For medical services recognised by Medicare, there is a Medicare Benefits Schedule (MBS) fee. This is the fee set by the Australian Government for each medical service.
Phoenix Health and Medicare can pay benefits up to 100% of the MBS fee. Doctors can choose to charge above the MBS fee, which may result in an out-of-pocket cost that you’ll need to pay. This out-of-pocket cost may be reduced or removed if your specialist elects to use our Access Gap Cover. Learn more about Access Gap Cover.
Yes, by choosing to be a private patient for your surgery, it’s likely you’ll have some out-of-pocket expenses.
The table below shows a breakdown of how some of the fees associated with your admission are paid.
| 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 will be an out-of-pocket expense. | ||
The specialists involved in your admission will provide you with what is known as Informed Financial Consent. This is a breakdown of the fees and costs they expect to charge for your treatment, including any amounts you may need to pay yourself. Depending on the service, some of these costs may be partially covered by Medicare, or by Medicare and Phoenix Health.
If there’s something on your Informed Financial Consent that you’re unsure about, 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 hospital stay, such as your excess where one applies. You generally won’t receive a bill for hospital accommodation or theatre fees, as the hospital will bill Phoenix Health directly for these costs.
Access Gap Cover is an agreement between Phoenix Health and a specialist doctor involved in your treatment, such as your surgeon, anaesthetist or assistant surgeon. Phoenix Health agrees to pay a higher benefit to the specialist and, in return, the specialist limits your out-of-pocket cost to $500 or, in some cases, removes it altogether.
Please note: Access Gap Cover only applies to out-of-pocket expenses for the specialist doctors involved in your procedure.
Access Gap Cover is available to specialists who have a contract with the Australian Health Services Alliance (AHSA); however, it’s completely up to the specialist whether they choose to use it. Specialists may decide whether to use Access Gap Cover on a case-by-case and patient-by-patient basis, so a specialist who uses Access Gap Cover for one patient may not use it for another.
We recommend asking your specialist at your first appointment whether they’ll participate in Access Gap Cover for your procedure.
Our Hospital Assistance Packages recognise the additional challenges that can come with accessing medical treatment when you live in a rural or regional area.
If you, your spouse or a dependant have hospital cover and are required to travel more than 300 kilometres return for medical treatment, you may be able to claim a benefit of up to $200 towards travel expenses.
In addition, a benefit of $60 per night for the duration of the hospitalisation may be available to help with accommodation costs for a parent or spouse.
Want more information?
Get in touch with the Phoenix Health team and we can check your eligibility for these benefits.
