Access Gap

What is Access Gap?

Access Gap is a scheme to reduce your out-of-pocket expenses for specialist treatment in a hospital or day surgery (also called inpatient services).* First you need to ask your specialist if they participate. If they do, we pay them more than the Medicare Benefit Schedule fee – resulting in lower or no out-of-pocket expenses for you. 

To make it easier to find specialists with a track record of providing Access Gap services, we’ve added a new search available here

Important changes to Access Gap

Current rules:

  1. There is a maximum gap of $400 per Medicare item number (explained below).
    Pregnancy and birth have a maximum gap of up to $800 per doctor.


From 1 July 2020:

  1. To simplify things, we are changing the rule so that the maximum gap is $500 per doctor per hospital episode, potentially saving you money. The maximum gap for pregnancy and birth remains at $800 per doctor.
  2. We are strengthening the Access Gap rules to ensure that specialists who use Access Gap do not charge non-clinical fees, such as booking or admin fees or any other fees not associated with your hospital procedure. The changes make it clear that your specialist can’t charge these fees if they bill using Access Gap.

If you have pre-booked a hospital admission for after 1 July 2020, call us on 1800 027 299 and we can talk about our transitional arrangements.



What is a Medicare item number? 

A Medicare Item is one of a large listing of Medicare services subsidised by the Australian government. This list is called the Medicare Benefits Schedule.

The MBS is the list of fees set by the government for medical services. Whether you have Private Health Insurance or are a private patient paying for all your own costs, the government provides a rebate on nearly all medical fees.

Your surgeon, anaesthetist and assistant surgeon can each bill their own Medicare items for a hospital stay, for instance. Together these MBS items provide a detailed hospital bill. Before any hospital admission using your health cover, it is a good idea to get an itemised quote, called Informed Financial Consent.

What is an episode?

A period of inpatient care in a hospital (from admission to discharge date), which is determined by the hospital treatment you need.

E.g. If you need surgery, you are a surgical inpatient. This starts your episode of care. If this care changes, such as for rehabilitation, a new episode of care will begin. 

Your doctor or treating team in hospital will let you know any changes to your care.

What are non-clinical fees?

Non-clinical fees are any charges that are not directly associated with your medical care. They could include, 

  • Booking fees
  • Management fees
  • Technology fees
  • Administration fees
  • Insurance levy fees
  • Hospital facility fees

From 1 July 2020, if your medical provider chooses to use Access Gap, they will bill the health fund directly and they must not charge you any non-clinical fees.