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Insure? Not Sure? |
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General InformationHealth insurer arrangements to cover 'the gap'The ‘medical gap’ is the difference between the doctor’s fee for services provided in hospital and the combined Medicare benefit and health insurance benefit. Unless your health insurer has a gap cover arrangement in place with your doctor to cover all of your doctor's charge, you will have to contribute towards the cost of the treatment out of your own pocket. Health insurers are able to negotiate agreements with hospitals to fully or partially cover other charges related to hospital treatment, such as accommodation. It is important that you contact your health insurer before you receive hospital treatment to check whether the insurer has an agreement with your hospital and whether your doctor is participating in the insurer's gap cover arrangements. You should also ask your doctor(s) and hospital for an estimate of their costs and how much will not be covered by your health insurer. Your health insurer should also be able to assist with calculating likely out-of-pocket costs. Hospitals that have agreements with health insurers submit to the insurer a single account for hospital services provided. Doctors participating in gap cover arrangements with health insurers also usually forward all accounts to the insurer. If you have a policy that requires you to pay part of the hospital or medical costs, the hospital or doctor will bill you directly. Hospitals that have agreements with your health insurer and doctors participating in your insurer's gap cover arrangements should, whenever possible, inform you before providing a medical service in hospital, of any amount you will have to pay. You should be aware that if you have a health insurance product that has an excess or co-payment provision you will have to pay some of the cost of hospital treatment out of your own pocket even if your hospital has an agreement with your insurer and your doctor is participating in the insurer's gap cover arrangements. Further information on excesses and co-payments is provided in the section 'Types of health insurance cover’. If you have any problems or complaints that cannot be resolved satisfactorily with your health insurer, you can have the problem fully examined by the Private Health Insurance Omsbudsman. You should always try to resolve the problem with your insurer before going to the Ombudsman.
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Private Health Insurance Administration CouncilSuite 16, Level 1, 71 Leichhardt Street, KINGSTON ACT
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Last modified: 22 July, 2005 |
