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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Medical costs
Medical services provided in hospital, or as an approved part of a 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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Doctor uses AGC schedule no gap fee
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Medicare pays 75% of MBS fee
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Defence Health pays
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Patient pays nothing
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25% of MBS fee
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the balance
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Doctor uses AGC schedule with known gap
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Medicare pays 75% of MBS fee
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Defence Health pays
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Patient pays the balance
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25% of MBS fee
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up to the AGC fee
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Doctor chooses not to use AGC schedule
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Medicare pays 75% of MBS fee
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Defence Health pays 25% of the MBS fee
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Patient pays the balance
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Note:
- MBS fee is the amount set in the Commonwealth Medicare Benefits Schedule
- AGC fee is the amount set in Defence Health's Access Gap Cover schedule
- No-gap agreements are the same as a doctor using the Access Gap Cover schedule no-gap fee
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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.
To be eligible for Access Gap Cover benefits, the doctor's account must be suitably endorsed, show financial consent for any amount payable by you and instruct you to send the claim directly to your health fund. If it is more convenient, you can ask your doctor to send the bill directly to Defence Health.
Search for doctors who may be willing to apply our schedule of fees (Access Gap Cover).
No-gap agreements
Defence Health has negotiated no-gap agreements with a number of facilities providing diagnostic services such as radiology and pathology. If your diagnostic service has been provided under such an agreement, the bill will be sent directly to Defence Health for processing.
Medical services not covered by Defence Health
Commonwealth legislation prevents health funds from providing a benefit for medical services provided out of hospital, unless it is an approved part of a hospital substitute treatment.
In these circumstances, Medicare will cover 85% of the MBS fee. If your doctor charges above this, you will have to pay the difference. If your doctor bulk bills, you will not have to pay anything.
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