The hospital and medical gap

The gap is the difference between the fee charged by the hospital or the amount the doctor charges for services in hospital, and the amount covered by Medicare and your private health insurer. It is the out-of-pocket expenses you may pay for your treatment.

The gap occurs for five reasons:

  1. You have chosen hospital insurance with an excess, exclusions or benefit restrictions
  2. You have chosen a hospital that does not have an agreement with Doctors’ Health Fund for that treatment
  3. Your doctor doesn’t participate/bill you under the Access Gap Cover Scheme
  4. Your doctor’s fee is more than the Access Gap Schedule or the AMA list of medical services and fees depending on your level of cover; this is called the medical gap
  5. You have incurred inpatient charges for items not covered under our health insurance hospital policies such as newspapers, telephone calls or prescribed medication

Doctors’ Health Fund offers benefits to cover some or all the medical gap between the Medical Benefits Schedule fee and the fee charged by the doctor, depending on your level of cover. The next section outlines how your gap is covered under our hospital cover options.

Doctors' Health Fund medical gap

Top Cover Gold for hospital – unique to us, with benefits based on AMA List of medical services and fees

Our premium hospital cover, Top Cover Gold, includes medical gap cover that pays benefits based on the AMA list of medical services and fees, where Medicare provides a benefit, meaning:

  • you will have no out-of-pocket expenses when the doctor charges the AMA List of medical services and fees or less
  • you will need to pay the difference if your doctor charges you above the AMA list of medical services and fees

Access Gap Cover

Our Prime Choice Gold and Smart Starter Bronze Plus hospital covers include medical gap cover that pays benefits according to the Access Gap Cover scheme. What this means is, where a participating doctor agrees to bill for their services according to this scheme for each medical service item, you will pay a gap of no more than $400 per service or $800 on the management of labour and delivery.

See the example below to compare the different medical benefit outcomes under each gap cover scheme.


Example: Medical services benefits for a knee reconstruction, Medical Item No.49542 as of April 2018.

Contracted No-Gap Cover

Our no-gap contractual arrangements with most pathology and radiology providers apply to all our hospital insurance products. The delivery of services by these contracted providers will have no out-of-pocket expenses.