How to stop out-of-pocket hospital costs from hurting


Unexpected out-of-pocket medical costs for hospital treatments can really hurt.  This article explains what out-of-pocket hospital costs are, and how to anticipate and minimise them, in a way that’s easy to follow, so you can get the most from your cover. 

What is an out-of-pocket cost?

‘Out-of-pocket costs’ or ‘gap payments’ are common terms that refer to any costs for hospital (or extras) services or treatments that Australian Unity or Medicare won’t reimburse you for.

What out-of-pocket costs might I expect if I go to hospital? 

The list below highlights common out-of-pocket hospital costs:

Hospital excess or co-payment

An excess or co-payment is an amount you might have to pay towards admission costs (including day surgery*) if you go to hospital. In return for paying an excess or co-payment, you reduce the price you pay for your cover. To find out more about excesses or co-payments, or if you’re unsure about the amount you will need to pay if you are admitted to hospital, please call us on 13 29 39. 

*An excess does not apply on day surgery for Smart Start cover.

Gap fee for doctor, specialist, surgeon, assistant surgeon or anaesthetist

As a private patient in a hospital or a day surgery centre, your doctor and any specialists who treat you, will each raise a bill for their services.

The Australian Government sets a schedule of fees for all medical treatments called the Medicare Benefits Schedule (MBS). 

For items on the MBS Medicare covers 75 per cent, while your Australian Unity private health cover picks up the remaining 25 per cent. 

However, some doctors and specialists charge more than the MBS fees, with the extra amount referred to as, the “medical gap” or your out-of-pocket cost.

The doctor’s booking fee

These costs are sometimes charged for pregnancy related treatments and services. As this is a charge not covered by Medicare, Australian Unity cannot reimburse you.

Leaving hospital costs (eg pharmaceuticals, phone calls, pay TV)

When leaving hospital you may find you are billed for some services you use in hospital such as phone calls, pay TV or the internet, although most of the time these things will be covered by Australian Unity. Potentially you may also need to hire an aid for use in the home (eg a wheelchair or crutches). You will also be billed for any pharmacy items that have not been opened before you leave hospital. Depending on your level of cover you may be able to claim this cost back on your extras cover.

How can you minimise your out-of-pocket hospital costs? 

Gap Cover helps you avoid out-of-pocket hospital costs. 

Available to most Australian Unity members as part of their hospital cover, Australian Unity’s Gap Cover is designed to reduce or remove your out-of-pocket costs created by the medical gap*.

To support our members, we set our own schedule of fees, which is higher than the Medicare Benefits Schedule (MBS). If your doctor or specialist charges more than the MBS fee and agrees to use Australian Unity’s Gap Cover scheme, we can help pay some or the entire medical gap.

Gap Cover is available to all doctors who treat private patients in public or private hospitals or day surgeries, but they don’t always have to participate. If a doctor participates but chooses to charge above our Gap Cover schedule of fees, they must inform you of the amount you will have to pay, in writing, before treating you.

Useful Tip – Always ask your doctor if they will be participating in Australian Unity’s Gap Cover scheme. 

You can find doctors that participate in Australian Unity’s Gap Cover here.

* Gap Cover is not available on any of our Overseas Visitors Health Covers. Gap Cover only applies to the treatment of illnesses or conditions available under your health cover.

You’re covered for 100% of accommodation costs and most other services in our agreement hospitals (not including your excess or co-payment).

Australian Unity has one of the highest numbers of agreement private hospitals of any Australian fund. We have negotiated a schedule of fees for hospital services with these private hospitals and day surgeries. 

To minimise your out-of-pocket costs we recommend that you avoid using non-agreement private hospitals where you may have to pay additional hospital service and accommodation charges.

You can find your nearest agreement private hospital here

Remember; always call us on 13 29 39 before you go to hospital or day surgery.

If you or a loved one is sick, it’s only natural you will want the best health care available.
Our trained team of experts are here to provide you with a full list of our agreement private hospitals and day surgeries or help you to find a Gap Cover doctor.  

They can also provide information on costs and the types of questions you need to ask your doctor as well as other services we offer to help you get better faster. Remember, we’re here to help.