Medicare pays 75% of the Commonwealth Medical Benefits Scheme (CMBS) fee for professional services while you’re in hospital. Westfund cover the rest of the CMBS fee.

Where the charge exceeds the CMBS fee, we will pay an additional benefit that will eliminate or reduce any out-of-pocket medical gap expenses if the doctor participates in our Access Gap Cover Scheme.

Doctors are independent of Westfund Health Insurance and can choose whether they take part in this scheme on a case-by-case basis. You should ask your doctor to explain the costs of your hospital admission including any prostheses gap amount, their own fees, any fees for other doctors involved (such as assistant surgeons and anaesthetists), 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 Informed Financial Consent

If your doctor charges you an out-of-pocket (gap) expense, they 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 need to make a claim from Medicare or Westfund

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.


Doctor Search Facility

This is designed to let you know about doctors who have participated in Access Gap Cover before (or indicated that they will) as well as those who have agreed to alternative no-gap arrangements.

Please be guided by the referral process initiated by your own doctor. If you have been referred to a doctor and that doctor’s name does not appear on this search facility, check with your doctor to see if they will use Access Gap Cover for you.

Find a doctor using our online search, however, remember to check if they will participate in The Access Gap Cover Scheme.


Doctor-Patient Relationship

Westfund will not interfere in the independent relationship between you and your doctor.

Frequently Asked Questions


How will I know if my doctor will participate?

Doctors can choose 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 with your doctor and ask if they are 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. We can also post you a hard copy – just call us on 1300 937 838.

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 an anaesthetist) use Access Gap Cover for the billing of their services too.

Your doctor may choose to send the Access Gap Cover account to you. If they do, they will include instructions to send it directly to your health fund.

It is important that you send this account directly to Westfund 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 invited to provide their services using Access Gap Cover however, there are some doctors not willing to do so.

If your doctor chooses not to treat you as an Access Gap Cover patient, we recommend that your discuss the charge with your doctor, before you are admitted to hospital if possible, and request full disclosure of any out-of-pocket expenses.

Your ability to afford the procedures should be discussed with your specialist. If you need to find an alternate specialist, ask your GP.