My Private Health Cover 

Private health cover can be difficult to navigate.  We do our best to be clear and upfront with our patients regarding their private cover.

Regardless of your health fund provider, you will have out of pocket costs.  This cost is known as “the Gap”.  Our practice has agreements with most funds that cap the patient Gap at $500.  (We do not have this agreement with NIB- please see below)

Dr. Jefferson charges the rates recommended by the Australian Medical Association (AMA).  The “Gap” that you pay will be the difference between the AMA rate and your health fund rebate.

For example:

Item # Procedure AMA Rate Bupa Rebate

Out of pocket

41789 Tonsillectomy (child less that 12 years of age) $  695.00  $ 485.00  $ 210.00


Unfortunately Ear Nose and Throat Newcastle no longer has a MediGap agreement with NIB Health Fund.  NIB pays significantly below the AMA rate to doctors under the MediGap arrangement and MediGap rebates are lower than any other fund.

Here is an example:

Procedure NIB out of pocket HCF Out of pocket BUPA out of pocket


(Children under 12 years)
$342.40 $162.50 $210
(over 12 years)
$513.50 $216.50 $275.80
Bilateral grommets $496.80 $210 $267.60
Sinus surgery $1, 646.50 $500 $500

**Please note that the above are not to be taken as exact quotes. Your exact quote will be dependent on the item numbers recommended by Dr Jefferson on the day of your consultation.

NIB customers will be responsible for the difference between the AMA Rate and the NIB rebate.  NIB customers have the option of accepting this gap payment or changing health funds.

Disappointed With Your Rebate?

We have found some patients are disappointed by the rebates offered by their health fund.  While we do not endorse any particular fund, we know that funds vary greatly in what they offer their customers and we encourage those not happy with their coverage to switch funds. In Australia, many funds are run to benefit members, but some like NIB and Medibank are listed companies, which have a legal obligation to maximise profits for shareholders. This can result in below-industry rebate ratios for their policy holders.

Switching Funds- What You Should Know

  1. Portability

The Private Health Insurance Act 2007 includes “portability” rules.  Portability means that when switching funds that there are no penalties or exit fees.

  1. Waiting periods are waived

If you are switching to a comparable policy, waiting periods that you have already served with your old health insurance policy are waived by your new health fund when you switch health insurance.

  1. Your new health fund does the paperwork!

Simply find and apply for the health insurance policy you want to switch to, and your new health fund will manage your transfer.  Once you give your new fund authorisation, they will cancel your old policy and retrieve your membership details.  Any portion of unused premium that you may have already paid to your old fund will be refunded to you.