Estimate Example - Known Gap (Scheme)

Scenario: The practitioner or practice opts into a scheme with the health fund but charges their own fee rate. Therefore, instead of paying up to the Medicare Benefit Schedule, the health fund will pay up to their own published rate.

The calculations are based on the following:

  • Doctor's fee is displayed under Fee.
  • Medicare rebate of (75%) is displayed under Medicare.
  • Health Fund Rate is the difference between the health fund published rate and the Medicare benefit.
  • Gap difference is displayed under the Gap column.


    This table shows an example of a practitioner charging above the schedule fee for item 32090.

    Practitioner Charges $450.00
    Less Rebate

    Medicare Rebate ($221.55)

    Health Fund ($157.20)

    $378.90
    Gap to pay $71.25