Access Gap Cover explained

Learn how Access Gap Cover works and how HBF members can benefit.

Access Gap Cover

Access Gap Cover (AGC) is a billing arrangement that can help minimise out-of-pocket expenses for certain medical services when you are admitted into a hospital in Australia (excluding WA). In this article, we’ll explain everything you need to know about AGC, including how to find an AGC doctor.

It is important to keep in mind that doctors choose to participate in AGC on a case by case basis, it is therefore important to ask your doctor, specialist, surgeon, assistant surgeon and anaesthetist whether they will participate in AGC for you and obtain a quote prior to undertaking any treatment.

How does AGC work?

In 2017, HBF partnered with the Australian Health Service Alliance (AHSA) to give members access to AGC across Australia (excluding WA). When you are treated by a doctor with an AGC arrangement, you’ll benefit from reduced or eliminated medical gaps – protecting your back pocket.

It is up to each doctor, including your surgeon, assistant surgeon and anaesthetist, to decide if they will participate in the AGC arrangement, and most will decide on a case-by-case basis.

The main advantages of AGC include:

  • Reduced or eliminated out-of-pocket expenses for certain medical services (such as costs charged by your surgeon, assistant surgeon and anaesthetist
  • Your doctor can submit your claim directly to HBF on your behalf
  • You will receive an estimate of fees charged by your doctor before treatment. This estimate will help you to provide Informed Financial Consent (IFC) for your treatment

How does AGC billing work?

When your doctor chooses to participate in AGC they have the option of billing one of two ways:

1. No Gap

When your doctor charges an amount for their services that is equal to the AHSA AGC benefit (being the amount paid for by HBF and Medicare), you will pay no gap.

Medicare Benefits Schedule item number
Item description
Surgeon's fee
AHSA AGC Benefit (paid by Medicare and HBF)
Gap (paid by you)
32228
Colonoscopy
$443.70
$443.70
$0
32229
Polyp removal
$178.90
$178.90
$0
Your out-of-pocket expenses for your surgeon
$0

The information provided in the table above is for example purposes only. You may still have out-of-pocket expenses for other services, including for your anaesthetist and/or assistant surgeon.

2. Known Gap

Some doctors may still choose to charge a gap. However, if they’ve chosen to opt-in to the AGC the maximum amount that each doctor (surgeon, assistant surgeon, anaesthetist) can charge you over the AHSA AGC benefit is $500 per hospital episode, irrespective of how many Medicare Benefits Schedule (MBS) item numbers are included in your treatment.

This ruling does not apply to obstetricians, who can charge up to $800 over the AHSA AGC benefit per obstetric service or MBS item number that relates to the management of labour and delivery.

Medicare Benefits Schedule item number
Item description
Surgeon's fee
AHSA AGC Benefit (paid by Medicare and HBF)
Gap (paid by you)
32228
Colonoscopy
$743.70
$443.70
$500 (combined with below)
32229
Polyp removal
$378.90
$178.90
$500 (combined with above)
Your out-of-pocket expenses for your surgeon
$500
Medicare Benefits Schedule item number Item description Surgeon's fee AHSA AGC Benefit (paid by Medicare and HBF) Gap (paid by you)
32228 Colonoscopy $743.70 $443.70 $500
32229 Polyp removal $378.90 $178.90
Your out-of-pocket expenses for your surgeon $500

As another example, if you require obstetric care in New South Wales and your obstetrician chooses to participate in AGC and charge you a Known Gap, the obstetrician's costs may look like the below:

Medicare Benefits Schedule item number
Item description
Surgeon's fee
AHSA AGC Benefit (paid by Medicare and HBF)
Gap (paid by you)
16519
Management of labour and birth
$2,100
$1,300
$800
Your out-of-pocket expenses for your obstetrician
$800

The information provided in the tables above is for example purposes only. You may have additional out-of-pocket expenses for other services, including for your anaesthetist and/or assistant surgeon.

Should your doctor choose to not participate in AGC, HBF and Medicare will pay up to the MBS fee. If the doctor charges above the MBS fee, you will need to cover the difference out of your own pocket.

