Access Gap Cover Scheme

Access gap cover scheme and Medicare

John Connor avatar
Written by John Connor
Updated over a week ago

What is the Access Gap Cover Scheme?

Access Gap Cover is a legislative scheme that helps to reduce or eliminate potential out-of-pocket costs that your Doctors may charge, in excess of what Medicare and we are allowed to pay towards your hospital treatment.

How does Access Gap Cover work?

For all medical and hospital procedures done whilst you are admitted into hospital, Medicare sets out a schedule of benefits for each item number, called the Medicare Benefits Schedule (MBS) fee.

Between Medicare and our health partner, Phoenix Health, when you are admitted to hospital, 100% of the Medicare Benefits Schedule fee will be covered.

There are no rules though that say that Doctors have to charge exactly the fee that Medicare have set out, and often Doctors will elect to charge a fee in excess of the MBS. Where a Doctor chooses to charge more than the MBS fee, it becomes your responsibility, as the Member, to pay the gap between what Medicare and our health partner, Phoenix Health can pay and what the Doctor is charging.

What does this mean for me?

Enter the Access Gap Cover Scheme. Where a Doctor chooses to participate in the Access Gap Cover Scheme for your admission, you can be sure that your Doctor will either not charge you any out of pocket gap, or the maximum gap they are able to charge will be $500*.

Will my Doctor participate?

The Access Gap Cover Scheme is open to all Doctors who perform inpatient hospital procedures; however, it is up to your Doctor whether or not they will participate for your admission. Doctors decisions on whether they will participate are considered on a case by case and patient by patient basis.

What questions should I ask my Doctor?

To help you plan your upcoming procedure, when you see your Doctor, here’s some important questions to ask them:

  1. Will you participate in the Phoenix Health Access Gap Cover Scheme?

  2. Will I have any out-of-pocket expenses, and if so, please provide a written estimate of the breakdown of how much of a gap I can expect to pay?

  3. Will any assisting Doctors also use Access Gap Cover and how can I obtain a quote for their services?

What if my Doctor won’t participate in Access Gap?

If your Doctor chooses not to participate and treat you as a Phoenix Health Access Gap Cover patient for your procedure, it is important you understand what your costs will be. We recommend that before you are admitted to Hospital (where possible), you ask your doctor to explain the costs of your hospital admission including any prostheses gap amounts, their own fees, any fees that other doctors involved in the admission such as assistant surgeons and anaesthetists might charge, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate. This is known as ‘informed financial consent’.

Who treats you is entirely your decision, and in the event that you don’t feel comfortable with the costs quoted to you, you can get a second opinion. Do some research and call another Specialist’s rooms with the Medicare Item Numbers for your procedure and see if they can give you an idea of what their fees would be, so you can compare. You can even speak with your GP about your concerns and the possibility of getting a referral to a different Specialist.

How can I find a Doctor that will participate in Access Gap for my admission?

Check out our Provider Search to generate a list of Doctors for the specialty you are after, who have previously participated in the Access Gap Cover Scheme. It is entirely up to the Doctor on a case by case basis if they will participate in Access Gap for your procedure, so it’s important that you ask the questions we have recommended above, so that you are fully prepared for your admission.

We’re here to help you

Going to Hospital? This is what we know and where we can really help you out. As soon as you find out you’ll need a hospital admission contact us so you can be confident in what to expect. We’ll talk you through minimising doctor’s fees and any other out-of-pocket costs as well as check your cover and discuss any pre or post-hospital support programs that we may have available for you.

Let us help you, so you can focus on what’s important; we’re here for you.

*Effective 1 July 2020, the maximum gap a participating Doctor will be able to charge is $500. It is each Doctor’s choice to participate in the Access Gap Cover Scheme.

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