Changes to the Medical Gap Agreements

What’s changed?

Since 1 October 2023, our Medical Gap agreements include:

  • Provider Choice which replaced (Known Gap); and
  • Full Cover

The HBF Limited Surgical Items List (HBF List) was removed.

Below you will find more information on these changes along with FAQs.

The full Medical Gap Agreement Terms and Conditions can be found here:

Terms &

Agreement types from 1 October 2023

Fully Covered Agreements

As a fully covered provider, you will be required to charge an amount that does not exceed the fee listed in HBF’s Full Cover or Specialist Anaesthetists Schedule of Fees. There are no exclusions to this condition.

In exchange for limiting your fees, you will receive a benefit above the MBS fee and your patients will enjoy a ‘no gap’ experience for the service(s) you provide.

The ‘no gap’ experience includes not passing on any other fees to eligible members, such as items previously on the HBF List, administrative fees or booking fees.

Provider Choice Agreement

The Provider Choice Agreement includes opt in/opt out options where on a patient-by-patient and episode-by-episode basis, you choose the out-of-pocket costs to pass on to eligible members. You are however not permitted to charge the member administration or booking fees under the Provider Choice agreement.

As part of the agreement, you will be able to bill in one of two ways:

  1. Opt in
  2. If you choose to charge fees that do not exceed the fee specified in the Provider Choice Schedule*, the services you provide will be paid in full by HBF and your patients with HBF memberships will incur no out-of-pocket costs.

  3. Opt -out
  4. If you choose to charge a fee that is greater than the Provider Choice Schedule*, the account will be paid up to the MBS fee. The difference between the MBS fee and your charge will be paid by the HBF member.

Status of the HBF List

On 1 October 2023, the HBF List was removed. We have set a scheduled fee for all items currently on the HBF List and your agreement type will determine whether you are able to opt in or out for services previously on the HBF List.

Full Cover Agreement: Providers who remain on a Full Cover Agreement will be required to charge fees equal to the Full Cover Schedule for all items (including items currently listed on the HBF List). This includes any associated anaesthetic services against those item numbers.

Provider Choice Agreement: Specialists on the Provider Choice Agreement or who choose to switch to it will have the ability to opt in or out of  these services.

We encourage you to read the Medical Gap Agreement Terms and Conditions, which can be found here.


When do the changes come into effect?

The Known Gap Agreement and the HBF List will cease on 30 September 2023 and the new Provider Choice agreement will take its place from 1 October 2023.

Why are you making these changes?

Our current medical specialist agreement offering can be quite challenging to understand for both our members and our Member Plus Medical Providers. Given the complexity of Private Health Insurance, we aim to simplify the process wherever possible.

What does this mean for existing Known Gap providers?

Our current Known Gap providers are being notified in stages based on their specific impact circumstances. Regardless of the specific impact, all Known Gap providers will be notified by 3 July 2023.

Unless the Known-gap provider makes contact with HBF requesting a different agreement, they will be automatically transferred to the new Provider Choice Agreement on 1 October 2023.

If you wish to change your agreement type, please contact us via the Request a Call Back form below.

What are the benefits of becoming a Provider Choice provider after being a Known Gap provider?

The benefits of the Provider Choice agreement are:

  • You will continue to have billing flexibility for patients on an episodic basis.
  • By charging a fee that does not exceed the Provider Choice Schedule, you receive a benefit above the MBS fee.

Can I charge a co-payment as a Provider Choice provider?

If you select the Provider Choice opt in option, you can only charge up to the fee set out in the Provider Choice Schedule of Fees.

If you select the Provider Choice opt out option, you are free to set a fee that you determine as reasonable. Please note, HBF will pay only up to the MBS fee.

Under both the Provider Choice opt in/out options you are unable to charge administration or booking fees.

How do I bill under the new Provider Choice Agreement?

For each episode, you have two billing options:

Opt in – Charge a fee equal to the fee set out in HBF’s Provider Choice Schedule of Fees for all MBS items and receive a benefit greater than the MBS fee.

Opt out – Charge a fee above the fee set out in HBF’s Provider Choice Schedule of Fees for all MBS items and receive a benefit up to the MBS fee.

What are the benefits of switching to Full Cover?

As a Full Cover provider, you will receive the following benefits:

  • Competitive scheduled rates, in most cases above major health insurers,
  • No out-of-pocket costs for your patients,
  • Visibility as an HBF Member Plus provider found here
  • Simplified billing and reduced administration costs,
  • Simplified claiming with payments submitted directly to HBF for full payment.

How do I switch to a Full Cover Agreement?

Visit medical providers to download a ‘Change of Arrangement’ form and submit it to or use the Call Back Booking Form to discuss your options.

Can I charge a co-payment if I become a fully covered provider?

No. You will be required to charge a fee equal to or less than the rate listed on our Full Cover or Specialist Anaesthetist Schedule.

Can I opt in/out of the fully covered agreement?

No. You are also unable to pass on any additional fees such as administration or booking fees to eligible members.

What will the removal of the HBF List mean for existing fully covered providers?

From 1 October 2023, fully covered providers cannot charge HBF members more than the fees set out in the HBF Schedule for treatments that were previously included on the HBF List.

Will any changes occur to the Full Cover schedule of fees?

No changes will occur to the Full Cover schedule on 1 October 2023.

I do not want to be a fully covered OR Provider Choice provider – what are my options?

If you would like to receive a rate equal to the MBS fee, have the flexibility to determine your own fees and continue to submit claims directly to us, you can register for our Direct Billing agreement.

To access registration forms and the terms and conditions of the Direct billing agreement visit medical providers.

Alternatively, you can use the Call Back Booking Form to request a call back timeslot to discuss your options.

What do these changes mean for new providers?

From 1 October 2023, you will have to make a choice between either:

  • Fully covered, or
  • Provider Choice.

Please contact us to understand what this means for you in relation to treatments provided before 1 October 2023.

Please note: If you are an existing provider wanting to switch agreements you are required to maintain agreement consistency over all provider numbers and there may be an agreement termination period to serve

Can I still register for the Known Gap Agreement?


Will this change impact what members are covered for?

No, the changes to our Medical Gap Agreements do not impact members’ policies.

Will HBF members be notified of the change?

Yes, members who hold an eligible HBF hospital cover and have visited a Known Gap provider within a specific timeframe will be communicated to in July 2023.

How long can I continue to submit my Known Gap claims with a date of service before 1 October 2023?

To avoid delays, all outstanding Known Gap claims from prior to 1 October 2023, must be submitted before 31 December 2023.

Who can I talk to about my agreement and what is right for me?

You can discuss the changes and your agreement options with one of our Specialist Medical Agreement Consultants. Our Call Back Request Form is located here.

Our call back time slots are subject to availability and opening hours of 8:00am - 4:00pm AWST, Monday to Friday. We will aim to confirm your preferred time slot via email prior to calling you.

I received a letter from HBF, it was specific to my claiming behaviour – how did you get this information?

We analysed your 2022 calendar year claim submissions to assist us in determining the impact of the changes specific to your circumstances.