Under what circumstances is the Bupa Medical Gap Scheme available?
The Bupa Medical Gap Scheme is available to Bupa private health fund members who:
- are financial members that contribute to a Bupa Hospital cover
- do not have the service excluded under their Hospital cover
- have served all applicable waiting periods specified in their hospital insurance policy
- are patients as defined by section 3 (1) of the Health Insurance Act 1973
- receive services that are eligible for Medicare benefits
- receive cosmetic surgery only in situations where it is clinically necessary
- Cannot claim compensation, damages or benefits from another source e.g. workers' compensation.
How does the Bupa Medical Gap Scheme work?
No Gap: your doctor agrees with Bupa to charge a certain amount for services and also agrees to bill us directly. When they 'opt in' to the scheme, in most cases you will have no 'Medical Gap' to pay for the treatment they provide. Accordingly, these doctors are known as “No Gap Doctors”. And, if there is a gap you should be advised by the doctor(s) of that amount before your treatment.
Known Gap: In some instances a participating doctor can charge you a 'known gap'. A known gap is an amount above the Medical Gap Scheme benefit. These are also capped at maximum amounts, giving you certainty regarding any possible out of pocket expenses.
Doctors are independent of Bupa and, as a result, we cannot guarantee participating doctors in every area.
Diagnostic Services: Bupa has made arrangements with providers of most pathology services that there will be no out-of-pocket expense for any of the services related to pathology test that you receive in hospital
Genesis Heart Care Group: this is the largest group of cardiologists in Australia and Bupa members are guaranteed to have no medical gap for inpatient cardiologist services provided by a Genesis Heart Care doctor.
How do I access the Bupa Medical Gap Scheme?
Access to the Bupa Medical Gap Scheme is included in all levels of Bupa Hospital cover. There is no need to buy any additional products.
Ask the doctors involved in your hospital care if they are registered as Bupa Medical Gap Scheme providers and if they are willing to participate in the scheme in relation to their services. When they do, doctors will bill us directly.
How do I find a Bupa Medical Gap specialist?
Your general practitioner is in the best position to refer you to a specialist who will meet your clinical needs. You should then ask the specialist whether they will accept as full payment the Bupa Medical Gap Scheme benefits for your inpatient hospital services.
If your doctor does not appear on the Find a Bupa Medical Gap specialist search tool, ask them if they participate in the Bupa Medical Gap Scheme for your treatment.
You can also click on the following links to find out if your radiology or pathology provider has entered into an arrangement with Bupa.
Alternatively, call Bupa on 134 135 for more information on registered Bupa Medical Gap Scheme specialists.
If a doctor is registered, can I be sure he or she will give me 'no gaps'?
Your general practitioner is in the best position to refer you to a specialist who will meet your clinical needs. You should then ask the specialist whether they will accept as full payment the Bupa Medical Gap Scheme benefits for your inpatient hospital services.
Will my family doctor know which specialists offer 'no gaps'?
Your family doctor is the best person to refer you to an appropriate specialist for the health care you require. If they do not know if the specialist you are being referred to is registered in the Bupa Medical Gap Scheme you can contact Bupa on 134 135. In most cases, we can confirm whether the specialist you have been referred to is registered.
If your specialist is registered, you will need to ask if they will accept the Bupa Medical Gap Scheme benefits as full payment for your treatment. Doctors are not obliged to use the scheme for every patient.
What happens to the doctor's invoice?
Your participating doctor should send the invoice directly to Bupa. If, however, they have sent the invoice to you (with the Bupa Medical Gap Scheme claim form attached), forward it on to Bupa immediately, not Medicare. We also advise that you do not pay the account. We will arrange for the Medicare portion to be paid on your behalf. The whole amount will then be sent to your doctor and you will be sent a statement showing what we have paid. In most cases you should not have to pay anything to a participating doctor for your in-hospital treatment.
