Dr Philip Cumpston

M.B.B.S. (SYD), F.A.N.Z.C.A., F.C.I.C.M., F.F.A.C.E.M.

Visiting Senior Specialist Anaesthetist

Senior Lecturer, The University of Queensland

What kinds of Health Funds are there?

There are two main types of Health Funds:

     •     NO GAP Health Funds

     •     KNOWN GAP Health Funds

NO GAP Health Funds do not pay a gap payment. In many cases, they also reduce their payment to the patient of a gap is charged, and instead of paying their published schedule, pay only the Medicare Rebate and a small amount extra.

KNOWN GAP Health Funds pay their scheduled rebate, even when a there is a gap between what the doctor charges and what the health fund schedule will pay. There are a few exceptions to this. Medibank Private and related Health Funds, as well as BUPA and its related health funds revert to being NO GAP health funds if the doctor charges a gap of $500 or more over the insurance payment the health fund is prepared to pay.

It is worth remembering that the doctors do not work for the health funds. Health funds are insurance companies that insure the patient against the risk of requiring health care, and reimburse some of the costs incurred.

More information about health funds can be found here:  https://www.privatehealth.gov.au/dynamic/search

What if I change my health fund?

If I want to change my health fund prior to surgery, what do I need to do to make sure I get the same benefits but a better repayment?

Visit the government website giving information about the different health funds: https://www.privatehealth.gov.au

Download the Private Health insurance Ombudsman brochure: "The Right To Change"


What will my health fund pay?

Most health funds will not fully cover the full cost of the anaesthetic. Their schedules usually cover approximately 50% of the maximum fee that can be charged by members of the Australian Society of Anaesthetists.

In some cases, health funds further reduce their payment below their own fee schedule and reimburse only the Commonwealth Government recommended Medical Benefits Schedule Fee. This is a fee that the Commonwealth Government states it is prepared to pay. It is not based on fees generally charged by specialist doctors, nor is it matched to the CPI.

Check with your health fund for more information.

Questions to ask are:

     •     If the anaesthetist charges more than your schedule, will you reduce the payout to be the same as the CMBS?

     •     How much does Medicare give you back, before you pay me your rebate?

Health Fund Information: