MediGap aims to reduce or eliminate the gap payments for specialist fees in hospital for Australian resident nib members.
When a specialist chooses to participate in our MediGap network for your procedure, they make a commitment regarding their fees:
No Gap option: They agree not to charge you a gap fee, also known as an 'out-of-pocket expense,' for their services.
Known Gap option: Alternatively, they may charge a Known Gap of up to $500.
The MediGap network is designed to provide more certainty when it comes to what you might have to pay out of your own pocket for specialist services. Specialists who join this network may agree to receive a higher benefit from nib than they would ordinarily receive in exchange for their agreement to eliminate or reduce the 'gap' for your out of pocket hospital costs. This means you can plan your healthcare costs better, knowing in advance whether there will be any extra charges beyond what your health insurance policy covers.
How does MediGap work?
The Government has a list of fees for services such as surgical procedures known as the Medicare Benefits Schedule (MBS). If you are treated by a specialist, Medicare pays 75% of the MBS fee, and nib pays the remaining 25%, provided the procedure is included on your cover. Some specialists charge more than the MBS fee, meaning you'll have to pay an additional cost that isn't covered by Medicare or your health insurance (an out of pocket or gap fee). MediGap means that nib agrees to pay an extra amount in addition to the standard 25% MBS fee. The service must be eligible for MediGap and your doctor must agree to participate in MediGap and bill nib directly for your procedure.
MediGap is not applicable to overseas nib members, as your OSHC or OVHC will cover your treatment instead of Medicare.
How can I access MediGap?
Doctors choose on a case-by-case basis if they will bill you as a MediGap patient. Ask your specialist if they will participate in MediGap to eliminate or reduce your out of pocket expenses for their fees, or charge a Known Gap of up to $500 to give you more cost certainty. If other doctors (such as anaesthetists) are part of your treatment plan, ask them if they'll agree to only charge the MBS fee, or participate in MediGap as well.
What happens if MediGap changes?
From time to time the amount paid to specialists under nib MediGap will change. Usually a review will see the payments increase, however if nib reduces the amount a specialist will receive for a procedure under MediGap, we'll provide prior notice of the change on our website, as well as written notice to any member who has claimed for an affected procedure in the two years before the change occurs. Other changes outside nib’s control, such as changes to the MBS, may mean nib is not able to provide notice in this form.
