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What is Gap Cover and how does it affect me going into hospital?

I've heard it hundreds of times from my clients...

"I want Gold Hospital so I don't have to pay out of pocket in hospital'

Slow down, Sally, that's not how it works

Let me tell you why...

See, there's something called the Medicare Benefits Schedule

MBS for short

It's a list of all the item numbers subsidized by the Australian Government, Medicare, when you go private.

In simple terms, it's a list of all possible medically necessary procedures that both Medicare and your private health fund pay to the hospital and surgeon...

Okay, so Medicare and your private health fund cover all the costs?

Not so fast...

They only pay up to the amount listed on the MBS...

And because the surgeons and anaesthetists generally charge ABOVE this MBS listed price,

You pay a gap.

So in short...

You've probably been paying private health for over 10 years...

You decide to skip the public hospital waiting list

And you choose your own private surgeon

Then you get slogged for THOUSANDS out of pocket?!

...No, not with all funds at least...

Let me explain,

See, I've been in the health insurance industry for 9+ years now

I've researched each and every health fund

And how they perform from state to state

(Yep, health funds perform differently in each state)

So I know the chances that you'll pay a gap or won't pay a gap, depending on your state and your fund.

Won't pay a gap?

Yep, that's right...

Did you know there's a group of health funds that participate in what's called 'Gap Cover'

And it does exactly that

Generally, IT COVERS THE GAP

That means, just by being with the wrong health fund in the wrong state, you could pay THOUSANDS in gap payment

But if you're with the right fund for your state

and they might even come in at a lower premium...

You could pay nothing.

Nada.

Zero.

Zilch.

Just your excess, of course.

So, you want to find out which health funds perform best in your state,

Get the email now

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FAQs

  • There are no waiting periods when switching health insurance funds, providing you have already served the waiting periods with your previous fund. However, if you’re upgrading and adding services on, you will need to serve a waiting period for the upgraded services.

  • It depends on multiple factors and comes down to your individual needs. If you use hospital cover regularly, you might prefer a fund that has better hospital gap cover in your state. If you use extras only a few times per year rather than every month, a percentage based rebate with a lower annual limit may work better for you. Your own needs will determine the best fund and policy for you.

  • You can reduce the cost of your private health insurance a few simple ways.
    Increasing your hospital excess, splitting your policy with your partner if your needs are vastly different, removing clinical categories you don't need, only covering extras you use regularly, finding a health fund offer for new members. It's best to compare to ensure you are on the right level of cover, with the right fund.

  • There are health funds that offer better gap cover than others depending on your state. If you're with a health fund that's part of Australia's largest gap cover arrangement called Access Gap Cover, your surgeon may decide to opt-in to their gap cover arrangement, meaning your out of pocket cost is either Known Gap ($500 cap per procedure) or No Gap (no out of pocket). It's important to check with your surgeon and ask if they will opt-in to your health funds gap cover arrangement.

  • Gold hospital cover has no excluded or restricted clinical categories. This level includes Pregnancy and Birth, Surgical Weight Loss and Psychiatric Treatment in a private clinic. If these clinical categories are not required, then you would be more suited to a lower level of hospital cover like Silver Plus. A common misconception is that Gold cover pays more or guarantees a private room, but this is not true. If you're on Bronze hospital cover or Gold hospital cover and have the same surgery done, the payout amount is exactly the same.