The Access Gap Cover Scheme allows Phoenix Health Fund members with private hospital cover to eliminate or reduce out-of-pocket expenses for medical gap payments for in-patient hospital treatments.


Phoenix Health Fund does not pay an amount charged by your doctor above the Medicare Benefits Schedule Fee unless your doctor agrees to participate in the Access Gap Cover Scheme. If a doctor does not use the Access Gap Cover Scheme, you will be responsible for any additional charges.


Doctors are independent of Phoenix Health Fund and each doctor can choose on a case by case basis whether to participate in the Access Gap Cover Scheme. Please be aware that you should ask your doctor to explain the costs of your hospital admission including any prostheses gap amount, their own fees, any fees that other doctors involved in the admission such as assistant surgeons and anaesthetists might charge, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate. This is known as ‘informed financial consent’.


Frequently Asked Questions:


How will I know if my doctor will participate?


Doctors can choose whether to participate in Access Gap Cover on a patient-by-patient basis. It’s important that you ask your doctor whether they will participate in Access Gap Cover for you. Ask these 4 questions:

1. Will you participate in the Access Gap Cover scheme?
2. Will I have any out-of-pocket expenses, and if so, can you provide a written estimate of how much?
3. Will any assisting doctors also use Access Gap Cover and if so, how can I obtain a quote for their services?
4. Are you prepared to send the bill to Phoenix Health Fund directly?


How can I encourage my doctor to participate?


Participation in Access Gap Cover is open to all doctors who perform inpatient services. It is best to consult your doctor to ask if he/she is willing to participate in your case.
All specialists can choose to use Access Gap Cover to bill Phoenix Health Fund for inpatient medical treatment. You can ask your specialist to recommend that any assisting specialists, such as anaesthetist, use Access Gap Cover for the billing of their services too.
Your doctor may elect to send the Access Gap Cover account to you. If he/she does so, they will include instructions on the account to send it directly to your health fund. In this instance, it is very important that you send the account directly to your health fund and not claim from Medicare first.
What if my doctor won’t participate in the Access Gap Cover scheme?


An enormous number of doctors throughout Australia have been contacted and invited to provide their services to their patients using Access Gap Cover, however there are some doctors not willing to do so.
If your doctor chooses not to treat you as a Phoenix Health Fund Access Gap Cover patient, your doctor will raise a fee for the service provided and the claims process will be as before. We recommend that you discuss the charge with your doctor, before you are admitted to hospital if possible, and request full disclosure of out-of-pocket expenses you may be asked to pay.
Your ability to afford the procedures should be discussed with your specialist and in the event of a decision to seek an alternate specialist, ask your GP.