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.

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.

Search for a contracted hospital

Our hospital contracts vary from time to time and you may have additional out-of-pocket costs for stays in non-contracted hospitals, so please check the below list of our contracted hospitals before each admission.

We also recommend you contact us to confirm your benefit entitlement prior to receiving hospital treatment.

Informed Financial Consent is your right to know what you’ll need to pay upfront before you receive any hospital treatment as a private patient, and to receive this information in writing. It’s important to ask your treating doctor, the hospital and us about any out-of-pocket expenses you may have to pay. 

Ask your treating doctor or specialist:

• How much is your fee?

• Do you participate in the Access Gap scheme under the Australian Health Service Alliance (AHSA)?

• If I have to pay a gap, how much will that be?

• What are my options if I can’t afford to pay this gap?

• Which other doctors and medical staff will be involved in my treatment, e.g. radiologist, anaesthetist, assistant?

• How can I get information about assisting doctors’ fees and Access Gap participation?

• Will I receive just one bill?

• If I am receiving a surgically implanted device or prosthesis, is it a Government approved device (covered by Union Health) or will I have to pay a gap?

• What are the MBS item numbers for this procedure? (see “Ask us” section below) 

Ask your hospital: 

• Does this hospital have any agreement with Union Health?

• Will I have to pay a gap for my hospital accommodation?

• What other out-of-pocket expenses apply during my time in hospital? 

Ask us:

• My doctor gave me these MBS item numbers for my procedure or service. Does my policy cover me for this?

• Under my policy, will I have to pay an excess or any other charges? If so, how much?

• Will I have to pay extra for my hospital accommodation, my doctor’s fees, and any assisting doctors’ fees, or is it all covered by my policy?

• If I have to pay extra, who do I pay, and when? 

Find out more about paying your hospital fees.

You may receive separate invoices from the hospital, each of your doctors, and each of the other medical practitioners, or some of these services may be grouped on a single invoice. 

Hospitals

Hospitals will usually charge us directly, and we’ll advise you when we’ve paid the invoice on your behalf. If your cover has an excess, you will need to pay it directly to the hospital before or on admission. 

Doctors

Doctors who participate in Access Gap Cover will usually send invoices directly to us, and we’ll pay them directly. If they send you the invoice instead, forward this on to us for payment. 

Other medical practitioners

Other medical practitioners will usually send you an invoice for payment, which you should submit with your claim to Medicare along with any payment receipts. There are two ways you can do this:

1. Submit your claim to Medicare. When you receive your Medicare Statement of Benefits, send it to us with your Union Health claim form and original accounts.

2. Submit your claim to Medicare along with a Medicare Two-way claim form, and they’ll forward your claim to us.

Contracted hospitals

We have contracts with an extensive network of private hospitals which enables us to pay agreed benefits for services included on your cover. Usually, this means you have nothing to pay for a hospital stay unless you have an excess on your cover or there are medical out-of-pocket expenses.

You can also choose treatment as a private patient in a public hospital. However, as we don't have agreed contracts with public hospitals, your treatment may cost you more. You can confirm the costs with the hospital prior to admission. Remember, you can be treated as a public patient in a public hospital at no charge, even if you have private health insurance.

Our hospital contracts vary from time to time and you may have additional out-of-pocket costs for stays in non-contracted hospitals, so please check our find a hospital list before each admission.