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The Bupa Medical Gap Scheme

Find out how the Bupa Medical Gap Scheme works, its benefits and how it might affect your private health insurance claims.

What is the Medical Gap?

The cost of hospital treatment comes from two sources:

1. The cost of your medical treatment.

2. The cost of your hospital accommodation.

We have arrangements that can assist with reducing or eliminating out of pocket expenses associated with both of these. This is designed to eliminate or reduce medical costs and doctor's fees associated with hospital treatment via a direct billing arrangement with Bupa. As the Bupa Medical Gap Scheme is optional for your doctor/specialist, we strongly recommend asking your doctor/specialist whether they will be using our gap scheme.

The term "medical gap" describes the amount above the Medicare Benefits Schedule Fee that some doctors charge for medical services which were traditionally not covered by health funds, but in some cases are covered by Bupa. Bupa has a few different types of arrangements with doctors to cover these medical gaps.

For all medical service charges from doctors while you are a hospital inpatient, Bupa will cover the 25% gap between what Medicare reimburses you or your doctor and the Medicare Benefits Schedule (MBS) fee for that service. Above that Bupa will also provide an additional amount to help eliminate or reduce your out-of-pocket expense for those doctors utilising one of our medical gap arrangements:

  • No Gap
  • Known Gap
  • Diagnostic Services (Pathology Tests)
  • Genesis Heart Care Group

What are the benefits of the Medical Gap Scheme?

  • Peace of mind. In most instances you will enjoy the financial certainty of 'no gaps' for medical services received in-hospital where your doctor opts in for your treatment.
  • Simplified medical insurance claims process. You do not have to make a claim - the doctor bills us directly.
  • Value for money. You get even more from your private health cover.

What gap fee should I expect to be charged?

Because of our Medical Gap Scheme, more than 90% of all medical services that our members claim will have a $0 gap or a gap that is capped at $500.

If your doctor chooses not to use Bupa’s Medical Gap Scheme, however, you may face additional out-of-pocket fees. This is why it’s important, as early as possible, to ask your doctor if they will charge the procedure under our gap scheme and what fees will be charged, including those of any other specialists involved in the procedure.

To help you understand what you might be charged, we’ve published information showing how often procedures have been charged with a gap of $0, less than $500, $501–$2,000, and $5001–$10,000.

> Download full listing of gap fee charging patterns by procedure (xls, 350kb)

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 eg. 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. Doctors operate independently of Bupa and, as a result, it is up to each individual provider to decide if they will participate in Bupa’s Medical Gap Scheme (the Scheme). 

When a provider chooses to '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. Bupa cannot guarantee that a provider will participate in the  Scheme.  Accordingly, you are encouraged to contact your provider in advance to discuss whether your provider will participate in the Scheme for your particular 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.

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 (PDF 197Kb) or pathology (PDF 190Kb) 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 healthcare 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.

What happens if I am an out-patient?

If you are an out-patient, the Commonwealth Government sets a fee for each medical service which is described in the Medicare Benefits Schedule (MBS). Medicare pays 85% of the MBS fee for most out-patient services (services outside hospital such as consultations, minor procedures, x-rays, etc). There is an exception for general practitioner consultations, where Medicare pays 100% of the MBS Fee.

The doctor can choose whether to bulk bill or not for the outpatient services:

  • If the doctor chooses to bulk bill, there is no out of pocket expense for the patient. In this case, the doctor accepts the Medicare benefit of 85% or 100% as full payment
  • If the doctor does not bulk bill, the patient is responsible for any charges over the Medicare benefit

Families and individuals also have access to the Medicare Safety Net benefit. This benefit is for those that have large out of pocket costs for out-patient services. Once the relevant threshold is met, the Medicare benefit increases. For further information please go to:

Bupa is not permitted by law to pay benefits towards out-patient medical services where a Medicare benefit is payable.