Out of Pocket Expenses & Medical Gap – What Are They?

Want to reduce your out-of-pocket expenses? Understanding the medical gap could help you reduce the cost of your health care.

Access Gap cover is a legislative scheme that helps to reduce, and in some cases, eliminate any out-of-pocket expenses you may incur when receiving medical treatments. This scheme accompanies your health insurance policy offering even more value from your private health cover.

Your medical practitioner and the type of treatment you require will greatly determine if you need to pay anything out of your own pocket after you’ve received treatment.

If your doctor charges above the Medicare Benefits Scheme, you’ll be charged a medical gap. With Access Gap cover, this out-of-pocket expense may be reduced or entirely covered by your health fund.

Whether your priority is to gain financial protection, simplify the insurance claim process, or look after your health better, the Access Gap can definitely benefit you.

It pays to understand the level of Access Gap cover your policy offers so you can budget for any expenses before receiving medical treatment.

If you think you’ve got a pretty good handle on the basics and see the benefit of taking out a health insurance policy to reduce your out-of-pocket expenses, you can always skip ahead and get started with an online quote right now.

Our comparison tool allows you to compare a range of options from health funds in just a few minutes.

What is ‘Access Gap’ cover?

Access Gap cover is a legislative scheme that allows private patients to reduce or even eliminate the out of pocket costs that may be incurred when claiming treatments. It’s available with any hospital cover.

Gap expenses are the most significant out-of-pocket expenses you may be expected to pay when receiving medical treatment. The ‘gap’ is the difference between how much the medical practitioner charges for the specific medical treatment and for how much you’re covered for.

This out-of-pocket expense can vary significantly depending on the practitioner and the type of medical treatment you require. Unless you are informed of the gap prior to your treatments, you could be in for an unwanted surprise when it comes time to pay the bill for your medical care.


The term ‘medical gap’ refers to the amount above the Medicare Benefits Schedule that some medical practitioners charge for medical services. This expense is not typically covered by health funds and includes day surgery or hospital procedures.

Some funds have an agreement with certain doctors that may cover some or all of the doctor’s fee for hospital treatments. If your health fund doesn’t have an agreement with your chosen doctor you may have to contribute an amount towards the bill out of your own pocket.

The term ‘hospital gap’ refers to the out-of-pocket expenses you may face for your hospital accommodation. Many hospitals have agreements with health insurance funds to cover the full or partial costs of your hospital accommodation.

If you choose to go to a hospital that doesn’t have an agreement with your health fund, you may have to pay a significant bill for your treatment.

If you opt for health insurance excess or a co-payment policy, you’ll have to pay an agreed amount towards the cost of your treatment. That applies even if your hospital has an agreement with your health fund.


To gain a better understanding of Access Gap Cover and related benefits, it pays to know the basics of the Medicare Benefits Schedule (MBS).

The MBS is an extensive list of medical procedures that are covered by Medicare and private health insurance hospital cover.

Regardless of whether you receive treatment at a public or private hospital, your private health insurance and Medicare will typically only cover the MBS cost. If you have private health cover, Medicare will contribute 75% to the MBS amount for your treatments and your fund will pay the remaining 25%.

If you don’t have a health insurance policy, Medicare will pay 100% of the MBS amount.

When your doctor charges an amount above the MBS for the treatment, you’ll be paying the gap. With Access Gap cover, this out-of-pocket expense may be reduced, and in some cases, covered entirely. Without private health cover, you’ll have to fund the medical gap entirely out of your own pocket.

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Who needs cover?

Single Male Single Female Couple Family Family (Single Parent)

How does Access Gap reduce my out of pocket expenses?

The amount a doctor decides to charge his or her patient isn’t regulated by the Australian Government. That means you could be paying a significant amount above the MBS for your treatment without Access Gap cover.

There are typically three levels of protection offered by most health funds:

  • Partial gap cover

    This form of protection will cover some of the gap, but not the entire amount. This means you’ll have to pay the remaining amount owed.

  • Known gap cover

    This form of protection covers you for the maximum capped amount for each treatment. While you may have to pay a gap, you’ll know what your out-of-pocket expense is before undergoing any treatment.

