WANT TO REDUCE YOUR OUT-OF-POCKET EXPENSES? UNDERSTANDING THE MEDICAL GAP COULD HELP YOU REDUCE THE COST OF YOUR HEALTH CARE.
Access Gap Cover is a legislative scheme administered by the Australian Health Services Alliance (AHSA) and provided by funds that are part of the AHSA. The program aims to reduce, and in some cases, eliminate any out-of-pocket expenses and healthcare costs you may incur when being treated as a private patient.
Tip: Your health care provider and the type of treatment you need play a large role in determining if you need to pay anything out of your own pocket after you’ve received treatment.
If your doctor charges above the Medicare Benefits Scheme (MBS), you’ll be charged a medical gap. With Access Gap cover, this out-of-pocket expense may be reduced or entirely covered by your health fund.
Whether you want to reduce your upfront medical treatment costs, simplify the insurance claim process, or simply look after your health, the Access Gap payment scheme is a great way to do it.
In this guide, we’ll cover everything you need to know about out-of-pocket expenses and the Access Gap cover so you can make an informed decision about your health.
If you think you’ve got a pretty good handle on the basics and see the benefit of taking out a health insurance policy to reduce your out-of-pocket expenses, you can always skip ahead and get started with an online quote right now.
How Does Access Gap Cover Reduce Your Out Of Pocket Expenses?
The amount a doctor decides to charge his or her patient isn’t regulated by the Australian Government.
That means you could be paying a significant amount above the MBS for your treatment without Access Gap cover.
THERE ARE TYPICALLY THREE LEVELS OF PROTECTION OFFERED BY MOST HEALTH FUNDS:
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PARTIAL GAP COVER
This form of protection will cover some of the gap, but not the entire amount. This means you’ll have to pay the remaining amount owed.
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KNOWN GAP COVER
This form of protection covers you for the maximum capped amount for each treatment. While you may have to pay a gap, you’ll know what your out-of-pocket expense is before undergoing any treatment.
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FULL GAP COVER
This form of protection is the highest level covering you for the entire amount owing above the MBS.
Remember, gap cover schemes can vary from fund to fund. Taking the time to compare cover and assess how the policies fit your needs and expectations will ensure you get the most value out of your health insurance.
How Do You Get Access Gap Cover?
Access Gap Cover is automatically included as part of your fund’s hospital cover. This means there are no additional costs or products required for you to benefit from the scheme.
The level of protection you’ll receive with Access Gap cover will depend on your chosen hospital cover.
How to Avoid Unexpected Medical Costs
There are several ways you can limit your out-of-pocket expenses or medical treatments and in some cases, avoid them altogether. These include:
- Make sure your chosen doctor or hospital participates in your health fund’s Access Gap scheme.
- Choose a health fund that offers 100% gap cover. If that policy isn’t affordable for you, consider a known Access Gap cover so you can budget any upcoming medical expenses.
- Take out a policy that doesn’t include any excess or co-payment.
- Before you receive treatment, find out what the fees are for any specialists or assisting medical practitioners such as anaesthetists or surgeons.
- Find out if the assisting medical practitioners are registered with your health fund.
- Avoid seeking treatment from doctors who charge above the MBS schedule fees.
Benefits of Choosing Access Gap Cover
There are several advantages of choosing Access Gap cover, including:
- You’ll know any out-of-pocket expenses prior to the treatment.
- You may even avoid out-of-pocket expenses entirely for some treatments.
- You can skip Medicare queues.
- Your doctor can claim on your behalf.
- You can get more value for money on your private health cover.
- You’ll have peace of mind.
There are also several benefits for doctors registered for Access Gap cover, including:
- Claims are paid within 21 days.
- Improved cash flow.
- Simpler billing systems.
- No contracts with Access Gap.
- Reduced risk of bad patient debtors.
- Doctors can accept or decline to participate in the scheme on a case-by-case basis.
What’s the Difference Between Medical & Hospital Gap?
Medical Gap
The term ‘medical gap’ refers to the amount above the Medicare Benefits Schedule that some medical practitioners charge for medical services. This expense is not typically covered by health funds and includes day surgery or hospital procedures.
Some funds have an agreement with certain doctors that may cover some or all of the doctor’s fee for hospital treatments. If your health fund doesn’t have an agreement with your chosen doctor you may have to contribute an amount towards the bill out of your own pocket.
Hospital Gap
The term ‘hospital gap’ refers to the out-of-pocket expenses you may face for your hospital accommodation. Many hospitals have agreements with health insurance funds to cover the full or partial costs of your hospital accommodation.
If you choose to go to a hospital that doesn’t have an agreement with your health fund, you may have to pay a significant bill for your treatment.
