What is medical gap cover?

What is ‘medical gap’?

An out of pocket cost is the 'gap' you pay for medical charges over what you get back from Medicare and GMHBA. Your doctor or specialist out of pocket costs can be capped if your medical provider is registered for, and bills through, Access Gap Cover.

If you have private hospital cover and are admitted to hospital for a procedure, your doctor can choose to bill more than the Federal Government scheduled fee. This can leave you with out of pocket costs that are not covered by Medicare or your health insurer.

What is Access Gap Cover?

Access Gap Cover is a billing system that provides higher benefits than the Federal Government’s set scheduled fee. It can reduce or even eliminate any out of pocket costs for medical provider fees when treated in hospital.

GMHBA pays higher medical benefits across a large number of procedures for you as an “in-patient” in hospital when your doctor or medical specialist is registered for, and uses, the Australian Health Service Alliance (AHSA) Access Gap Cover.

There are 2 scenarios for how you may be billed by your provider:

1 – No Gap – this is where there will be no out of pocket expense to you following the service performed

2 – Known Gap – this is where you will be charged a maximum of $400 out of pocket expense for each Medicare item number and $800 for obstetrics services

Search for Medical Specialists on the AHSA Agreement

Is your doctor registered for Access Gap Cover benefits?

If your doctor is registered for Access Gap Cover, your hospital out of pocket costs may be reduced or even eliminated. Before you go into hospital, you should discuss the cost of treatment with your doctor. Your doctor must advise of any out of pocket expenses that you will have to pay and provide a written estimate of the fees for treatment, before you go into hospital.

Search for Medical Specialists on the AHSA Agreement

It is your doctor’s choice to participate in Access Gap Cover on a patient by patient basis. If you choose a doctor that does not participate in Access Gap Cover, you will be covered for the scheduled fee, but you will need to pay the gap. The additional medical gap benefit will vary by eligible service.

Please contact GMHBA prior to treatment to determine your additional medical gap cover benefit.