Medical gap cover

Find a medical specialist

Contact GMHBA for assistance to find a specialist who has registered with us indicating that they may be willing to use Access Gap Cover. It is at the doctor's discretion whether they actually use it. If your doctor does not appear on this list that does not necessarily mean they will not use Access Gap Cover. Always ask your doctor to outline their fees and charges.

Ask for informed financial consent

Once you have chosen your specialist, ensure they supply you with an informed financial consent document. This document provides you with an estimate of fees for the proposed treatment and should indicate the medical gap or out-of-pocket expenses.

Please contact GMHBA prior to your treatment to discuss any medical gap that may apply for your procedure.

What is a medical gap?

In Australia, 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 doctor 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 are free to 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’ and is sometimes also called an out of pocket cost.

What is Access Gap Cover?

The Australian Health Service Alliance (AHSA) Access Gap Cover scheme 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 gap they charge to you.

There are two scenarios for how you may be billed by your specialist doctor when they use the Access Gap Cover scheme:

  • No Gap – this is where there will be no gap for you to pay following the procedure
  • Known Gap – this is where you will be charged a maximum gap of $500 per specialist, per admission to hospital or a maximum of $800 for obstetrics services.

Is your doctor registered for Access Gap Cover benefits?

If your specialist doctor is registered for Access Gap Cover, the gap may be reduced or eliminated for medical services they provide while you are an inpatient in hospital.

Specialists are free to choose to opt in or out of the Access Gap Cover scheme on a patient by patient and procedure by procedure basis – just because they are registered for the scheme doesn’t mean they always use it. If you choose a doctor that does not participate in the Access Gap Cover scheme for your procedure, you will be covered by Medicare and GMHBA for the scheduled fee, but will need to pay any gap.

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.