The gap

Minimising out-of-pocket hospital costs

The extent to which your hospital costs are covered will depend on the level of cover you choose, the hospital facility you use, whether your doctor agrees to use our Access Gap Cover schedule of fees, and which surgically implanted prosthesis (if any) is required.

Here's more information:

Hospital costs

As a private patient in either a private or public hospital, you may be charged for accommodation, operating theatre and other hospital related services.

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Reduce your medical costs

Medical services provided in hospital, or as part of an approved hospital substitute treatment, are charged by doctors (specialists, surgeons, anaesthetists, pathologists, radiologists, etc.) separately from hospital related services, such as accommodation and operating theatre fees. Health funds are able to provide a benefit where the treatment is recognised and claimable from Medicare.

When you receive medical treatment in hospital as a private patient, or as part of a Defence Health approved hospital substitute treatment, Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee and Defence Health pays the remaining 25%.

Some doctors may charge above the MBS fee resulting in additional expenses. Defence Health can help you minimise or even avoid these additional expenses if:

  • your doctor agrees to use our Access Gap Cover (AGC) schedule of fees, or
  • there is a no gap agreement between Defence Health and your doctor.

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Prosthesis costs

A prosthesis is an artificial or substitute component such as a pacemaker, defibrillator, cardiac stent, cochlear implant or joint replacement. For most surgical procedures requiring a prosthesis, your doctor will tell you about the choices available. If you choose a prosthesis from the Government’s Prostheses List for any Medicare Benefits Schedule (MBS) procedure, then it will be fully covered by Defence Health.

Other more expensive prostheses may be available for your surgery. However, if you agree to have one of these, your benefit will be limited to that payable for the no gap alternative.

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Access Gap Cover

You should encourage your doctor to use Access Gap Cover to help you minimise or even avoid any out-of-pocket expenses on your in-hospital doctor's fees. You will have either no out-of-pocket expenses, or prior to your treatment, you will be given an estimate of the costs you will have to meet.

A list of doctors who may be willing to apply for our Access Gap Cover schedule of fees is available on the Search for doctors page.

No-gap agreements
Defence Health has negotiated no-gap agreements with a number of facilities providing diagnostic services to hospitals. If your diagnostic service e.g. radiology or pathology has been provided under such an agreement, the bill will be sent directly to Defence Health for processing.

back to top

The gap

Minimising out-of-pocket hospital costs

The extent to which your hospital costs are covered will depend on the level of cover you choose, the hospital facility you use, whether your doctor agrees to use our Access Gap Cover schedule of fees, and which surgically implanted prosthesis (if any) is required.

Here's more information:

Hospital costs

As a private patient in either a private or public hospital, you may be charged for accommodation, operating theatre and other hospital related services.

back to top

Reduce your medical costs

Medical services provided in hospital, or as part of an approved hospital substitute treatment, are charged by doctors (specialists, surgeons, anaesthetists, pathologists, radiologists, etc.) separately from hospital related services, such as accommodation and operating theatre fees. Health funds are able to provide a benefit where the treatment is recognised and claimable from Medicare.

When you receive medical treatment in hospital as a private patient, or as part of a Defence Health approved hospital substitute treatment, Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee and Defence Health pays the remaining 25%.

Some doctors may charge above the MBS fee resulting in additional expenses. Defence Health can help you minimise or even avoid these additional expenses if:

  • your doctor agrees to use our Access Gap Cover (AGC) schedule of fees, or
  • there is a no gap agreement between Defence Health and your doctor.

back to top

Prosthesis costs

A prosthesis is an artificial or substitute component such as a pacemaker, defibrillator, cardiac stent, cochlear implant or joint replacement. For most surgical procedures requiring a prosthesis, your doctor will tell you about the choices available. If you choose a prosthesis from the Government’s Prostheses List for any Medicare Benefits Schedule (MBS) procedure, then it will be fully covered by Defence Health.

Other more expensive prostheses may be available for your surgery. However, if you agree to have one of these, your benefit will be limited to that payable for the no gap alternative.

back to top

Access Gap Cover

You should encourage your doctor to use Access Gap Cover to help you minimise or even avoid any out-of-pocket expenses on your in-hospital doctor's fees. You will have either no out-of-pocket expenses, or prior to your treatment, you will be given an estimate of the costs you will have to meet.

A list of doctors who may be willing to apply for our Access Gap Cover schedule of fees is available on the Search for doctors page.

No-gap agreements
Defence Health has negotiated no-gap agreements with a number of facilities providing diagnostic services to hospitals. If your diagnostic service e.g. radiology or pathology has been provided under such an agreement, the bill will be sent directly to Defence Health for processing.

back to top

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