Finder makes money from featured partners, but editorial opinions are our own.

What is Access Gap Cover and how does it work?

How to reduce health insurance gap expenses with Access Gap Cover.

Access Gap Cover is a gap cover scheme that is included as part of some health insurance policies. It helps reduce or, in many cases, eliminate potential out-of-pocket expenses that you may incur when claiming treatments under private health insurance plans. However, not all funds or practitioners participate in the Access Gap Cover Scheme.

What is the Access Gap Cover Scheme?

Access Gap Cover is the gap cover scheme administered by the Australian Health Services Alliance (AHSA) and provided by funds that are part of the AHSA. The program aims to cover the cost of gap expenses when being treated as a private patient. Funds that are part of the AHSA include many smaller brands, including Teachers, Defence, and CUA. Providers not part of the AHSA may have their own gap cover schemes.

The most significant out-of-pocket expenses that you may incur are gap expenses. These refer to the gap between how much you’re covered and how much a medical practitioner charges for a certain medical treatment.

This gap can vary widely depending on the practitioner and the type of treatment that’s needed. As such, the Access Gap Scheme simplifies the process, reduces costs and makes sure everyone knows exactly how much they’ll need to pay in gap expenses, if anything.

How the Access Gap Scheme works

Access Gap Cover helps cover the costs for private hospital treatments. To understand how it helps, it’s a good idea to get an understanding of the Medicare Benefits Schedule (MBS). The MBS is a list of the medical procedures covered by Medicare and private health insurance hospital cover, including the treatments costs.

Whether you go to a public or private hospital, Medicare and health insurance will generally only cover the MBS amount. If you don’t have health insurance, Medicare pays 100% of the MBS amount for your treatments. If you have private health insurance, Medicare will pays 75% while the health fund pays the remaining 25%.

When a doctor charges more for a treatment, the difference between the MBS amount and their fee is the gap. The Access Gap Scheme helps bridge the gap by benefiting both doctors and patients. It generally lets doctors receive more than the MBS amount without putting the full burden of gap expenses on the patient.

Most private health insurance hospital plans from participating funds include Access Gap Cover and doctors can choose whether to participate in the Access Gap Scheme. Patients can also ask whether a doctor participates in the scheme before undergoing a procedure and find out exactly how much they will need to pay, if anything, in gap expenses.

Private health insurance providers have their own Access Gap Cover arrangements, and different health funds may have different Access Gap arrangements with different doctors. This can affect the likelihood of you getting treatment from a provider that participates in the scheme. In general, all private health funds will have many participating practitioners.

Questions to ask your doctor

If your health insurance includes Access Gap Cover, you can ask the following questions prior to receiving treatments.

  • Are you going to treat me under my fund’s Access Gap Cover arrangements?
  • Will I incur any personal out-of-pocket expenses for my treatment, and can I get a written estimate?
  • Will any assisting doctors also use Access Gap Cover?
  • Are you prepared to send the bill to my fund directly, so that they can claim my Medicare benefit on my behalf and send the payment back to you?

Will they say yes? How Access Gap Cover benefits doctors.

The scheme is helpful to doctors and encourages their participation. Doctors may decide to participate in the scheme for the following reasons:

  • It simplifies payment and billing.
  • It improves a doctor’s cash flow with a clear 21-day bill turnaround.
  • It reduces the risk of bad debts for doctors.
  • Doctors can accept or decline to participate on a case-by-case basis.
  • Some health funds may agree to pay more for participating doctors, so they can earn more than the MBS amount for procedures.

Why compare health insurance with Finder?

  • We don't ask for your phone or email to see prices.

  • With 1 click, you can open your results to nearly every fund in Australia.

  • You pay the same price as going direct – we charge no fees.

Why you can trust Finder's health insurance experts


We're free

Our health insurance engine is completely free to use. You pay the same as buying directly from the health insurer. Better still, we regularly run exclusive deals that you won't find on any other site.
expert advice

We're experts

We've researched and rated hundreds of policies as part of our Finder Awards. We've published 250+ guides and our in-house experts regularly appear on Sunrise, 7News and SBS News.

We're independent

Unlike other comparison sites, we're not owned by an insurer. That means our opinions are our own and you can compare nearly every health fund in Australia on the site (and find a better deal).

We're here to help

Since 2014, we've helped 350,000+ people find health insurance by explaining your options simply. We'll never ask for your number or email to see prices. We're here to help you make a decision.

More guides on Finder

  • Health insurance for sterilisation

    Find out how to claim vasectomies and tubal ligation with Medicare or private health funds, and the things you should know before going in.

  • Medical costs comparison

    Doing a medical costs comparison could save you a lot of money. Here's how to reduce your out-of-pocket medical expenses.

  • How does health insurance cover brain surgery?

    Compare public and private health insurance for brain treatment.

  • Health insurance for cataract surgery

    Find out the pros and cons of cataract surgery with both public and private healthcare.

  • Health insurance for grommets

    Want to get health cover for grommets? Find out how private health insurance and Medicare costs compare and what you'll be covered for. Choose the option that suits you best.

  • Gold health insurance

    Gold hospital insurance is the most comprehensive hospital cover that money can buy – starting from around $53 per week.

  • Health insurance for appendicitis

    Wondering whether appendicitis will be covered by your health insurer? Your guide to private health insurance and appendicitis here.

  • How much does palliative care cost?

    Palliative care is the practice of easing the pain of a patient with a terminal illness and making them as comfortable as possible before death.

  • Health insurance for cosmetic surgery

    While private health insurance does not cover plastic surgery that is elective and performed for cosmetic purposes, it does provide cover for a wide range of reconstructive plastic surgeries.

  • Health insurance for insulin pumps

    If your doctor has recommended that you receive an insulin pump, check with your private health fund to find out whether the cost will be covered under your policy.

Save on your health insurance

Go to site