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About out-of-pocket expenses

What kind of out-of-pocket expenses can I expect if I go to a private hospital?

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.