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Mind the gap! Avoiding bill shock

So, what’s an out-of-pocket cost?

An out-of-pocket expense (or the ‘gap’) is the amount you pay for medical or hospital charges, over and above what you get back from Medicare and your private health insurer.

The Department of Health and Aged Care says: An out-of-pocket cost is the difference between the amount a doctor charges for a medical service and what Medicare and any private health insurer pays.

You might pay out-of-pocket costs for:

- treatments by doctors and other healthcare professionals (if they charge above the scheduled fee set by the government) treatment at a private hospital emergency room.

- hospital costs, like accommodation and theatre fees (if your cover does not include private treatment for the service you’re having)

- medical services when you’re not in hospital (appointments and diagnostic tests)

- treatment at a private hospital emergency room.

Information is power

So, how can you avoid or curb those out-of-pocket costs?


The cover you choose is important. Making sure you’re covered for the things you need (and not for the things you don’t) ensures you get value, but also the security of knowing you’re protected when you need it. And, it’s important not to get caught out, so being aware of your healthcare journey and assessing your health cover every year will always put you in good stead. No-one has a crystal ball, but it’s important when selecting your cover that you’re really clear on what’s included (and what’s not).


Medicover is our way of helping members reduce or cut out medical out-of-pocket costs when they receive treatment in hospital. And the good news is that it’s included in all of RT Health’s Hospital covers.


You can ask your doctors if they’ll participate in RT Health’s Medicover when you’re organising your treatment and hospital stay. If your doctors agree, they’re accepting a set fee (more than the MBS fee, but probably less than what they might otherwise charge). This means you’re likely to have lower out-of-pocket costs (and sometimes, none at all).

You can search which doctors currently participate in our Medicover on our website under Understanding Your Cover.

Doctors can choose whether they take part in Medicover on a case-by-case basis, so you need to ask your doctors each time you require hospital treatment. You’ll also need to have the same discussion with your surgeon, anaesthetist, pathologist and so on.


Even if your doctor or specialist doesn’t want to participate in Medicover, they’re legally bound to provide you with a written breakdown of expected costs for your procedure, and identify if there’ll be any out-of-pocket expenses. This is called an informed financial consent and you should always ask for it when planning your treatment or admission.

How can I arrange to be treated under Medicover?

When your doctor refers you to a specialist, ask them if they can recommend a specialist who participates in Medicover. If the doctor is unsure who to recommend, you – or the doctor – can search for a specialist via the Find a Doctor link on our website or by visiting healthshare.com.au.

Questions to ask your specialist:

1. Will you treat me under a Medicover arrangement?

2. Will I need to pay any out-of-pocket expenses for my treatment? If so, can you give me a written estimate of how much I’ll need to pay?

3. How many other doctors will be assisting with my treatment, and will they also participate in Medicover?