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Medical gaps are a common type of out-of-pocket expense members sometimes face when going to a hospital for a procedure. This gap occurs when there is a difference between the fee charged by your doctor and the amount covered by Medicare and HBF. A medical gap is an amount you need to contribute to your treatment.
In 2017, HBF partnered with the Australian Health Service Alliance (AHSA) to give you access to Access Gap Cover (AGC). AGC is a billing arrangement that can help reduce or eliminate your out-of-pocket expenses for certain medical services (such as costs charged by your surgeon, assistant surgeon and anaethesthetist) when you are admitted into a hospital in any state outside of WA.
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:
AGC does not apply to pathology and radiology services, outside of hospital medical services and services not included in your policy.
When your doctor chooses to participate in AGC they have the option of billing one of two ways:
When your doctor charges an amount equal to the AHSA AGC benefit (being the amount paid for by HBF and Medicare), you will pay no gap.
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.
If choosing 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.
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:
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.
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.
If you received treatment before 1 July 2020, your doctor could charge you a maximum of $400 above the AHSA AGC benefit per MBS item number. You would have to pay the difference between the AHSA AGC benefit and the fees charged by your surgeon, assistant surgeon, anaesthetist and any other specialist or health care provider (other than for pathology or radiology services).
The AHSA has AGC arrangements with thousands of doctors outside of WA. You can find out which providers are registered for AGC at provider search tool.
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 on a case by case basis.
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:
Before your procedure it’s important your doctor makes you aware of any out-of-pocket costs you may incur. Your doctor must advise you in writing how much your treatment will cost, what your health fund benefits are, any out of pocket costs you have and whether any other doctors will be involved in your treatment (for example, assistant surgeons and anaesthetists). Understanding this information and knowing all the estimated costs of your procedure will allow you to provide informed financial consent to the costs of your treatment.
More information on providing IFC can be found via the Australian Medical Association (AMA).
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.
Please do contact us to confirm that your treatment is included in your hospital cover and that you have served all applicable waiting periods. You should also confirm whether you will need to pay an excess and whether your hospital is a Participating Hospital, as you may have significant out-of-pockets if your hospital is not a Participating Hospital. Prior to your treatment, also ensure your Medicare card is up to date. You can also ask any other questions you need to alleviate concerns.
The company was formed in 1994 to provide management services to private health insurers around Australia. By pooling their resources and creating AHSA, participating funds can respond more effectively to the numerous changes occurring in private health insurance industry.
AHSA provides a range of services including management of:
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