Information about changes to Access Gap Cover

GMHBA has an arrangement with the Australian Health Service Alliance to give GMHBA members access to Access Gap Cover, a billing system that can reduce or even eliminate any gap for medical fees when treated as an inpatient in hospital.

The Access Gap Cover medical gap rule is changing from 1 July 2020. The changes are aimed at making things simpler for members and reducing potential out of pocket costs for hospital treatments when multiple Medicare item numbers are used.

What’s changing?

Currently, with the Access Gap Cover Scheme, patients could pay an out of pocket cost of up to $400 for each Medicare item number a specialist uses for the hospital treatment they provide. 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 applicable under the Access Gap Cover scheme is $500 per specialist, per admission to hospital.

These changes will apply to all GMHBA members who hold hospital cover.

Frequently asked questions

In Australia, certain medical services provided by doctors have a Medicare Benefits Schedule (MBS) fee, set by the Government. This is called the ‘scheduled fee’.

For medical services provided by a specialist while you are admitted as an inpatient in hospital, Medicare pays 75% of the scheduled 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 scheduled fee, you will need to pay the difference. This is called a ‘medical gap’ or an out of pocket cost.

GMHBA has an arrangement with the Australian Health Service Alliance to give GMHBA members access to Access Gap Cover.

Access Gap Cover is a billing system that provides higher benefits than the Government’s scheduled 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, the Access Gap Cover scheme get a higher fee from GMHBA (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. 

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.

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 the Access Gap Cover scheme. 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 prosthesis.


Access Gap Cover changes – example table

Below is an example of how the current benefit structure works, compared to how it will work from 1 July 2020 for treatment in hospital for a broken hip by an orthopaedic surgeon who chooses to participate in Access Gap Cover.

Broken hip example – current Access Gap Cover benefit structure

Broken hip Medicare item numbers

Specialist fees

Total benefit (including Medicare and GMHBA Benefit)

Out of pocket

48200

$1,460.80

$1,060.80

$400.00

48424

$802.70

$602.70

$200.00

47729

$183.00

$83.00

$100.00

Total

$2,446.50

$1,746.50

$700.00

Broken hip example – Access Gap Cover benefit structure from 1 July 2020

Broken hip Medicare item numbers

Specialist fees

Total benefit (including Medicare and GMHBA Benefit)

Out of pocket

48200

$1,260.80

$1,060.80

$500

48424

$802.70

$602.70

47729

$183.00

$83.00

Total

$2,246.50

$1,746.50

$500


The information provided in the table above is for example purposes only. You may still have out of pocket costs for other services, including for your anaesthetist and/or assistant surgeon.