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.
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.
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.
| Response | |
|---|---|
| Yes | 65.54% |
| No | 34.46% |
If your health insurance includes Access Gap Cover, you can ask the following questions prior to receiving treatments.
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:
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 compare with us
Our customers trust us
Find out how to claim vasectomies and tubal ligation with Medicare or private health funds, and the things you should know before going in.
See how private health insurance can offer support if you suffer from chronic pain.
Find out spinal fusion costs, waiting times, out-of-pocket expenses and more.
Compare public and private health insurance for brain treatment.
You can get cover for varicose vein treatment with Medicare or a Silver Insurance Policy, provided the treatment is medically necessary. Compare the costs of both below.
Will private health insurance provide cover when you need to travel far from home and stay overnight to access medical treatment? Find out here.
Medicare and private health insurance can work together to bring down the costs of your gender reassignment surgery.
Find out if being treated as an inpatient or an outpatient will affect your private health insurance cover.
Does health insurance cover MRI scans, and if so, for what treatments?
There are more than 10,000 prosthetic devices that can be covered through private health insurance. Here's how to identify if you're covered.
