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.
See more helpful articles in Health insurance explained:
What are Medical Gap Agreements
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.
Skip straight to:
Medical Gap Agreements
Full Cover
Provider Choice
Provider Choice is a flexible agreement 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:
- Opt-in:
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.
- Opt -out
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.
Breakdown of agreement billing
In general, Medicare and HBF will cover the cost of inpatient medical treatment if the specialist chooses to be Fully Covered or opt-in to the Provider Choice Agreement. If the provider chooses to opt-out of the fully covered options or is registered under the Direct Billing agreement, only the MBS fee will be paid by Medicare and HBF.
These graphs do not represent real costs of any procedure and should not be used as a reference of how much a procedure will cost.
Full Cover
Provider Choice Opt-in
Provider Choice Opt-out
Direct Billing
Medicare pays
HBF pays (MBS fee)
HBF pays (Additional benefit)
Member pays (Gap)
I will be receiving inpatient treatment what will my out-of-pocket cost be?
What is Informed Financial Consent?
Before receiving treatment, your doctor, health provider and/or hospital should provide you with a quote which sets out any out-of-pocket costs that you will be required to pay. If they do not provide this upfront, you are entitled to request this quote.
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 providing Informed Financial Content can be found on the Australian Medical Association's (AMA) website.
What is the Medicare Benefits Schedule (MBS)?
What is the Provider Choice schedule of fees?
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.
Explore our Help Centre
Health insurance explained
Gold, Silver, Bronze and Extras cover explained, what is an excess and more.
Manage your membership
Access your cover online, order a member card, manage members on your policy and more.
Membership & claims
Making claims, managing your cover, updating payment details and more.