Gap and no-gap, explained.
What is a gap payment?
A gap is the difference between what a doctor charges and what your health fund and Medicare pay back between them. If the fee is higher than the combined benefit, the remainder is the gap and you pay it out of your own pocket. Gaps vary between doctors and between funds, and they are not fixed by any schedule.
What is a no-gap arrangement?
An agreement between practitioners and a health fund to accept the fund's benefit as payment in full. Under the arrangements Professor Rodda participates in, this covers the surgeon's fee, the anaesthetist's fee and the surgical assistant's fee. If you hold eligible cover with a participating fund and have served any relevant waiting periods, there is no gap to pay on those fees. Your hospital excess is separate and still applies.
Are the implants different under a no-gap arrangement?
No. The implant used in your joint replacement is chosen by Professor Rodda based on your anatomy, your age and the surgical technique planned for you. A no-gap arrangement determines how practitioner fees are paid. It has no bearing on which implant is used or on how your surgery is performed. Every patient receives the same standard of care regardless of their health fund.
What about my hospital excess?
Your excess is a fixed amount set by your policy, usually payable once per year or per admission depending on your cover. It is charged by the hospital, not by the practice, and it is not affected by a no-gap arrangement. Your fund can tell you the exact amount and whether you have already paid it this year.
Do waiting periods apply?
Yes. Health funds apply waiting periods for joint replacement, and these must be served before your fund will pay benefits, including under a no-gap arrangement. Waiting periods are commonly twelve months for a pre-existing condition, and arthritis you already have counts as pre-existing. The exact terms depend on your policy and your fund can confirm your status in a single phone call.
The full set of questions, including changing funds, portability of waiting periods and who to contact about billing, is on no-gap cover.
This page provides general information about a medical condition and a surgical procedure. It is not individual medical advice and does not replace consultation with a qualified practitioner. Outcomes vary between individuals and all surgery carries risk. A referral is needed for a consultation with Professor Daevyd Rodda; without one, you can start with the practice nurse practitioner, who can provide it.