Accessing specialist healthcare in Australia is easier than in many places, but the costs involved can still surprise people. Even when Medicare applies its rebate, you may be left with an out-of-pocket payment, commonly referred to as the gap. Understanding what the gap is, why it exists and how to manage it can make a big difference when preparing for specialist care.
What Exactly Is the “Gap”?
When you visit a specialist privately, the government supports part of the cost. That support is based on a Schedule Fee — a set amount listed in the Medicare Benefits Schedule (MBS). Medicare then pays back a proportion of that fee as a Medicare rebate. For most out-of-hospital specialist services, the rebate is 85 percent of the MBS Schedule Fee.
The gap is the difference between what Medicare rebates and what the specialist actually charges. It is the part you pay yourself.
Imagine a dermatologist charges $200 for an initial consultation.
- Schedule Fee set by Medicare: $100
- Medicare rebate (85 percent of Schedule Fee): $85
- Specialist charge: $200
- Gap: $200 – $85 = $115
In this case, you must pay $115 out of pocket before the Medicare rebate arrives. The gap is separate from any private health insurance rebate you might receive, and Medicare usually processes the rebate after you have paid the full amount.
Common Specialist Costs to Watch Out For
Costs vary widely between specialists and services, but some categories tend to have higher fees.
Initial Consultations
Often the most expensive visit, initial consultations can range from around $200 to $500 or more, depending on the specialty and location.
Diagnostic Scans
Private MRIs and ultrasounds that are not bulk-billed can cost hundreds of dollars before any rebate is applied.
Day Surgery and In-Room Procedures
Biopsies, endoscopies, and minor surgical procedures performed in a private clinic may carry separate fees for the procedure, consumables and specialist time.
Because specialist charges are not regulated to match Schedule Fees, gaps for these services can rise quickly, sometimes amounting to high out-of-pocket costs.
The “Pay on the Day” Policy
Unlike some GP visits that may be bulk-billed (where no gap is charged and Medicare is billed directly by the doctor), most specialist clinics require full payment up front at reception.
In other words, even though Medicare will refund a portion of the cost, you typically need the total fee in your bank account when you check in. The rebate is processed later, usually electronically within a few days, but you cannot subtract the rebate before you pay.
This immediate cash flow requirement can feel like a hurdle when the gap is large, and that is where financial planning becomes important. While Medicare covers a portion of the fee, the gap payment for a private specialist often needs to be settled at the reception desk immediately.
Small personal loans can help patients manage these out-of-pocket health costs without delaying their treatment.
Prioritising Health When Finances Are Tight
It is understandable to hesitate before scheduling a specialist appointment if you are worried about costs. However, delaying diagnosis or treatment often leads to worse health outcomes and higher costs later on. According to some reports, many Australians skip or postpone specialist visits because of the cost involved.
In situations where you must be seen promptly and your savings are limited, financing options exist that can help you attend appointments and manage the gap responsibly. Health issues rarely wait for your savings to build up. Bad credit loans can provide a safety net for medical necessities, ensuring you do not have to cancel an important appointment due to a lack of funds. The aim is to avoid postponing essential care because of short-term financial pressure.
It is important to weigh the cost of loans against the value of timely care for serious conditions. Always consider your personal circumstances and seek financial advice if needed.
Tips for Reducing the Gap
There are several practical steps you can take to reduce the amount you pay out of pocket.
Ask for the ‘Financial Consent’ Before Your Appointment
Before booking, request a written estimate of the specialist’s fees. Clinics are generally required to provide fee information if you ask. Knowing the gap in advance allows you to budget and avoid surprises on the day.
Use the Medicare Safety Net
The Medicare Safety Net is designed to reduce costs for people with high medical expenses. Once your accumulated gap payments for out-of-hospital services reach a threshold within a calendar year, Medicare increases the rebate for future eligible services.
For 2025, the Original Medicare Safety Net threshold is $576.00. After that is reached, Medicare will reimburse 100 per cent of the Schedule Fee (not necessarily 100 percent of what the specialist charged).
There is also an Extended Medicare Safety Net, which provides extra support once your total out-of-pocket expenses reach a higher threshold.
You can check your Safety Net balance through your MyGov Medicare account to plan ahead.
Shop Around for Specialists
Specialist fees can vary significantly, even within the same area of medicine. Your GP can suggest alternative specialists who charge lower fees. Keep in mind that wait times might differ, but this can reduce the gap substantially.
Conclusion
The gap is a routine part of private specialist care in Australia, representing the difference between what Medicare pays and what you owe on the day. Understanding it helps you prepare financially and avoid unexpected bills.
Arrange an estimate of fees before your appointment, check your Medicare Safety Net status, and make sure you have access to funds so you can focus on your health and recovery rather than the cost of care. If you need support covering immediate out-of-pocket fees, financing such as small personal loans or bad credit loans may be an option — but use them thoughtfully.
With planning and awareness of your choices, the gap does not need to be a barrier to accessing the care you need.
