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.

 

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.

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. 

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. 

 

Carefully choose your specialist

Specialists can choose to be part of our Access Gap scheme on an individual basis, so make sure you find out where they stand on this!

Ask your specialists about fees

If you ask your specialist about their procedure fees before you’re treated, they will be more than happy to break down the costs – including how much is covered by Medicare and insurance. In fact, they’re obligated to reveal these costs to you. It’s called Informed Financial Consent.

Make sure you also ask if other specialists will be involved with your treatment, and if you’re expected to pay for their services.

Be sure to directly ask whether any of your treatment will result in out-of-pocket expenses for you: Do they participate in Access Gap? Is it no gap or known gap arrangement? How much is it? What other costs are involved? You have a right to know. 

No gap

If your chosen specialist chooses to bill you with no gap, fantastic! Then we’ve got you sorted, and you’re free from paying a medical gap for their service.

Known gap - with Access Gap

If your chosen specialist bills with a known gap through Access Gap, your out-of-pocket expenses will be capped and you won’t get any surprises other than what you’ve agreed to in your Informed Financial Consent before treatment.^

Known gap - without Access Gap

If your specialist decides to opt out of the known-gap with RBHS’s Access Gap in your individual case, there’s no limit to what your out-of-pocket expenses might be. That can be a pricey experience and might be worth avoiding if possible!

You can find a list of specialists registered for RBHS’s Access Gap scheme here.

 

* Consultations, for instance, are only claimable through Medicare. Procedures (also called treatment, operation, surgery) may be claimed from a health fund.

^There may still be unexpected out-of-pocket expenses if you suffer complications or require additional surgery.