Other fees

When opting-in to AGC, doctors are unable to charge you additional fees like booking fees, administrative fees, or any other fees that are not associated with an MBS item number.

How can I find an AGC doctor?

The AHSA has AGC arrangements with thousands of doctors across Australia (excluding WA). You can use the AHSA’s provider search tool to find registered AGC providers near you.

It is important to note that while doctors may be registered for AGC, it is up to each individual doctor, specialist, surgeon, assistant surgeon and anaesthetist to choose if they will participate in AGC on a case by case basis.

How will I know if my doctor will participate in AGC?

As doctors choose to participate in AGC on a case by case basis, it’s important to ask your doctor, specialist, surgeon, assistant surgeon and anaesthetist whether they will participate in AGC for you.

Questions to ask each provider:

  • Will you treat me under Access Gap Cover?
  • Will I incur any out-of-pocket expenses, and can I get a written estimate of the medical fees you will charge?
  • What other fees are associated with treatment?
  • Can these fees change and how will you let me know if they do change?
  • Will I need to pay you upfront?
  • Will you send the bill directly to HBF, so that they can claim on my behalf?

Frequently asked questions

What is Informed Financial Consent?

Before receiving treatment, your doctor, health provider and/or hospital should provide you with a quote which sets out any out-of-pocket costs that you will be required to pay. If they do not provide this upfront, you are entitled to request this quote.

Understanding this information and knowing all the estimated costs of your procedure will allow you to provide informed financial consent for the costs of your treatment.

More information on providing Informed Financial Content can be found on the Australian Medical Association's (AMA) website.

Who provides me with the costs for my proposed treatment in order for me to give my Informed Financial Consent for that treatment?

You should obtain a written estimate of medical fees from any doctor assisting with your procedure; this includes your specialist, anaesthetist and assistant surgeon. You should also ask your hospital if you will have any out-of-pocket costs - this allows you to fully understand any out-of-pocket expenses you will need to pay.

Learn more about Informed Financial Consent

What happens if my doctor chooses not to participate in Access Gap Cover?

If your doctor doesn't participate in Access Gap Cover, your doctor should issue you with a written estimate of medical fees and you will be required to pay the difference between their fees and what Medicare and HBF pay. If they do not provide you with a quote upfront, you are entitled to request this from them.

The amount you will need to contribute to your treatment will depend on the amount they charge. There is no limit to this amount and your doctor will charge you what they believe to be a reasonable amount.

I want to be treated under the Access Gap Cover scheme. Does my GP have to refer me to a certain specialist, or can I choose my own?

No, referrals do not need to be addressed to a specific doctor. The GP can let you choose a specialist by issuing an open referral letter. This gives you the freedom to consult with a specialist that participates in the Access Gap Cover scheme.

I've received written estimates from each of my doctors. Do I need to contact HBF?

No. Once you have received your written estimate of medical fees from all doctors, surgeons and specialists providing treatment to you, you do not need to contact HBF to confirm your out-of-pocket expenses for these medical fees.

You should contact us if you need to:

  • Confirm that your treatment is included in your hospital cover and that you have served all applicable waiting periods.
  • Confirm whether you will need to pay an excess, and whether your hospital is a Participating Hospital; you may have significant out-of-pockets if your hospital is not a Participating Hospital.
  • Ask any other questions relating to your health cover.

Prior to your treatment, always ensure your Medicare card is up to date.

What happens if my out-of-pocket expenses do not match the amount quoted in the written estimate of medical fees?

Please discuss any discrepancies with your doctor.

When should I provide an Informed Financial Consent form?

You should provide an Informed Financial Consent form to a patient when there will be a patient gap or at any time that a patient requests one.

It is crucial to the success of the Access Gap Cover scheme that your patients are correctly informed of their out-of-pocket expenses. This can also be a helpful tool to allow your patient to understand the fees for the procedure and can assist us to provide our member with quotes or further information if requested.

You can download the Estimate of Fees form from the Australian Health Service Alliance's website.