Bupa Medical Gap Scheme

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 doctor.

Each doctor involved in your treatment can choose to use the Bupa Medical Gap Scheme for your admission in a Public Hospital, or a Private Hospital with which Bupa has an agreement.

Australian Citizens, Permanent Residents & Applicants for Permanent Residency

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 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 'Bupa Medical Gap Scheme'
• How the Bupa Medical Gap Scheme works in different types of hospitals

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?

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%.

What do I have to pay?

You’ll need to pay the difference between what your doctor chooses to charge, and what we pay. The Bupa Medical Gap Scheme reduces or eliminates this difference, or 'gap'.

If your doctor chooses not to use the Bupa Medical Gap Scheme, the doctor can decide what to charge you and you’ll need to pay any 'gap' (or amount above what we and Medicare pay) yourself.

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 doctor 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 doctor.

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

Click the image below to enlarge.

What can I expect if my doctor uses the Bupa Medical Gap Scheme?

You will usually have multiple doctors or specialists involved in your treatment.

If each doctor involved in your treatment chooses to use the Bupa Medical Gap Scheme for your treatment:

In a Public Hospital:

• If you have a pre-booked admission, you will never have to pay more than $500 per doctor while you’re in hospital.
• If you are admitted any other way such as through the Emergency Department, your doctor will bill Bupa directly and you will pay nothing while you’re in that hospital.

In a Private Hospital with which Bupa has an agreement:

• You’ll never have to pay more than $500 for medical treatment per doctor – we may even pay for the full cost while you’re in that hospital.

Find a Members First or Network Hospital near you.

What can I expect if my doctor does not use the Bupa Medical Gap Scheme?

Your doctor can only use the Bupa Medical Gap Scheme in:

• public hospitals, or
• private hospitals that have an agreement with Bupa.

Over 96% of all private hospital beds across Australia are in hospitals that have an agreement with Bupa.

If you’re treated in a hospital that doesn’t have an agreement with Bupa, or your doctor decides not to use our gap scheme for your treatment:

• Your doctor can decide what to charge you.
• Together with Medicare, we will cover 100% of the fee on the government’s list, called the MBS.
• It’s important to check what your doctor plans to charge, as you’ll need to pay any 'gap' (or amount above what we and Medicare pay) yourself. It’s called Informed Financial Consent.

Overseas Visitors & Students

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 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 'Bupa Medical Gap Scheme',
• How the Bupa Medical Gap Scheme works in different types of hospitals

What are 'medical cost'?

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.

Who decides what I'm charged?

Your doctor can charge whatever they'd like to, but they must tell you what they'll charge you and what it is for.

What does Bupa pay?

There are three types of fees that we might pay:

The Australian Medical Association Fee

Depending on your cover, and whether your doctor uses the gap scheme, we'll pay:

The MBS fee, or

• The MBS or 'Medicare Benefit Schedule Fee' is a fee on a government list, that suggests an appropriate fee for each medical service. This list is created by Medicare, a government organisation that provides access to public healthcare to eligible people.

The AMA fee, or

• The Australian Medical Association (AMA) has created a list of fees that they think are appropriate for a doctor to charge for each medical service. These fees are called 'AMA fees'.

The Bupa Medical Gap Scheme fee

• Where a doctor 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 doctor.

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

To confirm what we'll pay, check your policy information, and ask your doctor whether they'll use our gap scheme for your treatment.

What do I have to pay?

You'll need to pay the difference between what your doctor chooses to charge, and what we pay. The Bupa Medical Gap Scheme reduces or eliminates this difference, or 'gap'.

If your doctor chooses not to use the Bupa Medical Gap Scheme, the doctor can decide what to charge you and you’ll need to pay any 'gap' (or amount above what we pay) yourself.

What can I expect if my doctors use the Bupa Medical Gap Scheme?

You will usually have multiple doctors or specialists involved in your treatment.

If each doctor involved in your treatment chooses to use the Bupa Medical Gap Scheme for your treatment:

In a Public Hospital:

• If you have a pre-booked admission, you will never have to pay more than $500 per doctor while you’re in hospital..
• If you are admitted any other way such as through the Emergency Department, your doctor will bill Bupa directly and you will pay nothing while you're in that hospital.

In a Private Hospital with which Bupa has an agreement:

• You'll never have to pay more than $500 for medical treatment per doctor – we may even pay for the full cost while you’re in that hospital.
• Find a Members First or Network Hospital near you.

What can I expect if my doctor does not use the Bupa Medical Gap Scheme?

Your doctor can only use the Bupa Medical Gap Scheme in:

• public hospitals, or
• private hospitals that have an agreement with Bupa.

Over 96% of all private hospital beds across Australia are in hospitals that have an agreement with Bupa.

If you’re treated in a hospital that doesn't have an agreement with Bupa, or your doctor decides not to use our gap scheme for your treatment:

• Your doctor can decide what to charge you.
• Depending on your cover, we'll pay, the MBS fee, or the AMA fee. Check your policy information to confirm what we'll pay.
• It’s important to check what your doctor plans to charge, as you'll need to pay any 'gap' (or amount above what we pay) yourself. It's called Informed Financial Consent.

Important information for all Bupa members

Your doctors must tell you what you need to pay

Informed Financial Consent means that before your treatment, your doctor needs to get your consent for what they’ll charge, and what you’ll need to pay. Each doctor has a responsibility to ensure you understand what they plan to charge. This is important, because you'll need to pay anything above what you’re covered for. This varies depending on your cover, so check your policy information to confirm what we’ll pay.

Finding a Bupa Medical Gap Scheme provider

Asking your GP to refer you to a specialist doctor that participates in Bupa Medical Gap Scheme can help to reduce your medical costs. Find one near you.

Paying the bill

If your doctor 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, so there’s nothing left for you to do. 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 doctor.

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