Access Gap Cover... what you need to know! When you are admitted into hospital, your accommodation, doctor, surgeon and anaesthetist costs are all charged separately. These medical expenses are assessed against the Medicare Benefits Schedule (MBS), which is a fee set by the government that they determine to be reasonable for the medical service you’re receiving. When you have private health insurance with Queensland Country Health Fund, you’re guaranteed to be covered for the MBS fee – Medicare covers 75% of the MBS
the new maximum gap allowed
the agreed Access Gap Benefit
for Access Gap Cover will be up
amount, you’ll have out-of-pocket
to $500 per doctor per medical
expenses to pay. Some doctors
episode, except for obstetrics
don’t participate in the Access
which remains unchanged at $800.
Gap Scheme at all while some
We expect a very low impact
participate on a patient-by-patient
regarding any changes to gaps
basis. In the instance your doctor
and hope that it will encourage
doesn’t participate, we’ll only be
increased compliance by doctors
able to cover the 25% between the
to charge the correct gap. This
Medicare rebate and MBS fee.
will mean less or no out-of-pocket
Be prepared, plan ahead
expenses for you.
to treatment, we recommend
Change to the rule regarding booking or administrative fees
contacting your treating doctor
The Access Gap Cover Terms and
to find out if they will participate
Conditions have been strengthened
in the Access Gap Scheme and
to ensure that doctors who use
discuss all fees up front.
Access Gap Cover do not charge
To make sure you are aware of all fees to be charged prior
additional fees, such as ‘Booking
fee and we cover the remaining
We want you to be fully prepared
25%. Some doctors however,
and aware of any out-of-pocket
charge more than the MBS fee.
expenses before you go to
Queensland Country try and make
hospital. If your treating doctor
treatment more affordable by
doesn’t participate in the Access
The current Access Gap Cover rules
offering Access Gap Cover where
Gap Scheme, or won’t agree to
state that doctors can’t charge
your doctor participates in what’s
participate for your treatment,
‘Other Fees’, however it does not
called the Access Gap Scheme.
you can find doctors who may
and Administrative Fees’ or any other fees not associated with the Medicare item number.
state that if they do, they will not be
participate by visiting the ASHA
paid the Access Gap Cover benefit.
website.
Effective 1 July 2020, a new term will make it clear that these additional
some doctors charge more than
Change to the Access Gap Cover patient gap rule
the MBS fee, we offer Access
Access Gap Cover has always had a limit on the maximum gap that
Gap Cover for you.
Gap Cover to make treatment more affordable for you. If your
a specialist can charge you, this
doctor participates in the Access
can be complicated to understand.
Gap Scheme, there is an agreed
Prior to 1 July 2020, depending on
maximum amount we’ll pay up to
your procedure, the gap could have
for your doctor’s services, this is
been any amount up to $400 for
known as the Access Gap Benefit.
one Medicare item number, or $800
What is Access Gap Cover? Access Gap Cover is a big feature of our hospital cover. Because
Your doctor may choose to accept this amount as full payment for your treatment which means no out-of-pocket expenses for you. Alternatively, they may choose to
10
If your doctor’s fee is higher than
for obstetrics. Where you may have had a combination of procedures or item numbers billed by your specialist during a single episode*, the cost would have been much higher.
charge an allowable known gap
To simplify things, the rule has been
(limits apply) under the Scheme.
changed. Effective 1 July 2020,
Queensland Country Health Fund • Living Healthy Winter / Spring 2020
fees cannot be charged to you if the doctor chooses to use Access Remember to always contact Queensland Country Health Fund if you are charged these types of additional fees. Our team are here to help and we also encourage our Members to make contact with us prior to going into hospital for treatment. *Definition of episode: The period of admitted patient care between a formal or statistical admission and a formal or statistical separation, characterised by only one care type. Example: If a patient changes care type (in the same or different hospital), e.g. Acute to Rehabilitation then back to Acute this would be three separate episodes. This would apply even if there has not been more than a seven-day break between two acute episodes as there was a separation between each care type.