  • Full gap cover

    This form of protection is the highest level covering you for the entire amount owing above the MBS.

    Remember, gap cover schemes can vary from fund to fund. Taking the time to compare cover and assess how the policies fit your needs and expectations will ensure you get the most value out of your health insurance.

What are the benefits of choosing Access Gap cover?

There are several advantages of choosing Access Gap cover, including:
  • You’ll know any out-of-pocket expenses prior to the treatment.
  • You may even avoid out-of-pocket expenses entirely for some treatments.
  • You can skip Medicare queues.
  • Your doctor can claim on your behalf.
  • You can get more value for money on your private health cover.
  • You’ll have peace of mind.
There are also several benefits for doctors registered for Access Gap cover, including:
  • Claims are paid within 21 days.
  • Improved cash flow.
  • Simpler billing systems.
  • No contracts with Access Gap.
  • Reduced risk of bad patient debtors.
  • Doctors can accept or decline to participate in the scheme on a case-by-case basis.

Is my doctor registered for Access Gap cover?

To take advantage of the Access Gap Cover, your doctor will need to be registered with the scheme with your individual health fund.

You can find out whether your doctor is registered by contacting your health fund directly or asking your doctor. It’s important you do this, as even if you have Access Gap cover, if your doctor isn’t associated with your health fund and charges over the MBS fee, you may have to pay most of the bill yourself.

We also recommend before you go to hospital you discuss the cost of your treatment with the doctor. Your doctor is obliged to inform you of any out-of-pocket expenses that you may need to pay in a written estimate before you go into hospital.

Here are some questions you should ask your doctor before accepting treatment:
  • Are you able to treat me under my health fund’s Access Gap cover?
  • Are there any out-of-pocket expenses and if so, can you please provide me with a written estimation of how much?
  • Are there any assisting doctors using the Access Gap cover?
  • Will the bill be sent to my fund directly so they claim my Medicare benefit on my behalf and send the payment directly to you?

What is excess in health insurance and how does it affect my out-of-pocket expenses?

An excess is an agreed sum of money you elect to pay towards the cost of your medical treatment. You make this agreement with your health fund when you take out your policy.

An excess on private health insurance sees a reduction in the cost of your premiums. Typically, the higher the excess you’re prepared to pay, the lower your annual premiums should be.

You’ll only be required to pay the excess if you’re admitted to hospital for treatment. The excess is not applicable for any extras benefits.

Even if you opt for a higher excess, without Access Gap cover you may still have some out-of-pocket expenses depending on the type of treatment you receive and the doctors or specialists involved.

How do I get Access Gap cover?

Access Gap Cover is automatically included as part of your fund’s hospital cover. This means there are no additional costs or products required for you to benefit from the scheme.

The level of protection you’ll receive with Access Gap cover will depend on your chosen hospital cover.

How can I avoid unexpected medical costs?

There are several ways you can limit your out-of-pocket expenses or medical treatments and in some cases, avoid them altogether. These include:
  • Make sure your chosen doctor or hospital participates in your health fund’s Access Gap scheme.
  • Choose a health fund that offers 100% gap cover. If that policy isn’t affordable for you, consider a known Access Gap cover so you can budget any upcoming medical expenses.
  • Take out a policy that doesn’t include any excess or co-payment.
  • Before you receive treatment, find out what the fees are for any specialists or assisting medical practitioners such as anaesthetists or surgeons.
  • Find out if the assisting medical practitioners are registered with your health fund.
  • Avoid seeking treatment from doctors who charge above the MBS scheduled fees.

What’s next with your health cover?

Finding the right health insurance can help you avoid or reduce the medical gap so you’re not left with expensive out-of-pocket costs after you’ve received treatment.

The best way to find a good value health cover that meets your lifestyle needs and budget is by comparing.

With our online comparison tool you can compare a range of policies from health funds.

If you have any questions or queries with your health cover or how the rebate works, we have friendly staff who are all health insurance experts. You can call one of our team on 1300 806 119