Dodging the Gap Attack

Stethoscope - orange

Remember that creepy cop from Terminator who just does not die? Without wanting to be overdramatic, that’s how the gap can feel when you need to make a claim for treatment: unbeatable. Luckily for you, we really want to help you (think of us as a less muscular version of Arnie), so make yourself a cuppa and let us guide you, my friend!

Know your enemy

If you do your homework first, you can potentially save yourself a lot of gap pain later, so know what the go is! ‘How?’ you ask? We’re glad you did. Let’s break down the basics.

Medicare Benefits Schedule (MBS)

The MBS is the list of fees set by the government for medical services. Whether you’ve got private health insurance or are a private patient paying for all your own costs, the government provides a rebate on nearly all medical fees – thanks guys! The Medicare rebate is 75% of the MBS fee for in-hospital medical fees and 85% of the MBS fee for medical fees outside hospital. For in-hospital services, depending on your level of cover and waiting periods being served, your private health cover will pay the remaining 25% of the MBS fee.

Thing is, doctors are free as birds to set their own fees, and they often set them much higher than the MBS. This means – you guessed it – gap attack. We know how frustrating that sucker can be, so we lovingly encourage providers across the country (around 36,000 of them!) to deliver services at either no gap or at the very least a modest gap*. We call this helpful little arrangement ‘Access Gap Cover’ or ‘Medical Gap Cover’.

Carefully choose your doc

We all make tough choices in life, whether it’s choosing chocolate or vanilla cupcakes or getting leopard or zebra print glasses. Your choice of doctor, though, is obviously super important and key to how much you’ll have to fork out for treatment. Doctors can choose to be part of our Access Gap arrangement on an individual basis, so make sure you find out where they stand on this!

Have the chat

We don’t mean discussing the procedure in general (although we really, really hope you’re not just waltzing in under the knife without that chat!), we mean having the gap chat.

If you ask your doctor about their fees before you’re treated, they will be more than happy to break down the costs – including how much is covered by Medicare and insurance. In fact, they’re obligated to reveal these costs to you. It’s called Informed Financial Consent.

Make sure you also ask if other doctors or specialists will be involved with your treatment, and if you’re expected to pay for their help.

Be sure to directly ask whether any of your treatment will result in out-of-pocket expenses for you: Do they participate in Access Gap? Is it no-gap or known-gap arrangement? How much is it? What other costs are involved? You have a right to know.    

Mind the gap

No gap

If your chosen doctor is registered with us as a no-gap provider (hoorah!) and uses it in your case, then we’ve got you sorted, and you’re free from paying a medical gap for their service (good times!). If your doctor decides to opt out of Access Gap though, you’ll pay the difference between the MBS scheduled fee and your doctor’s total charge (not so good times).

Known gap

If your chosen doc is registered with Peoplecare as a known-gap provider and uses it in your case, then you won’t get a surprise visit from Mr Gap*. You’ll know exactly what your out-of-pocket expenses will be before treatment.

If your doctor decides to opt out of the known-gap arrangement with Peoplecare in your individual case you’ll cop the difference between the MBS benefits and your doctor’s total charge. Boo!

You can find a list of doctors registered for Peoplecare’s Access Gap arrangement here 


*There may still be out-of-pocket expenses, so always be sure to check with your doctor before treatment.