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Check that the private hospital is contracted with ACA Health through the Australian Health Service Alliance (AHSA) by using our Hospital Search.

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If you need hospital treatment, we recommend the following steps to determine your benefit and the amount of gap fees you may need to pay:

1. Contact us straight away to find out your level of hospital cover and whether you will be covered for the treatment you need.
2. Ask your doctor(s) whether they participate in the Access Gap Cover Scheme and if so, to bill your accordingly. This may help you avoid or lower your out-of-pocket expenses.
3. Check that the private hospital is contracted with ACA Health through the Australian Health Service Alliance (AHSA) by using our Hospital Search.

If your hospital stay is longer than 35 days and your doctor considers that you no longer need acute care, you will need to pay a contribution to your living costs in much the same way as nursing home type residents contribute to the cost of their care. The patient contribution is payable by public and private hospital patients and ACA Health is unable to pay benefits on this fee. Contact us for more information.

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In the past, large out-of-pocket expenses were often part of any hospital stay for people with private health insurance. To help improve this, ACA Health offers you the Access Gap Cover Scheme as part of our hospital cover.

Medical (doctor/specialist) services provided to hospital in-patients are charged separately from hospital accommodation/theatre fee charges. Medicare pays 75% of the Medicare Schedule Fee and ACA Health pays the remaining 25%.

Some doctors/specialists charge an amount above the Medicare Schedule Fee. These costs are generally referred to as out-of-pocket expenses, and in the past, health funds were unable to pay benefits on these amounts.

Now, out-of-pocket doctor/specialist expenses for hospital patients can be eliminated completely or dramatically reduced with our ‘Access Gap Cover’ payment and billing scheme.

Doctors/specialists who choose to participate in the ‘Access Gap Cove’ scheme agree to charge for services with either no out-of-pocket expenses or a predetermined amount, which is capped. In return, ACA Health can pay the doctor above the Medicare Schedule Fee.

ACA Health has “Access Gap Cover” arrangements with over 11,000 Doctors Australia wide, established on our members’ behalf by the Australian Health Service Alliance (AHSA). You can find out which doctors are using the scheme by logging into your Member Portal and clicking the “Find a doctor” button at the bottom of the page (click here to login). Not all doctors in the scheme have agreed to have their names listed, so keep this in mind when you are looking.

Finally, your doctor will usually lodge your claim for you − making the whole process even easier.

Please note: ACA Health is unable to provide recommendations on health care providers, hence the search function is not intended as a list of ‘preferred providers’.