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Out of pocket expenses

A “gap” or “out of pocket cost” is when you're charged more for medical or hospital services than the amount you get back from Medicare (if you're an Australian resident) and your health cover. It’s therefore not something you can claim for.

No matter what level of cover you have, it's important to check all the costs associated with your hospital treatment, as you may end up having to pay more than just your excess.

In 2016, 74% of Australian resident nib members who went to an nib Agreement Hospital, or public hospital as a private patient, had less than $100 in out of pocket costs to pay for medical services whilst in hospital for a procedure included on their cover (excluding hospital excess).

How can I help reduce my out of pocket expenses?

  • Check you have the right cover to suit your needs - depending on your policy, you can compare and change your cover in Online Services
  • Always call nib before going to hospital
  • Choose a specialist registered with nib MediGap and ask if they’ll participate for you
  • Attend an nib Agreement Hospital
  • Ask for written confirmation of fees from your doctors and the hospital prior to your admission
  • Ask your specialist about all potential costs that may be involved in your procedure, including the fees of other specialists involved
  • Check if there are alternative options which could cost you less

Depending on your cover, you might have to pay an excess for your hospital stay when you’re admitted. This is paid directly to the hospital and is separate to your potential out of pocket expenses.

Specialists can choose how much they charge for each patient, and these fees can vary significantly, sometimes by thousands of dollars.

We always recommend contacting us before you get medical treatment, so we can let you know how best to avoid out of pocket costs. We have a network of healthcare providers who may agree to charge little or no costs above what you’re covered for, for certain services.

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