Access Gap Cover: What you need to know

What is Access Gap Cover?

Access Gap Cover (AGC) is a way to reduce your out-of-pocket expenses for medical services in hospital. Out-of-pocket expenses or the ‘gap’ is the amount you pay for medical or hospital charges, over and above what you get back from Medicare and your private health insurer. Without AGC, you’ll need to pay some of your medical costs for procedures at day surgery or hospital.

AGC is the Australian Health Service Alliance (AHSA) Member Fund gap cover arrangement.

How it works

If you’re an in-patient in a hospital as a private patient, your medical services will be charged separately from hospital accommodation and theatre fees. Medicare pays 75% of the Medicare Schedule Fee and your private health fund pays the remaining 25%. The Medicare Schedule Fee is set by the Department of Health Australia.

Some doctors charge an amount above the Medicare Schedule Fee. This amount is known as out-of-pocket expenses or the gap amount. With AGC, you can reduce this gap amount or not have to pay at all.

If a doctor treats you under the AGC Scheme, they’ll usually process the claim for you. This includes any Medicare benefit claims. We will be unable to reimburse you the AGC benefits if you pay the accounts yourself.

How can you find a doctor who participates in Access Gap Cover?

Not all doctors take part in the AGC scheme, and those that do may not list it on their website. Each doctor can decide on a case-by-case basis.

You can try our  Access Gap Search to find a doctor that generally participates or who has agreed to alternative ‘no gap’ arrangements. You’ll still need to ask the doctor if they’ll treat you under CBHS Access Gap Cover arrangement.

Your doctor may have never used AGC before but may still consider it if you ask them.  

Questions to ask your doctor

• Will you treat me under CBHS Access Gap Cover arrangement?
• Will I need to pay any out-of-pocket expenses for my treatment? If so, can you give me a written
  estimate of how much I’ll need to pay?
• Will any of the doctors assisting with my treatment also participate in Access Gap Cover?
• Will you send the bill to CBHS directly so that they can claim my Medicare Benefit on my behalf?

Doctors who do use the scheme will usually bill CBHS directly. This includes anaesthetists, surgeons and pathologists.

How to get Access Gap Cover

If you have any questions about Access Gap Cover, you can find out more on our website or email CBHS Member Care at help@cbhs.com.au

Sources

https://www.ahsa.com.au/web/doctors/agc

https://www.privatehealth.gov.au/health_insurance/howitworks/out_of_pocket.htm

All information contained in this article is intended for general information purposes only. The information provided should not be relied upon as medical advice and does not supersede or replace a consultation with a suitably qualified health care professional.