What is Access Gap Cover?
Access Gap Cover is a medical gap cover arrangement designed to minimise or eliminate out-of-pocket ('gap') expenses for medical procedures conducted in approved day or overnight facilities.
Doctors can choose whether to participate in Access Gap Cover on a patient-by-patient basis.
How does it work?
Doctors who choose to participate in Access Gap Cover for your hospital admission will tell you in advance what the cost of service will be and, if applicable, detail any payment you will need to make to cover the difference between the Access Gap Cover benefit and their fee.
They then bill CBHS directly and we settle the claim on your behalf. We even take care of the Medicare claim for you.
Your doctor may elect to send the Access Gap Cover account to you. If they do so, they will include instructions on the account to send it directly to CBHS. In this instance, it is very important that you send the account directly to CBHS and not claim from Medicare first.
Ask your Doctor
If you are unsure whether your doctor will participate in the Access Gap Cover arrangement, please ask them whether they are willing to do so. If they are unaware of Access Gap Cover, advise your doctor that CBHS provides cover for medical gap and that you wish to access this cover. A list of questions to ask your doctor is available.
Please note: Access Gap Cover is a billing arrangement for use by doctors in licensed hospital and day surgery facilities. Services provided by doctors whist you are not an inpatient in hospital are not eligible to be billed under Access Gap Cover.
Why would my doctor participate?
We are hopeful that most specialist medical providers will embrace Access Gap Cover. Consider the advantages:
- Specialists are not required to sign a contract with CBHS. They can opt in or out of the scheme at will.
- Your treatment remains an issue between you and your doctor.
- The Access Gap Cover benefit will usually be far higher than the Schedule fee and it will be reviewed yearly.
- Special claim processing arrangements speed the payment directly back to your specialist's bank account.
- Reduces bad debts for doctors.
- Doctors do not have to deal with Medicare - CBHS claims the Medicare benefit for the patient as well as dealing with any claiming issues.
What does it mean for me?
Access Gap Cover benefit levels are substantially higher than under the previous arrangements. In many cases this means that CBHS can cover the entire doctor's charge. If not, you will have a significantly reduced out-of-pocket expense.
If your doctor charges you an out-of-pocket he or she should inform you in writing in advance of treatment or as soon as practicable in cases of emergency. Contrast this to the present situation where substantial costs can come as a surprise at the end of the treatment.
Claims processing is also easier - in most instances, your specialist will bill CBHS directly and we will take care of the Medicare claim on your behalf.
How will I know if my doctor will participate?
Doctors can choose whether to participate in Access Gap Cover on a patient-by-patient basis. It's important that you ask your doctor whether they will participate in your case.
How can I encourage my doctor to participate?
Participation in Access Gap Cover is open to all doctors who perform in-patient services. It is best to consult your doctor to ask if they are willing to participate in your case.
Download and print the information card, [link] and hand it to your doctor at your appointment. It provides your doctor with details about Access Gap Cover, including how to participate.
All specialists can choose to use Access Gap Cover to bill CBHS for in-patient medical treatment. You can ask your specialist to recommend that any assisting specialists, such as anaesthetists, use Access Gap Cover for the billing of their services too.
Is there a list of participating doctors?
As Access Gap Cover is open to all doctors, we prefer you to talk to your doctor to see if they will participate in your case. Your doctor may be happy to participate, but not to be listed on our website. However, you can search for registered participating doctors who have agreed to be listed by clicking here. [link]
Please note that these lists are subject to change and are updated regularly.
There are a number of things to be aware of when searching for Access Gap Cover doctors.
- Even if the doctor is on the list they may choose not to use Access Gap Cover in your case
- There would be doctors who are willing to participate in Access Gap Cover but have not participated to date; therefore their name would not be on the list.
- The list will be out of date very quickly as new doctors are added all the time.
- The list is not complete - if doctors ask not to be included we honour that request.
- The choice of the right specialist for you is a matter for you and your GP.
How will I know if my doctor used the scheme?
Your doctor will either send the account directly to CBHS or advise you to forward the account straight to CBHS rather than sending it to Medicare. CBHS will send you a statement outlining all the benefits that have been paid on your behalf including the Medicare portion.
Will I have any out-of-pocket medical expenses?
This will depend on how much your doctor charges for their services. Doctors are free to charge their private patients any fee they consider appropriate. However, because Access Gap Cover specialist medical benefits are higher than the Medicare Benefit Schedule Fee, we anticipate that many specialists who participate will accept the higher Access Gap Cover benefit as full payment.
If your doctor charges more than the Access Gap Cover schedule, you simply pay the difference between the benefits and the doctor's charge. These gaps may be up to a maximum defined amount per item, but should be considerably less than the gaps experienced for non-Access Gap Cover services.
Obstetricians may charge a co-payment of up to $800 per confinement for Management of Labour and Delivery (items are defined in the Medicare Benefits Schedule).
If you have not served waiting periods, or your condition is pre-existing, Access Gap Cover benefits may not be payable. If considering treatment, and you have joined CBHS or upgraded your cover in the past 12 months, please contact us to confirm your eligibility for benefits.
What if my doctor won't treat me with Access Gap Cover?
An enormous number of doctors throughout Australia have been contacted and invited to provide their services to their patients using Access Gap Cover, however there are doctors not willing to do so.
If your doctor chooses not to treat you as a CBHS Access Gap Cover patient, your doctor will raise a fee for the service provided and the claims process will be as normal. We recommend that you discuss the charge with your doctor, before you are admitted to hospital if possible, and request full disclosure of out-of-pocket expenses you may be asked to pay.
Your ability to afford the procedures should be discussed with your specialist and in the event of a decision to seek an alternate specialist, ask your GP.