2. Understand Access Gap Cover and HBF Member Plus arrangements
Access Gap Cover specialists
In general, if you choose to be treated as a private patient in a private hospital, Medicare pays 75% of the Medicare Benefits Schedule (MBS) fee, and we pay the remaining 25%. But many specialists (doctors, surgeons, anaesthetists) choose to charge more than the MBS fee. If this happens, there may be a ‘gap’ (the difference between the MBS fee and the specialist’s fee).
That’s where Access Gap Cover comes in. To help eliminate or reduce this ‘gap’ for you, we participate in the Australian Health Service Alliance (AHSA) Access Gap Cover (AGC) arrangement for all states outside of Western Australia.
If your specialist participates in the AGC arrangement, they have the option to opt-in or opt-out of the arrangement on a case-by-case basis. Your specialist will choose to bill you in one of two ways – opt in or opt out/no agreement
What it means for you
If your specialist chooses to charge a Known Gap they will charge up to the maximum agreed fee and we will pay an additional amount above the MBS, leaving you with a maximum out-of-pocket expense of $500 for inpatient services (or $800 for obstetric services).
Opt-out (or no agreement)
If your specialist chooses to opt-out of the arrangement or are not registered to participate in an arrangement, their in-patient services will be covered up to the MBS fee. You will need to pay the difference between the MBS fee and the specialist’s fees (this is your out-of-pocket expense).
Remember: No matter what category of agreement your specialist falls under, you may still need to pay an agreed hospital excess on your policy and other out-of-pocket costs. We also can’t pay benefits for specialists’ fees if the treatment category is excluded on your level of cover.
Medicare Benefits Schedule (MBS) fee
Paid by HBF
Paid by HBF
Paid by Medicare
HBF Member Plus hospitals
When choosing your specialist, consider whether they will treat you at a Member Plus hospital. Member Plus hospitals offer members a range of great benefits, including fully covered accommodation and theatre fees.
Before you arrange a hospital stay, call us on 133 423 to confirm that you are being admitted to a Member Plus hospital and, if you have the MBS item numbers for your treatment, we’ll tell you what you’re covered for and any out-of-pockets you may incur.
What about other private hospitals?
You can choose to be treated at non-Member Plus private hospitals, but you may incur significant out-of-pocket costs. Chat to us on 133 423 for more information.