GapCover Checklist

There are five easy steps to leaving hospital better, not poorer. Please read them carefully, in case you ever need hospital care.

Step 1 – Talk to your GP

If you ever need to go to hospital, check with your GP that the specialist they are referring you to uses Medibank Private GapCover. Another way to assist you to find out is at medibank.com.au, where we’ve published a list of the specialists who have participated in GapCover. The information is also available at any of our Retail Centres.

If the specialist you are referred to isn’t on our list, they may still participate in GapCover – you will need to check with them. Also, some specialists who don’t use GapCover may charge fees at the MBS level – there will be no gap to pay for their services. If you need to go to hospital in an emergency or are referred to another specialist while you are in hospital, you will need to ask your specialists if they participate in GapCover.

Step 2 – Confirm with your specialist

Remember, it is up to the specialist to participate in GapCover, and they may do so on a case-by-case or episode-by-episode basis. So, the next step is to contact the specialist who will be treating you and confirm with them that they will be charging you in accordance with Medibank Private’s GapCover arrangements for the treatment you’re about to have. They should also be able to tell you if other specialists will be involved in your treatment (eg an assistant surgeon or an anaesthetist), so you can find out whether they are also going to use GapCover.

In general, if all treating specialists confirm that there will be ‘no gap’, you can commence your treatment knowing that you will not be left out of pocket for their services. However, where changes are required to your treatment after your admission to hospital, there may be some out-of-pocket expenses.

Some specialists may charge you more than you are covered for by Medicare and Medibank Private. You will be responsible for paying this ‘known gap’, and the specialist generally must tell you, before your treatment, how much it will be. For any one hospital admission, $800 is the highest known gap that may be charged collectively by the specialist(s) who will be treating you under the Medibank Private GapCover arrangements. While you may be entitled to benefits for your treatment under your policy, you will be unable to take advantage of GapCover arrangements if their fees exceed that amount.

Step 3 – Obtain an estimate

Your specialists are generally required to provide estimates of any out-of-pocket costs you will need to meet (including any known gap), in advance of your treatment. To be eligible for GapCover, you will need to acknowledge receipt of the estimates.

Step 4 – Ask about billing

Once your specialist confirms they’ll be using GapCover, you will need to ask how you’ll be billed. That is, will you be receiving an account from them, or will they charge Medibank Private direct? In the case of a ‘known gap’, you will be responsible for paying the gap, but we will pay the remainder of the bill if you take it to a Retail Centre (Step 5).

Step 5 – Make a claim

Even if your specialist bills you directly, there’s no need to claim from Medicare when your treatment’s complete – we’ll do that for you. Just take your bills to any Medibank Private Retail Centre, fill out a GapCover claim form and we’ll take care of the rest. Claim forms are available at all Medibank Private Retail Centres.

Points to remember

Always remember, participation in GapCover is at your specialist’s discretion and you will need to check with them prior to receiving treatment to confirm whether they’ll be using GapCover for your fees. It is available only under the policies listed above. GapCover does not eliminate amounts that you’ve agreed to pay under your policy with Medibank Private, such as any applicable excess, co-payment or other hospital charges. And remember it only applies to medical procedures performed by specialists in hospital or day hospital facilities.

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