It's any expense for a hospital or extras service or item for which you won't be reimbursed – by either us or Medicare.
The out-of-pocket expense will be the difference between the provider's charge and the benefit we pay. To help reduce your out-of-pocket expenses, visit a Members' Choice extras provider where you can access capped and/or discounts and generally receive higher benefits than you would with a non Members' Choice provider.
Although hospital cover helps reduce the cost of your private hospital visit, you'll still have out-of-pocket expenses for things like your excess and any difference between what the hospital charges and the benefit we pay for the hospital services.
You can also expect to pay the difference between the charge for in-hospital medical services (eg. doctors' services, pathology and radiology) and what you receive from Medibank and Medicare. To explain it further, the benefits you're entitled to for the medical services you receive while you're in an overnight or day hospital facility are based on the Medicare Benefits Schedule (MBS) fee. The MBS is a list of all the services Medicare pays benefits for and the rules that apply to payment of those benefits.
Medicare pays 75% of the MBS fee and Medibank pays 25% (if the treatment is covered under your policy).
When a doctor charges more than the MBS fee, you'll have out-of-pocket expenses. These can vary and may be significant. This is what's referred to as a ‘gap'. Have a look at the diagram below – it shows you the amount Medicare takes care of and the amount we cover for in-hospital medical services. It also shows you the gap.
If possible, go to a Members' Choice hospital where our agreement with the hospital limits what you can be charged.
This means your out-of-pockets for hospital charges should be limited to things like:
Any excess you may have with your cover
Any pharmaceuticals not covered by our agreement with the hospital. This includes the cost of any drugs issued on discharge from hospital
Any gap for surgically implanted prostheses and other items on the Federal Government's Prostheses Schedule
Costs for services not covered, or not fully covered, by our agreement with the hospital or under your cover
Costs for treatment in an emergency department in a private hospital. Note, with Ultra Health Cover you can claim benefits on the facility fee charged (subject to annual limits).
If you go to a non Members' Choice private hospital, you're likely to have significant out-of-pocket expenses.
Before you go to hospital, try to arrange to see a doctor who'll participate in our GapCover scheme. This is because GapCover can help reduce or eliminate your out-of-pocket expenses for doctors' services received in a private hospital. It's important to be aware that doctors can choose to participate in GapCover on a claim-by-claim basis and more than one doctor may be involved in your treatment
GapCover doesn't apply to pathology and radiology services, any applicable excess payment, services not included under your cover or out-of-hospital consultations.
Ultra Health Cover
Ultra Health Cover includes additional features to help reduce or eliminate your out-of-pocket costs when you are admitted to hospital. For example, if your doctor agrees to participate in GapCover there will be no out-of-pockets for your doctor's charge. There is also an Ultra bonus which is automatically applied to reduce any eligible out-of-pockets costs for in-hospital medical treatment and hospital related costs. Call us to find out more on 1300 183 959.
Call us first on 1300 183 959 so we can help you understand what's involved and the types of questions you need to ask your doctor or specialist.