What is the “gap” and how can it be avoided?
The Federal Government has a list of fees for surgical procedures. This list is called the Medicare Benefits Schedule (MBS). It’s like a recommended retail price list for surgical procedures. When you undergo a procedure, provided that the procedure isn’t excluded on your cover and the procedure is one that Medicare pays for, Medicare pays 75% of the MBS for the procedure, while nib pays the remaining 25%.
Some doctors and specialists charge more than the fee outlined in the MBS. When this happens, you pay a “gap” (also called an out-of-pocket expense). The gap is the difference between the price listed in the MBS and what the doctor or specialist charges.
To help you avoid paying a gap, nib has established a network of specialists and doctors who can elect to participate in nib’s MediGap scheme.
What is the nib MediGap scheme?
The nib MediGap scheme aims to eliminate the gap amount you may have to pay for care you receive as a patient in a hospital. When a doctor or specialist participates in the nib MediGap scheme, he or she bills nib directly for an agreed amount. Medicare still contributes 75% of the MBS amount, but nib will contribute the 25% plus the amount agreed upon by nib and the doctor or specialist. This leaves you with no out-of-pockets to pay.
Remember:
- Doctors and specialists can choose on a case by case basis to treat you under the nib MediGap scheme
- Always ask your doctor or specialist, “Will you treat me as an nib MediGap patient?”
- Ask if the other specialists (e.g. anaesthetists or assistant surgeons) will be involved in your treatment. You’ll need to contact these other specialists directly to ask if they’ll treat you as an nib MediGap patient
- nib MediGap only covers you for your in-patient hospital treatment
- nib MediGap does not cover you for any consultations before or after your hospital stay
- nib MediGap does not cover you for any administration or booking fees charged by the hospital
What should you do if your doctor or specialist won’t treat you as an nib MediGap patient?
If your doctor or specialist won’t treat you as an nib MediGap patient, you can:
- Ask how much the procedure is going to cost you and agree to pay the extra cost above the MBS (i.e. you pay the out-of-pocket costs)
- Seek a second opinion from another doctor or specialist. Ask if they will participate in the nib MediGap scheme. If they won’t, be sure to ask how much the procedure is going to cost. That way you can at least compare the out-of-pocket costs between the two specialists.
- Enquire about a being treated as a public patient in a public hospital. The only way to absolutely avoid the risk of out-of-pocket costs is to be treated as a public patient in a public hospital.
- Depending on the severity of your condition, eing treated as a public patient for an elective procedure may mean you need to wait to have the procedure done. You can literally wait years to have a procedure done in the public system. Your ability to choose which specialist does your procedure is also reduced.
In order to avoid the risk of out-of-pocket costs you would need to:
- Obtain a referral from your GP to a doctor who specialises in your condition and who is able to work in the public hospital
- Organise an appointment with the doctor at the public hospital clinic
- Be considered by that doctor as requiring the procedure
- Go onto that doctor’s waiting list at a hospital where the doctor is permitted to perform the procedure
- Wait your turn on the list of people waiting for surgery. Your position on a public hospital waiting list is decided by your doctor, and depends on how urgently he or she thinks you need your surgery compared with others on their list. For this reason it could take a short time or very long time for you to reach the top of public hospital waiting list, depending on how urgently your public hospital specialist thinks you need the procedure.
There are some procedures which are not usually or only rarely done in public hospitals. It’s important to note, then, that being able to get on a public waiting list at a public hospital may not be an option for every condition.