Mind the gap: how you can avoid out-of-pocket expenses
Updated August 2025
Words by Angela Tufvesson
Getting the care you need shouldn’t come with a side of bill shock. Here’s how to stay on top of your cover and steer clear of out-of-pocket expenses.
Cost is often one of the first things that comes to mind when you go into hospital or need to see a physio or dentist. As the cost of living continues to stretch household budgets, unexpected medical fees can add to that pressure.
That’s why it’s important to understand what’s covered under your hospital and extras cover, and how to avoid those unexpected out-of-pocket expenses. These practical tips will help you get the most from your health cover.
What are out-of-pocket expenses?
These costs are the difference between what Medicare and your private hospital and extras cover may pay towards your treatment, and what your doctor or hospital charges.
Often called ‘the gap payment’, this leftover amount is what you'll need to pay.
Things that affect the amount you may need to pay include:
- your level of cover
- whether your treatment is in a public or private hospital
- whether your health fund has an agreement with the hospital or healthcare provider.
Sometimes, health funds have agreements with doctors and hospitals to cover all or part of the gap (a no- or known-gap), which remove or reduce your out-of-pocket medical expenses.
How to reduce out-of-pocket expenses for hospital cover
Start by making sure you understand what your policy covers. Ideally, this should be before you need to use it. Questions to consider include:
- Are there waiting times?
- Which procedures are you covered for?
- Is there an excess to pay before a hospital stay?
Contact RT Health if you have any questions or need more information about your policy.
When you find out you need to go to hospital, choose a doctor who participates in our Medicover program. This is a ‘gap cover scheme’ that helps us provide benefits to cover some or all of any gap payments.
Going with a doctor who participates in our Medicover program is the best way to make sure you have less out-of-pocket expenses when you need to go to hospital. Doctors can choose to participate on a case-by-case basis, so you’ll need to check first with your specialists.
If you choose to go to a public or private hospital that’s contracted with RT Health, your hospital fees should generally be covered (as long as you’re covered for the treatment you’re having).
When you visit your specialist, you’ll learn about the treatment options recommended for you. They should be able to give you a breakdown of the cost of your treatment. This is known as informed financial consent.
Don’t be afraid to ask questions like:
- Is the procedure covered by my hospital policy?
- Will I be charged a gap fee?
- What’s the total amount I will need to pay?
- Will I be charged out-of-pocket expenses from other treating specialists or care providers like assisting surgeons, anaesthetist or pathology?
If you’re not happy with the specialist and their costs, you can ask your GP for another referral, or you can also ask for an ‘open referral’. This means you can choose from a list of appropriately qualified specialists and select the one who suits you best.
After your procedure, review your bill and speak up if you notice a discrepancy.
How to reduce out-of-pocket expenses for extras cover
Before you need to get your eyes checked or your teeth cleaned, read through your extras policy and make sure you’re across the details. Dental, optical and physio are covered by most extras policies, but the level of cover can vary significantly between policies.
Our Health Cover Guide lays out which services you’re covered for, the benefits covered, the annual limit and any waiting periods. Get in touch with us if there’s anything you’re unsure about.
Usually, you can’t claim anything in the first two months after you get extras cover, and possibly longer for major dental treatments.
It’s helpful to know your extras cover annual limit and monitor how much you’re using throughout the year. Most RT Health extras benefits reset every year on 1 January, so if it’s coming towards the end of the year and you haven’t reached your limit, it’s worth booking in a check-up with your dentist or optometrist.
Plus, just like with hospital cover, using our preferred providers and taking advantage of no-gap services can reduce your out-of-pocket expenses. When you visit an HCF Dental Centre or More for Teeth provider, you can get 100% back on two check-ups, two scale and cleans, one fluoride treatment and one mouthguard every year. Use our handy Find a Dental Clinic tool to find a More for Teeth provider near you.
RT Health members also get access to a range of great-value optical providers, including HCF Eyecare Centres. Use our Find an Optical Provider tool to find one near you.
We’re here to help
We get it. Private health insurance can be complicated, but we’re here with you every step of the way to help you get more value from your cover.
If you have any questions about your cover, our Member Care team has the answers. Give us a call on 1300 886 123 or get in touch via email to help@rthealth.com.au
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