Access Gap Cover

What is Access Gap Cover and what are the changes?

Access Gap Cover is a program that can help you to reduce or eliminate your out-of-pocket costs by making certain arrangements with your doctors before you go into hospital. As of 1 July, there will be some changes.

What is an out-of-pocket cost?
In Australia, certain medical services provided by doctors have a Medicare Benefits Schedule (MBS) fee, set by the Government. This is called the ‘schedule fee’.

For medical services provided by a specialist while you are admitted as an inpatient in hospital, Medicare pays 75% of the schedule fee and your health insurer pays the remaining 25%.

Specialists can charge whatever fee they deem appropriate for their services. If this fee is more than 100% of the schedule fee, you will need to pay the difference. This is called a ‘medical gap’ or an out-of-pocket cost.

What is Access Gap Cover?
Transport Health has an arrangement with the Australian Health Service Alliance to give our members access to Access Gap Cover.

Access Gap Cover is a billing system that provides higher benefits than the Medicare Benefits Schedule fee. It can reduce or even eliminate any gap for medical fees when treated as an inpatient in hospital.

Specialist doctors who are registered for, and use, Access Gap Cover get a higher fee from Transport Health (more than the standard 25%), in exchange for limiting the out-of-pocket cost they charge to you.

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

If you would like to read more about Access Gap Cover, click here.

Do all medical specialists participate in Access Gap Cover?
Each individual specialist can choose if they will participate in Access Gap Cover on a case by case basis, so we recommend talking to your specialist about potential out-of-pocket costs before going into hospital.

What should I ask my specialist before going into hospital?
Before deciding to have a procedure, you should discuss the cost of treatment with your specialist doctor. Your specialist must advise of any gap that you will have to pay and provide a written estimate of the fees for treatment, before you go into hospital.

You may also receive services from an assistant surgeon and anaesthetist for your procedure – they can also choose whether or not to participate in Access Gap Cover. You may have separate gaps to pay for their services.

Even if your specialist participates in Access Gap Cover, other out-of-pocket costs may arise for your in-hospital procedure such as costs associated with your hospital accommodation and any prostheses.

Finding a specialist who participates in Access Gap Cover is made easier as Transport Health has teamed up with HealthShare, a leading health technology company, to enable you to see if specialists charge out-of-pocket costs. Click here to access HealthShare.

Recent changes to Access Gap Cover - What has changed?

Access Gap Cover medical gap rule changes

The Access Gap Cover medical gap rule is changing from 1 July 2020.

Previously, with Access Gap Cover, you could pay an out-of-pocket cost of up to $400 for each Medicare item number your specialist uses for the treatment they provide while you’re in hospital. There may be multiple Medicare item numbers used during a procedure, depending on what the treatment is.

From 1 July 2020, the maximum out-of-pocket cost you will pay under Access Gap Cover is $500 per specialist, per admission to hospital.

The aim of this is to make things simpler for members and reduce potential out-of-pocket costs for hospital treatments when multiple Medicare item numbers are used.

The rules for obstetricians are separate from the above and will not be changing.

In line with the Access Gap Cover rules, obstetricians can charge patients an out-of-pocket fee of up to $800 for obstetrics services that relate to the management of labour and delivery.

Booking or administrative fees rule changes
The terms and conditions of Access Gap Cover are also being strengthened from 1 July 2020 to ensure specialists who use the scheme can’t charge you additional non-clinical fees such as ‘booking’ or ‘administrative’ fees.

Remember to always contact Transport Health if you are charged these types of fees by your specialist.

Transport Health Pty Ltd ABN 39 099 028 127 is a registered Health Benefits organisation.