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Access Gap Cover: What you need to know

13 April, 2015
Access Gap Cover

You may have heard of our ‘Access Gap Cover’, but you may not be sure what exactly it means. Here we take a look at what Access Gap Cover really is, why you should have it, and how to acquire it:

What is ‘Access Gap Cover’?

Access Gap Cover (AGC) is a special gap cover scheme that allows admitted private patients to reduce or eliminate out-of-pocket expenses associated with medical procedures and the doctor’s fees. It’s an AHSA Member Fund arrangement that was approved by the Health Minister under the Health Legislation Amendment Act 2000.

The term ‘medical gap’ describes the amount above the Medicare Benefits Schedule Fee that some doctors charge for medical services traditionally not covered by health funds. These include medical procedures undertaken at a day surgery or hospital.

Without Access Gap Cover, you should expect to contribute to your medical costs.

Not all doctors take part in the Access Gap Cover scheme, and many who do choose to take part don't list it on their website or information. Therefore, always ask your doctor if they participate in AGC before you have any treatment. You should also ask if there are any additional costs over and above what’s covered. 

It is up to each individual doctor to decide whether or not they will use a fund’s gap cover arrangement, and most doctors decide on a case-by-case basis.

Using CBHS’ Access Gap Search, you can determine which doctors participate in Access Gap Cover, as well as those who have agreed to alternative ‘no gap’ arrangements. Remember, however, that there is no guarantee a doctor will accept AGC in regards to your particular case. This decision remains solely with the doctor.

If your chosen doctor does not appear in this search, ask your doctor if AGC is a possible option for you and whether or not they’d consider it. More than 30,000 doctors have already chosen to participate in the scheme, and many more are joining each year.

Doctors who do use the scheme (including anaesthetists, surgeons and pathologists) will usually bill CBHS directly.

How it works

Medical services provided to private hospital in-patients are charged separately from hospital accommodation/theatre fee charges. Medicare pays 75% of the Medicare Schedule Fee, while your health fund pays the remaining 25%.

Some doctors charge an amount above the Medicare Schedule Fee. These costs are referred to as ‘out-of-pocket expenses’. Now through the Access Gap Cover payment and billing scheme, out-of-pocket expenses can be reduced and, in some cases, wiped out entirely.

When a doctor treats a patient under the AGC scheme, they will generally process the claim on the member’s behalf. This includes taking care of the applicable Medicare benefits. As a member, you will be able to receive an estimate of the medical fees BEFORE receiving any treatment. You should always ask for a written estimate.

The benefits of Access Gap Cover for members


By asking your doctor, specialist and/or anaesthetist to participate in access gap cover, you can potentially eliminate all costs associated with your hospital or day surgery visit. Or if not eliminate, you can most certainly reduce the associated costs.

The main advantages of choosing Access Gap Cover include:

  • You will receive an estimate of fees prior to treatment;
  • Doctors can claim directly on your behalf (inclusive of Medicare benefits);
  • No more Medicare queues;
  • Peace of mind; and
  • Value for money – you get even more from your private health cover.

Main advantages for doctors:

  • Improved cash flow;
  • Claims will be paid within 21 days;
  • Reduced risk of bad patient debt; and
  • No contract, as Access Gap is an ‘opt in’ or ‘opt out’ arrangement.

How to get Access Gap Cover

Talk to us about Access Gap Cover. All hospital arrangements include Access Gap Cover automatically, meaning there are no extra costs. Access Gap Cover gives your private health cover more bang for your buck, and makes the process of claiming even easier.

Ask about Access Gap Cover today, talk to your doctor, or search for participating doctors in your area through the CBHS Member Fund website today. 

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