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Bupa Medical Gap Scheme

If you need to go to hospital, the first question you might ask yourself is, what will it cost me? Our Medical Gap Scheme will help you keep these costs low, and make it clear what you need to pay.

What is the Bupa Medical Gap Scheme?

The Bupa Medical Gap Scheme is all about reducing the medical costs you need to pay for treatment when you’re admitted to hospital. If your doctor uses our scheme, you’ll never pay more than $500 per specialist for your treatment.

It’s hard to understand all the jargon and medical terms, so we’re here to make them simple for you. Some of the most complicated parts of a hospital visit to understand are:

  • What medical costs are, and how they’re different from ‘hospital costs’,
  • What you’re covered for and what you pay, and
  • What it means for you if your doctor uses the ‘Gap Scheme’

What are ‘medical costs’?

When you’re admitted to hospital, the fees your specialist or doctor charges you for your treatment are called medical costs. These are different from ‘hospital costs’, which are the fees for things like your accommodation, and use of the operating theatre.

What do Bupa and Medicare pay toward your medical costs?

Medicare has a list of fees for medical treatments called the “Medicare Benefit Schedule’ or ‘MBS’. Health funds and Medicare together pay 100% of the fee on that list. Health funds pay 25% of this fee, and Medicare pays 75%.

Will I have to pay anything myself?

Sometimes specialists may choose to charge more than the fee on the government’s list. When this happens, a ‘gap’ occurs, where you have an amount to pay yourself. The Bupa Medical Gap Scheme is here to help you avoid this bill-shock.

How does the Bupa Medical Gap Scheme reduce what I have to pay?

We pay more, so that you pay less.

The Bupa Medical Gap Scheme is designed to remove or reduce the costs you pay for your treatment in hospital. Where a specialist has signed up to the Bupa Medical Gap Scheme, and agrees to use it for your treatment, the costs you pay are reduced. Your doctor agrees to only charge up to a certain fee. We then pay a much higher amount than what we normally would, so that:

  • You pay nothing; or,
  • You pay up to $500 out of pocket for medical treatment, for that specialist.

Remember, you may have to see multiple specialists for one procedure.

Click the image below to enlarge.

Where can I find a Bupa Medical Gap Scheme provider?

A list of specialists that participate in Bupa Medical Gap Scheme can be found at

To reduce or eliminate your medical costs, you should ask your GP to refer you to a specialist that participates in Bupa Medical Gap Scheme.

How do I pay my medical costs when I use a Bupa Medical Gap Scheme provider?

If your specialist uses the scheme, they can choose to either eliminate or reduce your costs to a max of $500.

If they eliminate your costs, they will bill Bupa directly to save you the inconvenience of making a claim.

If they cap your out of pocket costs, they will bill Bupa directly, but there will be up to $500 left over for you to pay directly to your specialist.

Where can my doctor use the Bupa Medical Gap Scheme?

From 1 August 2018, we’ve changed where your specialist will be able to use the Bupa Medical Gap Scheme. From 1 August, they will be able to use it if:

  • You’re treated at a hospital that we have an agreement with or;
  • You pre-book your treatment as a private patient in a public hospital. This is as long as:
    • The hospital doesn’t charge you anything extra for hospital costs (for things like accommodation and use of the operating theatre).
    • The hospital confirms your cover with us online, 2 days before your admission or treatment.

The hospitals we have agreements with are called ‘Members First, Network or Fixed Fee’. This represents over 90% of the beds in the private system.

They will not be able to use the scheme in private hospitals that Bupa does not have an agreement with.

Why have we changed where a specialist can use the Bupa Medical Gap Scheme?

We want to make it clearer what costs you need to pay yourself when you go to hospital, so you can make fully informed choices about your treatment. When providers treat you at hospitals we don’t have agreements with, it is not always as clear what costs your hospital and specialists will charge, so sometimes there are unexpected costs you pay.

When you are treated in a hospital that Bupa has an agreement with, there are no hospital costs for you to pay. You only need to pay any excess or co-payment you have on your policy. You choose this when you select your cover. When the specialist uses the Bupa Medical Gap Scheme, you will know what medical costs you need to pay. You’ll either pay nothing, or at most, $500 per specialist.

Find a Members First or Network Hospital near you.

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