1 July 2020 Changes

From 1 July 2020 there will be changes to your medical gap cover.  Access Gap Cover (AGC) is Westfund’s medical gap cover scheme.  If you need to go to hospital and your doctor uses AGC, then your benefit from us will be higher, resulting in no or lower out-of-pocket costs. 

1.  Change to Access Gap Cover patient gap
AGC has always had a limit on the maximum gap that a doctor can charge but the rule is complicated.  Currently, your gap could be any amount up to $400 for one Medicare item number and it could be more than that for multiple procedures or item numbers; it could even be in the vicinity of $1,200 for a combination of some Medicare item numbers for an individual doctor.
To simplify things, we are changing the rule. From 1 July 2020 the new maximum gap allowed for AGC is $500 per doctor, per hospitalisation. We expect a very low impact regarding any changes to gaps and hope that it will encourage increased compliance by doctors to charge the correct gap.

2. Change to Booking or Administrative fees
Westfund would like to strengthen the Access Gap Cover Terms and Conditions  to ensure that doctors who use AGC do not charge additional fees, sometimes referred to as ‘Booking Fees’ or ‘Administrative Fees’ or any other fees not associated with the Medicare item number/s for your procedure.
Though the current AGC rules state that doctors can’t charge ‘Other Fees’ – it does not state that if they do, they will not be paid the AGC benefit. The new condition which will become effective from 1 July 2020 will link these two things to make it absolutely clear that these additional charges cannot be raised to you as a member if the doctor chooses to use AGC for you.

Remember to always contact Westfund if you are charged these types of additional fees. Our main focus is on the long-term affordability of private health insurance for you as a member. We also want to ensure that you are well informed about any out-of-pocket costs that you might be charged and that they are minimised and manageable.