What are out‑of‑pocket costs?

Why might I have out-of-pocket costs as a private patient?

Your specialist may charge more than the MBS fee  

Specialists can charge what they like, if they charge more than the Medicare Benefits Schedule (MBS) fee, you may need to pay the difference, unless they use and agree to bill with Access Gap Cover.

Many hospital procedures involve multiple specialists (like a surgeon and an anaesthetist). Each sets their own fee. 

Your excess 

An excess is what you agree to pay towards a hospital stay. Choosing an excess can lower your premium (what you pay for your cover), but you’ll need to pay it if you’re admitted. 

The good news: your excess is $750 per person up to a maximum of $1,500 per policy. So, you’ll only pay it once per person, per calendar year. 

Tests and scans 

Things like blood tests, X‑rays, ultrasounds and scans are partly covered by Medicare and your insurer. If your provider charges above the MBS fee, you may have a gap to pay. These bills often arrive after your hospital stay and may need to be claimed through Medicare.

Medications after you leave hospital 

Medications given during your hospital stay are usually included, but you may be charged for take‑home medications (discharge drugs). 

Medical devices and human tissue products 

Your insurer will pay a set minimum benefit based on the government’s approved list.

If the cost is higher than this amount you may need to pay the difference. 

Extra hospital charges 

Some extras aren’t covered, such as: 

• TV or phone use 
• Parking 
• Newspapers 
• Take‑home aids (like crutches) 
• It’s worth checking these with the hospital beforehand

How do I reduce my out-of-pocket costs?

You can take a few simple steps to keep costs down: 

• Check your cover – Know what’s included and what’s not by reviewing your policy details in your cover fact sheet located in your member area or app. 
• Choose specialists that bill using Access Gap Cover – This can reduce or remove extra costs. 
• Ask for a cost estimate upfront – Also called Informed Financial Consent. 
• Know your excess – So there are no surprises at admission. 
• Check waiting periods – To avoid unexpected charges check your waiting periods in the member area or app. 
• Talk to Frank – our team can explain your cover, expected costs, and what to ask your providers.