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Access Gap Cover

What is a medical gap?

Medical gaps are a common type of out-of-pocket expense members sometimes face when going to 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 the amount you need to contribute to your treatment.

How do we help minimise your gap?

In 2017, HBF partnered with the Australian Health Services Alliance (AHSA) to give you access to Access Gap Cover (AGC). AGC is a billing arrangement which can help reduce or eliminate your out-of-pocket expenses for certain medical services (such as the costs charged by your surgeon, assistant surgeon and anaesthetist) when you are admitted into hospital in any state outside of WA.

It is up to each individual 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
  • Your doctor can submit your claim directly to HBF on your behalf
  • You will receive an estimate of fees charged by your doctor prior to treatment. This estimate will help you to provide Informed Financial Consent (IFC) for your treatment.

AGC does not apply to pathology and radiology services, outside of hospital medical services and services not included in your policy.

How does AGC work?

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

1. No Gap

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

As an example, if you require a colonoscopy and removal of polyps in New South Wales and your surgeon chooses to participate in AGC and only charge you an amount equal to the AHSA AGC benefit, the surgeon's costs could 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)
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

Under AGC, a doctor can currently charge a maximum of $400 more than the AHSA AGC benefit (the amount paid by Medicare and HBF) per Medicare Benefits Schedule (MBS) item number or $800 for each obstetric service. You will be required 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 and radiology services). This is the "Known Gap".

If any of your doctors choose to participate in AGC and charge you a Known Gap, they must provide you with a written estimate of medical fees for the cost of the services they will provide. This estimate will allow you to provide IFC for your treatment.

As an example, if you require a colonoscopy and polyp removal in New South Wales and your surgeon chooses to participate in AGC and charge you a Known Gap, the surgeon's costs could 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)
32228 Colonoscopy $843.70 $443.70 $400
32229 Polyp removal $378.90 $178.90 $200
Your out-of-pocket expenses for your surgeon $600

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.

Changes to AGC on 1 July 2020

To help limit your out-of-pocket expenses and provide you with better financial certainty, the AHSA are making two key changes to AGC from 1 July 2020:

1. Known Gap

The new maximum amount that each doctor will be allowed to charge over the AHSA AGC benefit will be $500 per hospital episode, irrespective of how many MBS item numbers are included in your treatment.

This change does not apply to obstetricians, who will still be able to 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 an example, from 1 July 2020, if you require a colonoscopy and polyp removal in New South Wales and your surgeon chooses to participate in AGC and charge you a Known Gap, the costs could 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)
32228 Colonoscopy $743.70 $443.70 $500
32229 Polyp removal $378.90 $178.90
Your out-of-pocket expenses for your surgeon $500

The information provided in the table 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.

2. 'Other' fees

From 1 July 2020, when participating in AGC, your doctor is 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 outside of WA. You can find out which providers are registered for AGC using AHSA’s 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.

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

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).

You will need to 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 what out-of-pocket expenses you will need to pay.
Your doctor will 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. 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.
No, referrals do not need to be addressed to a specific doctor. This is a common misconception. The GP can let their patients choose a specialist by issuing an open referral letter. This gives you the freedom to consult with a specialist that participates in the AGC arrangement.

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.

Please discuss any discrepancies with your doctor.

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:

  • Access Gap Cover
  • Educational services and training
  • Integrated health management services
  • Negotiation of contracts
  • Protheses and claims support
  • Provider relations
  • The collection, dissemination and analysis of data.

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