Q: How does Access Gap Cover reduce my out-of-pocket expenses?


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’.