Why do I have out-of-pocket costs?

Cost can be one of the biggest factors when it comes to making decisions about our health. Although we always strive to make things as easy as possible for our members, the bottom line is that private health insurance is complicated and there are many things that influence the costs of treatment. Through your treatment journey you will see lots of terms that may be unfamiliar, like 'Medicare Benefit Schedule’, ‘Item number’, ‘scheduled fee’ for example. We’re here to help you understand these terms and the role they play in the costs associated with your hospital treatment.

Medicare Benefits Schedule

The Medicare Benefits Schedule (the MBS) is a list of the medical services for which the Australian Government will pay a Medicare rebate, to provide patients with financial assistance towards the costs of their medical services. The ‘schedule fee’ or ‘set fee’ is the set amount defined by the government. Each service contained in the MBS is allocated a unique item number which should be included on your quote.

Doctors are not required to charge the schedule fee and may choose to charge above this amount. The ‘gap’ between the schedule fee and the amount charged by your doctor becomes an out-of-pocket expense for you.

You should ask your doctor to explain the costs of your hospital admission including any prostheses gap amount, their own fees, any fees for other doctors involved (such as assistant surgeons and anaesthetists) and any other expenses involved. If there are any out-of-pocket costs for you to pay ask for a written cost estimate. Don't forget, you can also search online for doctors who have previously participated in Access Gap to help reduce or avoid out-of-pocket costs associated with your treatment.

Other out-of-pocket costs can come from:

  •         Excess
  •         Going into hospital for restricted service
  •         Additional hospital expenses (e.g. fees for TV, internet)
  •         Not a contracted hospital
  •         Gap for prostheses
  •         Pharmacy (items prescribed outside of pharmaceuticals required as part of treatment)
  •         Allied Health services (if not part of hospital contract)
  •         Parking fees or travel costs.