How much could I owe? Step through your situation to understand how private hospital gap fees work and what you might be exposed to.
📋 This estimator explains how the private hospital billing system works in Australia. It does not reflect the specific gap arrangements of any individual fund or doctor. Actual out-of-pocket costs depend on your policy, your doctor, and the exact items billed. For your specific entitlements, contact your fund directly or use the government’s free comparison tool at privatehealth.gov.au. This is general information only — not financial or insurance advice.
🇦🇺 Australia — how the system works
⚠️ This is an estimator, not a calculator. Actual gap fees depend on your specific fund, your doctor, and the exact MBS items billed. Use this to understand how the system works and what questions to ask — then call your fund for your exact entitlements.
1What level of private hospital cover do you have?
Your tier determines which procedures your fund will contribute to at all.
2What type of procedure are you having?
This affects whether your tier covers it, and typical MBS fee ranges.
3Do you know if your doctor participates in your fund’s gap scheme?
This is the biggest variable in your out-of-pocket cost. You can check with your fund before the procedure.
How private hospital billing works
Who pays what
Amount
Notes
Medicare
75% of MBS fee
For in-hospital medical services
Your fund
25% of MBS fee
Tops up to 100% of MBS. Some funds pay more under gap cover schemes.
You (the gap)
Any charge above MBS
If doctor charges $600 and MBS fee is $400, you pay $200.
You (excess)
Your policy excess
Paid once per admission (or per year on some policies)
The hospital charges (accommodation, theatre, nursing) are separate from the doctor’s fees. Your fund covers most or all hospital charges if the hospital is contracted with your fund. The gap fee issue is almost always about the doctor’s fee, not the hospital itself.