Changes to the Access Gap Cover (AGC) schedule
From 1 July, the Access Gap Cover (AGC) schedule will be adjusted to ensure it remains up to date relative to the industry and the Medicare Benefits Schedule (MBS). Importantly, the changes are a redistribution of benefits for individual items and don’t change the total medical benefits paid by Doctors’ Health Fund or the known gap that can be charged by doctors under the scheme. Many items will increase, some benefits will decrease, and some benefits will not change.
This information was provided in your recent premium increase notice if you have Prime Choice Gold or Smart Starter Bronze Plus hospital cover. If you are a practitioner registered to participate in Access Gap Cover, you would have received more information about these changes from the Australian Health Services Alliance.
Medical benefits on Top Cover Gold hospital cover remain unchanged; being up to the AMA list of medical services and fees.
What is Access Gap Cover?
AGC refers to the schedule of medical benefits designed to reduce or eliminate the medical costs you would ordinarily pay for treatment when you're admitted to hospital. Doctors’ Health Fund pays benefits above the Medicare benefit, up to the AGC schedule, when your doctor agrees to bill you using the AGC scheme. They can bill you with no gap, or a known gap of up to $500 per episode of care (or up to $800 for obstetrics).
What are the changes to AGC?
The schedule is regularly reviewed to ensure benefits remain up to date relative to the industry. Some benefits in the AGC schedule have increased, and to balance the increases, some other benefits have decreased, but only where it was reasonable to do so. Most of the items remain unchanged.
You should always speak to your doctor about any upcoming hospital admissions and ensure you receive informed financial consent about any potential out-of-pocket costs. Our hospital policies also include excess options of either $0, $500 or $750, which will remain the same despite changes to the AGC schedule.
What if I have surgery booked in?
The AGC changes will come into effect for admissions on or after 1 July 2024. If you already have a quote from your doctor about an admission after 1 July, we recommend you contact them to discuss these changes.
Informed financial consent
It is important that when you have a surgery booked in, you understand the out-of-pocket costs involved and what’s covered under your health insurance policy. To protect patients and doctors, an informed financial consent agreement is created between you, your doctor and hospital, that outlines the expected costs for the procedure. This information is provided so there are no unexpected out-of-pocket costs and so you can make transparent and informed decisions about your healthcare. It is up to your medical practitioner to set the fees of their medical services and whether they will choose to utilise your medical gap cover. This is why it’s important to ask about these costs before your procedure, through informed financial consent.
To find out more
If you have any questions about the upcoming changes to the AGC schedule, you can call our team on 1800 226 126.
Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy, available at www.doctorshealthfund.com.au/our-cover.
