The Medicare Benefit Schedule Fee (MBS) is a guideline fee the Government have set for doctors to charge for all medical procedures; think of it like a recommended retail price.
Phoenix Health and Medicare can only pay a benefit up to 100% of the MBS. Doctors will charge you whatever price they deem reasonable for your treatment, and we have no say in how much or little they charge you. If your Specialist charges over the MBS, then the amount above the MBS fee will be an out-of-pocket expense that you will need to pay. This out-of-pocket may be reduced or removed if your Specialist elects to use our Access Gap Cover. See Section 3.3
Yes, by choosing to be a Private Patient for your surgery, it is likely you will have out-of-pocket expenses.
The table below shows a breakdown of how some of the fees are paid for.
Service Type | Claimable through | How much is covered |
|---|---|---|
Specialist Consultations | Medicare | 85% of the MBS fee |
Surgeon Fees | Medicare & Phoenix Health | 100% of the MBS fee |
Anaesthetist Fees | Medicare & Phoenix Health | 100% of the MBS fee |
Hospital Accommodation | Phoenix Health | 100% of the fee |
Theatre Fees | Phoenix Health | 100% of the fee |
Remember.... Any charges above the MBS fee amount, will be an out-of-pocket expense. |
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The Specialists involved in your admission will supply you with what is known as Informed Financial Consent which in a nutshell is the list of the fees and costs they will be charging you for your treatment. Some of these fees will be partially covered by Medicare and some will be partially covered by Phoenix Health and Medicare.
If there is something on your Informed Financial Consent that you are unsure about either have a chat with your Specialist or give us a buzz on 1800 028 817.
Once you’re booked in for your surgery, the hospital you’ve chosen will also advise you of any out-of-pocket expenses related to your hospitalisation (usually just your excess). You will not see a bill for the Hospital Accommodation or Theatre Fees as the hospital will bill us directly for them.
Access Gap Cover is an agreement between Phoenix Health and a Specialist Doctor (this could be your surgeon, anaesthetist, assistant surgeon etc), where Phoenix Health agrees to pay a higher benefit to the Specialist, and in return the Specialist limits the out-of-pocket to $500 or in some cases removes it altogether.
*Please Note – Access Gap only applies to the out-of-pocket expenses for the specialist doctors involved in your procedure.
Access Gap Cover is available to any Specialist who has a contract with the Australian Health Services Alliance (AHSA), however it’s completely up to them to use it or not. Often, they’ll assess the use of Access Gap on a case by case and patient by patient basis – so where they may use Access Gap for you, they may not for another one of their other patients.
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We recommend having a chat to your Specialist on your first visit and ask them if they will participate in the Access Gap Cover Scheme. |
Our Hospital Assistance Packages recognise the need for benefits in rural and regional areas.
If you, a spouse or dependant have Hospital Cover and are required to travel over 300 kilometre’s return for medical treatment, a benefit up to $200 for travel expenses can be claimed and in addition a benefit of $60 per night for the duration of the hospitalisation can be claimed to assist with parent/spouse accommodation costs.
Want more information? Get in touch with the Phoenix Health team and we can check your eligibility for these benefits.
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