Understanding medical fee coverage in your plan
All hospital policies include medical gap cover. This is a type of cover that can help to reduce your out-of-pocket costs for medical bills when you go to hospital.
At Doctors' Health Fund, we offer two different types of medical gap cover.
- Access Gap Cover, and
- Medical gap cover up to the AMA list of services and fees
The gap cover you have depends on your level of cover.
Access Gap Cover
Smart Starter Bronze Plus and Prime Choice Gold include Access Gap Cover. This medical gap cover is comparable to what other health funds provide. If your doctor chooses to bill according to this scheme, they can either charge at the ‘no gap’ fees or alternatively, charge a ‘known gap’ of up to $500. This gap amount is per practitioner for the episode of care, so each doctor involved in your surgery/treatment could charge $500, including your anaesthetist. If your doctor does not bill according to this scheme, we can only pay benefits up to the Medicare Schedule Fee (MBS) and higher out of pocket costs can apply.
Medical gap cover up to the AMA list of services and fees
Top Cover Gold provides medical gap coverage up to the AMA list of medical services and fees. This cover is unique to Doctors’ Health Fund and provides greater coverage than general industry medical gap schemes. You won’t have any out-of-pocket costs if your doctor charges up to the AMA list of medical services and fees.
An important difference with this cover is that it is not a scheme like Access Gap Cover, where your doctor needs to agree to participate and abide by other terms and conditions when charging you. With Top Cover Gold hospital cover, Doctors’ Health Fund simply pays benefits up to the AMA list of services and fees for all applicable services.
Medical benefits up to the AMA list of services and fees aren’t new to us. In fact, we’ve offered the best medical gap cover in Australia for a while. This offering is an important part of our foundations, starting as The AMA Health Fund in 1977.
This unique gap cover just became more affordable
From 1 July, we introduced a new excess option of $750 to Top Cover Gold, which brings down the cost of its premium. You can now choose a nil or $750 excess for Top Cover Gold, providing more options to be covered with medical benefits up to the AMA list of services and fees.
It’s important to always speak with your doctor
Familiarising yourself with your policy will allow you to have a more informed discussion when planning an admission. You will be able to discuss your medical gap cover and ask whether your doctor will bill their services according to it. It is ultimately up to your doctor to set the costs for their services and whether they will choose to utilise your medical gap cover. You should always be provided with informed financial consent before your procedure so you can make an informed decision about your healthcare.
Speak with our team to learn more
Our team is readily available to explain any details of your policy and how your medical gap cover works if you need to go to hospital. To provide the most accurate information, it is important to have the Medicare Benefit Schedule (MBS) items proposed to be used in the surgery or treatment. Most of our telephone enquiries are answered within 30 seconds during business hours, so you won’t be waiting around on hold for a long time for someone to answer any questions you may have.
They can also provide quotes for cover if you’re interested in a different level of cover.
