Understanding out of pockets

Understanding how your cover works and the fees involved isn’t as easy we’d like it to be. Here at health.com.au, try our best to be simply helpful by giving you a step by step way of understanding how it works.

We try to help reduce or eliminate your out of pocket expenses by participating in the Access Gap Cover Scheme. 

The Access Gap Cover Scheme is administered by the Australian Health Services Alliance to help reduce your out of pocket expenses. However, doctors can decide on a case-by-case basis whether or not they choose to participate in the scheme.

In the instance that your doctor decides to not participate in the Scheme, Medicare will pay 75% of the fee set in the Medicare Benefits Scheme (MBS) and health.com.au will pay the other 25% of the scheduled amount. Because doctors can set their own fees, if your invoice is more than the MBS fee you'll need to pay the difference. This is classified as your out of pocket expense.

Remember to ask your main doctor/surgeon, anaesthetist and assistant doctor for “informed financial consent”  - which is the doctor’s quote. This will give you more detail on the following points:

Things to ask your doctor:

  • What are your fees?
  • What is the MBS number for my treatments/s?
  • Can you tell me how much out of pocket I will be, if at all?
  • If I cannot afford to pay immediately, can I set up a payment plan?
  • Will I receive one bill or will you bill my health fund directly?

Things to ask your hospital:

  • Do you have an agreement with my insurer, health.com.au?
  • Am I required to pay extra for my hospital accommodation?
  • Are there any out of pocket expenses I should know about?