The Access Gap Cover Scheme
For in-patient hospital treatment, Medicare will pay 75% of the MBS, and Westfund will pay up to 25% of the MBS. If you are treated by a doctor who charges above the MBS this will create an expense not covered by either Medicare or Westfund unless the doctor agrees to participate in the Access Gap Cover Scheme. Please note that radiology and pathology services are considered to be Doctors' Charges.
The Access Gap Cover Scheme allows patients with hospital cover to eliminate or reduce out-of-pocket expenses for medical gap payments for in-patient hospital treatments. Westfund does not pay an amount charged by your doctor above the Medicare Benefits Schedule Fee unless your doctor agrees to participate in the Access Gap Cover Scheme. If a doctor does not use the Access Gap Cover Scheme, you will be responsible for any additional charges.
Doctors are independent of Westfund and each doctor can choose on a case by case basis whether to participate in the Access Gap Cover Scheme. Please note that you should ask your doctor to explain the costs of your hospital admission including any prostheses gap amount, their own fees, any fees that other doctors involved in the admission such as assistant surgeons and anaesthetists might charge, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate. This is known as 'informed financial consent'.
The Access Gap Advantage
Financial Certainty due to IFC
If your doctor charges you an out-of-pocket (gap) he or she should inform you in writing in advance of the treatment or as soon as practicable in cases of emergency. Under Access Gap Cover, you will receive a written quote or an estimate of medical fees from your doctor if there will be a gap.
No claiming from Medicare and the Health Fund in most cases
In most cases, the doctor will bill Westfund directly and we settle the claim on your behalf. We even take care of the Medicare claim for you. Westfund will also send you a statement outlining all the benefits that have been paid on your behalf including the Medicare portion.
Doctor Search Facility
You can find a Doctor Search on this web site where you can search Doctor’s by name, specialty and/or area. This search facility is designed to inform you of doctors who have previously participated or have indicated their intention to participate in Access Gap Cover, as well as those who have agreed to alternative no gap arrangements. Patients are advised to be guided by the referral process initiated by their own doctor. Where you have been referred to a doctor and that doctor's name does not appear on this search facility, you should check with your doctor as to whether they would use Access Gap Cover for you.
Doctor Patient Relationship
Westfund will not interfere in the autonomous relationship between you and your doctor.
Frequently Asked Questions:
How will I know if my doctor will participate?
Doctors can choose whether to participate in Access Gap Cover on a patient-by-patient basis. It's important that you ask your doctor whether they will participate in Access Gap Cover for you.
Ask these 4 questions:
- Will you treat me under Access Gap Cover?
- Will I have any out-of-pocket expenses, and if so, can you provide a written estimate of how much?
- Will any assisting doctors also use Access Gap Cover and if so, how can I obtain a quote for their services?
- Are you prepared to send the bill to Westfund directly?
How can I encourage my doctor to participate?
Participation in Access Gap Cover is open to all doctors who perform inpatient services. It is best to consult your doctor to ask if he/she is willing to participate in your case.
You can download and print the Access Gap brochure to hand to your doctor at your appointment. It provides your doctor with details about Access Gap Cover, including how to participate. Westfund can also post you a hard-copy of this brochure - just contact us on 1300 552 132 and quote your membership number and address.
All specialists can choose to use Access Gap Cover to bill Westfund for inpatient medical treatment. You can ask your specialist to recommend that any assisting specialists, such as anaesthetist, use Access Gap Cover for the billing of their services too.
Your doctor may elect to send the Access Gap Cover account to you. If he/she does so, they will include instructions on the account to send it directly to your health fund. In this instance, it is very important that you send the account directly to your health fund and not claim from Medicare first.
What if my doctor won't treat me with Access Gap Cover?
An enormous number of doctors throughout Australia have been contacted and invited to provide their services to their patients using Access Gap Cover, however there are some doctors not willing to do so.
If your doctor chooses not to treat you as a Westfund Access Gap Cover patient, your doctor will raise a fee for the service provided and the claims process will be as before. We recommend that you discuss the charge with your doctor, before you are admitted to hospital if possible, and request full disclosure of out-of-pocket expenses you may be asked to pay.
Your ability to afford the procedures should be discussed with your specialist and in the event of a decision to seek an alternate specialist, ask your GP.