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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.

Finder survey: Do Australians of different ages feel like their hospital cover offers good value for money?

Source: Finder survey by Pure Profile of 1006 Australians, December 2023

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.

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Andrew Munro was the global cryptocurrency editor at Finder. During his time he covered all aspects of cryptocurrency and the blockchain. Before he became cryptocurrency editor, he was a content writer for Finder covering various topics over his nearly 5 years in the role. Prior to joining Finder he was a web copywriter. Andrew has a Bachelor of Arts from the University of New South Wales. See full bio

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