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St Lukes Medical Gap

St Lukes Medical Gap

About St Lukes Medical Gap
When you hold private hospital cover and receive an eligible medical service in hospital Medicare will pay a benefit of 75% of the Medicare Benefits Schedule (MBS) Fee. St Lukes will pay the remaining 25% of the MBS fee subject to Medicare benefits being paid in line with the MBS rulings. This means you will be fully covered up to the MBS fee. However, doctors can charge above the schedule fee and when they do, the difference between the MBS fee and the doctor’s charge is called the ‘gap’.

St Lukes Medical Gap is designed to eliminate or reduce this ‘gap’. If your doctor agrees to participate in
St Lukes Medical Gap you will either be fully covered for your inpatient medical services or your ‘gap’ will be significantly reduced. Your doctor can participate either as a “No Gap” provider, or as a “Known Gap” provider.

A “No Gap” provider agrees to charge no more than the St Lukes Medical Gap schedule fee, in which case you will have no gap or out-of-pocket expense to pay.

A “Known Gap” provider agrees to charge no more than a specified known gap for each medical service, in which case your out-of-pocket expense will be reduced.

Doctors who charge a “Known Gap” under the St Lukes Medical Gap arrangement, will be required to inform you in advance of the out-of-pocket expense that applies to your treatment. This is known as “informed financial consent” and should be obtained by the doctor prior to treatment, or in the case of emergency treatment, as soon as practical.

Not all medical services provided during a course of hospital treatment will necessarily be covered by the
St Lukes Medical Gap arrangement. As doctor participation is voluntary, it is possible for only some services to be covered by the arrangement if multiple providers are involved in your treatment.

If your doctor does not participate in the arrangement and charges over the MBS fee, you will have to pay the gap or out-of-pocket expense for the difference between the amount charged and the MBS fee. Patients using non- participating doctors will be billed directly by the doctor and where services qualify for benefits will still be able to claim the 25% gap between the Medicare benefit and the MBS fee from St Lukes.

A key feature of the gap cover arrangement is a simplified billing process for services provided by participating doctors. The doctor can send accounts direct to St Lukes for payment of both Medicare and Fund benefits. If you are treated by a “No Gap” participating doctor, you will not receive an account for services provided by that doctor. If you are treated by a “Known Gap” participating doctor, you will receive an account for the agreed out-of-pocket charge.

Who is eligible for St Lukes Medical Gap?
If you hold private hospital cover and have served all your waiting periods, you may be eligible for St Lukes Medical Gap benefits when treated by a participating doctor.

Eligibility for benefits is dependent upon being a financial member of St Lukes at the time of your admission, that you are entitled to receive Medicare rebates for the services performed, are not entitled to claim a benefit for the services from any other source (including from another insurer or worker’s compensation) and are not subject to any pre-existing condition limitations. For further information on pre-existing conditions please contact our Customer Care Centre on 1300 651 988.

Only hospital in-patient medical services provided by a participating provider are eligible for St Lukes Medical Gap benefit. Out-patient services or services provided to patients who are not formally admitted to an approved hospital or day hospital facility, will not qualify for St Lukes Medical Gap benefit.

If your level of hospital cover carries an excess, this excess does not apply to the St Lukes Medical Gap Cover benefit.

Does my doctor participate?
St Lukes encourages all eligible members to check if their doctor participates in the St Lukes Medical Gap arrangement before commencing hospital treatment. If your doctor does not have information about the arrangement, ask them to contact St Lukes for details.

We also encourage members to check which other medical providers will be involved in their hospital treatment and whether they too will be participating in the gap cover arrangement.

If your doctor is a participating doctor you will need to provide them with your St Lukes membership number.

If your doctor is not a participating doctor, ask your doctor to consider billing you under this arrangement and ask what your out-of-pocket expenses are likely to be.


Further information regarding medical providers can be found here.

Want to find out more?

Want to find out more?

Contact St Lukes today!