Access Gap Cover is a scheme that can help you minimise, or avoid, out-of-pocket costs for in-hospital (inpatient) specialist treatment.

It’s available to Teachers Health members who are planning treatment that’s marked as ‘covered’ or ‘restricted’ on their Hospital Product Sheet.

The Medicare Benefits Schedule (MBS) is a list of fees the government has set for medical services, including specialist treatment. Each item on the list has an item number.

When you use your Hospital cover, Medicare pays 75% of the MBS fee for each item and we pay the other 25%.

In the private system, specialists can set their own fees. If your specialist charges more than the MBS fee (which many do) there’ll be a shortfall, known as ‘the gap’. If you’re staring into this abyss, the Access Gap scheme can come in very handy.

Simply ask the specialist if they’ll treat you under Access Gap.

If they agree, the maximum you’ll pay is as a known gap of up to $500 per doctor per hospital episode ($800 for obstetrics). They might even agree to no gap – even better!

Specialists aren’t obliged to participate in the scheme, so if one specialist won’t, you can keep looking. The vast majority of Teachers Health members are treated under Access Gap, so it’s worth doing the legwork.  

You and/or your GP, can use the nifty Healthshare tool to locate specialists who’ve treated other people under Access Gap. You can find out:

• which specialists have previously participated in Access Gap
• the percentage of health fund members they’ve done this for
• the total number of patients the percentage is drawn from (for context)

If you have any questions about Access Gap, or what you’re covered for, please give us a call on 1300 727 538.