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Access Gap Cover Co-Payment Rule Changes

The new rule that will come into effect on 1 July 2020
AGC $500 Gap Rule Change (Increasing from $400)

Access Gap Cover (AGC) enables medical providers to charge patients a copayment if they wish to do so.

  • Each individual medical provider in the admitted Episode* of care can choose to charge their patient a maximum out of pocket cost of up to $500. They cannot charge any non-clinical fees to the patient such as ‘Booking Fees’, ‘Management Fees’, ‘Technology Fees’, ‘Administration Fees’, ‘Insurance Levy Fees’ or ‘Hospital Facility Fees’ and the like.
  • Obstetricians can choose to charge their patient a maximum out of pocket cost of up to $800 per episode for MBS items that relate to ‘Management of Labour and Delivery’ as defined in the MBS. Again, if the obstetrician charges using AGC they cannot charge any non-clinical fees to the patient such as ‘Booking Fees’, ‘Management Fees’, ‘Technology Fees’, ‘Administration Fees’ or ‘Hospital Facility Fees’ and the like.
  • Each medical provider must submit one claim only to the Fund covering an entire episode.
  • If medical providers have elected to charge a co-payment, they must inform the patient in writing of the charge prior to treatment (i.e. Informed Financial Consent).
  • This amount is to be billed direct to you the patient.

VERY IMPORTANT: The total charge on the account to the Fund should be inclusive of any patient co-payment.

  • If medical providers charge above and beyond the maximum patient copayment, AGC benefits will not be payable. ACA Health will pay up to the MBS fee only. Medical Providers cannot on-charge the difference to the patient as the conditions of Informed Financial Consent do not allow this.
  • If medical providers want to charge the patient more than AGC allows, then they opt out of Access Gap Cover. You should be advised about the charges and any medical gaps, i.e. Informed Financial Consent should also form part of this process.

You should be informed that the co-payment is not claimable through any other source.

* Definition of Episode – ‘The period of admitted patient care between a formal or statistical admission and a formal or statistical separation, characterised by only one care type.’ [METeOR ID 268956] Example: If a patient changes care type (in the same or different hospital), e.g. Acute to Rehabilitation, then back to Acute this would be three separate episodes. This would apply even if there has not been more than a 7 day break between the two acute episodes as there was a separation between each care type.

The Health Insurance Act 1973 stipulates that Medicare benefits are payable for professional services. Each medical provider is free to charge a patient gap according to the rule entitled ‘MAXIMUM PATIENT COPAYMENT (ALLOWABLE KNOWN GAP)’, however, the amount specified in the patient’s account must be the amount charged for the service specified. The fee may not include a cost of goods or services which are not part of the MBS service specified on the account. Even where a provider opts-out of Access Gap Cover, billing practice still must comply with the Act and MBS rules.

Posted: July 6 2020