may increase. Between HBF and Medicare, we will pay up to the MBS fee only. The difference between your specialists charge and the MBS fee will be the amount you are required to pay out of pocket.

If you have an upcoming hospital treatment, please contact us for a benefit quote so you know what’s covered and any out-of-pocket costs you may expect to incur.

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