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Access Gap Cover Scheme
Sometimes, you may face extra expense if your specialist or doctor charges above the Medicare Benefits Schedule (MBS) fee for their services. The Access Gap Cover scheme helps remove or reduce these costs so that you pay less for your specialist treatment in hospital, or pay nothing at all.
- If your doctor participates in the Scheme
- If your doctor declines to participate
- Need a hand with Doctor's bills?
- Search for your doctor
If your doctor participates in the Scheme
- Ask your doctor to fill in an ‘Estimate of Medical Fees’ form so that you
can see exactly how much you’ll have to pay before your treatment begins.
You can download an Estimate
of Medical Fees form here or call us on 134 246 for more information.
This estimate enables you to make a fully informed decision about the cost of your treatment prior to giving consent to your doctor. This is called ‘Informed Financial Consent’.
- We’ll pay up to the Access Gap Cover schedule fee.
- Doctors usually send the bills directly to us and we send you a statement detailing how much we’ve paid. Some doctors may bill you direct.
How it works
| Medical Benefits Schedule Fee | Above MBS fee | Above Access Gap Cover Schedule fee | |
| Medicare pays 75% | Your Health Fund pays 25% | Your Health fund pays up to the agreed Access Gap Cover schedule fee | Patient pays the balance |
Important to know
To ensure the Access Gap Cover Scheme maintains some control over costs, a cap of $400 per item above the Access Gap Cover fee has been put into place.If you’re quoted a charge in excess of this amount then the Access Gap Cover scheme can’t be used. This means you’ll have to pay the amount between the MBS fee and the doctor’s charge.
Obstetricians may charge a gap of up to $800 for prenatal care and delivery.
If your doctor(s) decline to participate in the Scheme
- Make sure you give your doctor the ‘Estimate of Medical Fees’ form and ask for ‘Informed Financial Consent’.
- We’ll only be able to pay up to the MBS Fee set by the government.
- You’ll have to pay the amount above the MBS Fee.
- Doctors involved in your treatment will each bill you separately.
| Medical Benefits Schedule Fee | Above MBS fee | |
| Medicare pays 75% | Your Health Fund pays 25% | Patient pays |
Outpatient Services
Medicare will only cover 85% of the MBS fee when you receive medical services outside hospital, such as visits in a specialist’s room, or in an accident and emergency room, or as a on-admitted patient in a hospital.
Health insurance benefits don’t apply to outpatient medical services when Medicare pays 85% of the benefit and where the service provider doesn’t have an agreement with ahm.
Need a hand with doctor's bills?
If your doctor participates in the Access Gap Cover Scheme they will send the bills directly to the fund. We will send you a statement detailing how much has been paid. Some doctors will also bill you directly.
If your doctor does not participate in the Scheme you will be sent a separate bill from each doctor and practitioner involved in your treatment. If this occurs you will need to contact us for a "Two Way Claim Form". This form will enable us to co-ordinate payment of your medical bills with Medicare at Medicare Offices. Just call 134 246.