Access Gap and out-of-pocket expenses
What is Access Gap Cover?
Access Gap Cover is designed to reduce the medical costs you need to pay for treatment when you're admitted into hospital. Medical costs are the fees your specialist or doctor charges you for your hospital treatment (as opposed to hospital costs such as accommodation and theatre fees).
Access Gap Cover is included with each of our private hospital covers and can also simplify your claims, as most Access Gap doctors send the bill straight to us, and we handle Medicare claims on your behalf.
How Access Gap Cover works
We pay more, so you pay less.
Each time you enter hospital you may have multiple medical providers involved in your care. Each medical provider will classify their interactions with you in terms of Medicare item numbers on the Medicare Benefits Schedule (MBS).
When you’re admitted to hospital as a member of our health fund, Medicare pays 75% of the MBS fee for eligible inpatient services, and we pay the remaining 25%. If your doctor charges more than the MBS schedule fee, you will be out-of-pocket for this additional amount unless billed under Access Gap Cover.
Under Access Gap Cover your doctor agrees to only charge up to a certain fee. We then pay a higher amount than we normally would, so you pay lower, or no out-of-pocket costs.
If your doctor uses our scheme, you won't pay more than $500 per doctor, per episode of care (regardless of the number or type of Medicare item numbers applicable). This excludes obstetricians who can charge up to $800 per confinement for management of labour and delivery.
"Episode" is a term that is used to describe a type of hospital care and you may have more than one "episode" during your admission - for example, if you are transitioned from acute care to rehabilitation before you are discharged.
Prior to treatment, you can request a written estimate of costs from your doctor, so you understand how much you will be out of pocket (if at all). See Hospital treatment costs.
Ask your doctor:
Will you treat me under Union Health’s Access Gap Cover?
Can you give me a written estimate of any personal out-of-pocket expenses I might incur?
Will assisting doctors also use Access Gap Cover?
Will you send the bill directly to my fund so they can manage my Medicare claim for me?
For more information please refer to the Ombudsman’s brochure ‘Doctor’s Bills’ which you can download from ombudsman.gov.au.
Find a specialist
Use the search below to find out if your specialist has participated in the Access Gap Scheme.