If you opt for health insurance excess or a co-payment policy, you’ll have to pay an agreed amount towards the cost of your treatment. That applies even if your hospital has an agreement with your health fund.
Understanding the MBS
To gain a better understanding of Access Gap Cover and related benefits, it pays to know the basics of the Medicare Benefits Schedule
The MBS is an extensive list of medical procedures that are covered by Medicare and private health insurance hospital cover.
Regardless of whether you receive treatment at a public or private hospital, your private health insurance and Medicare will typically only cover the MBS cost. If you have private health cover, Medicare will contribute 75% to the MBS amount for your treatments and your fund will pay the remaining 25%.
If you don’t have a health insurance policy, Medicare will pay 100% of the MBS amount.
When your doctor charges an amount above the MBS for the treatment, you’ll be paying the gap. With Access Gap cover, this out-of-pocket expense may be reduced, and in some cases, covered entirely. Without private health cover, you’ll have to fund the medical gap entirely out of your own pocket.
How to Know if Your Doctor is Registered for Access Gap Cover
To take advantage of the Access Gap Cover, your doctor will need to be registered with the scheme with your individual health fund.
You can find out whether your doctor is registered by contacting your health fund directly or asking your doctor. It’s important you do this, as even if you have Access Gap cover, if your doctor isn’t associated with your health fund and charges over the MBS fee, you may have to pay most of the bill yourself.
We also recommend before you go to hospital you discuss the cost of your treatment with the doctor. Your doctor is obliged to inform you of any out-of-pocket expenses that you may need to pay in a written estimate before you go into hospital.
Here are some questions you should ask your doctor before accepting treatment:- Are you able to treat me under my health fund’s Access Gap cover?
- Are there any out-of-pocket expenses and if so, can you please provide me with a written estimation of how much?
- Are there any assisting doctors using the Access Gap cover?
- Will the bill be sent to my fund directly so they claim my Medicare benefit on my behalf and send the payment directly to you?
FAQs
What is health insurance excess and how does it affect my gap amount?
An excess is an agreed sum of money you elect to pay towards the cost of your medical treatment. You make this agreement with your health fund when you take out your policy.
An excess of private health insurance sees a reduction in the cost of your premiums. Typically, the higher the excess you’re prepared to pay, the lower your annual premiums should be.
You’ll only be required to pay the excess for hospital admission as an inpatient for treatment. The excess is only applicable for a hospital stay and not applicable for any extras cover.
Even if you opt for a higher excess, without Access Gap cover you may still have some out-of-pocket expenses depending on the type of treatment you receive and the doctors or specialists involved.
What is a "no gap" payment under Access Gap Cover?
A "no gap" payment means that there are no out-of-pocket expenses for the patient. The health fund and the doctor have an agreement where the doctor charges only the Medicare Benefits Schedule (MBS) fee or a lower fee, eliminating any additional costs for the patient.
What is informed financial consent in relation to Access Gap Cover?
Informed financial consent refers to the process where the doctor provides the patient with a written estimate of any potential out-of-pocket expenses before the treatment. This allows the patient to make an informed decision and understand the financial implications of the treatment.
Are consultations covered under Access Gap Cover?
Consultations with medical practitioners, such as specialists or general practitioners, may be covered under Access Gap Cover. The extent of coverage and any potential out-of-pocket expenses for consultations can vary, so it's important to check with your health fund and doctor before scheduling an appointment.
What is the Medicare Benefits Schedule (MBS) fee and how does it relate to Access Gap Cover?
The MBS fee is the fee set by the Australian government for specific medical procedures and services. Access Gap Cover helps bridge the gap between the MBS fee and the doctor's fee, reducing or eliminating out-of-pocket expenses for the patient.
How can I search for a provider who participates in Access Gap Cover?
You can use the provider search tool offered by your health fund to find doctors or specialists who participate in Access Gap Cover. This tool helps you locate healthcare providers who have agreements with your fund and can provide treatment with reduced or no out-of-pocket expenses.
What is a rebate?
A rebate refers to the amount refunded by Medicare or your health fund for medical services covered under Access Gap Cover. The rebate helps offset the costs of the treatment and reduces the out-of-pocket expenses for the patient.
Do I need a referral to use Access Gap Cover?
In most cases, a referral from a general practitioner or specialist is required to access specialist services under Access Gap Cover. The referral helps ensure that the treatment is appropriate and necessary, and it may also impact the level of coverage and potential out-of-pocket expenses.
What are waiting periods?
Waiting periods are the specified time frames that you must wait after purchasing health insurance before you can access certain benefits, including Access Gap Cover. The length of waiting periods can vary depending on the insurance policy and the specific treatment or service you require.
