Phoenix Health Access Gap Cover Scheme

The Phoenix Health Access Gap Cover is a scheme administered by the Australian Health Services Alliance (AHSA), designed to reduce or eliminate out-of-pocket costs that may otherwise be incurred during your hospital admission. Where your doctor agrees to participate in the scheme for your procedure, they agree to only charge up to a certain fee, ensuring that you will experience a reduced or no gap for your procedure.

The Federal Government sets a schedule of fees for all medical procedures, knowing as the Medicare Benefits Schedule or MBS. When you go to hospital as a private patient, Medicare will cover 75% of the MBS fee and your private health insurance will cover the remaining 25%.

However, Doctors often charge above the MBS fee, and as such the difference between what they charge and the MBS fee will become your ‘gap’ or out-of-pocket cost.

As a Phoenix Health member with hospital cover, you have access to more than 36,000 doctors who participate in Access Gap Cover; a scheme administered by the Australian Health Services Alliance (AHSA) and designed to reduce or eliminate out-of-pocket costs that you may otherwise experience during your hospital admission.

Where a doctor agrees to participate in the Access Gap Scheme for your hospital procedure, the most they will be able to charge you out-of-pocket is $500 (or $800 for obstetrics) and in some cases will not charge you a gap.

This is completely up to the Doctor and is usually decided on a case-by-case basis. Doctors have no obligation to participate in Access Gap for a particular procedure, and just because they have previously participated, doesn’t mean they will again.

Here’s some questions to ask your doctor:

• Will you participate in the Phoenix Health Access Gap Scheme for my procedure?
• Will I have any out-of-pocket expenses? Can you provide an estimate of these costs?
• Are there any other doctors participating in my procedure? (e.g. anaesthetist, pathologist, radiologist) and would they also be willing to participate in Access Gap?

Check out our Provider Search to generate a list of Doctors for the specialty you are after, who have previously participated in the Access Gap Cover Scheme.

It is entirely up to the Doctor on a case by case basis if they will participate in Access Gap for your procedure, so it’s important that you ask the questions we have recommended above, so that you are fully prepared for your admission.

The Phoenix Health Access Gap Cover Scheme is administered and governed by the Australian Health Services Alliance (AHSA), and recently they completed a review of the benefit schedule used for our agreements with participating doctors and specialists in the hope of lessening out-of-pocket gap payments for members.

The AHSA have reviewed all the items we pay under the Access Gap Cover Scheme and adjusted the benefits with the aim of lessening patient gaps, meaning benefits have been increased on a number of items. To balance this however, there are some instances in which benefits have been decreased for certain items, where the AHSA felt were too high in the current market and some benefits haven’t changed at all.

• What does this mean for me?
  These changes have been structured to ensure they are cost neutral – we don’t want costs being passed on to our members through benefits or premium increases, because we’re focused on the long-term affordability of private health insurance for you, our member. We believe in most cases that these changes won’t affect our members but want to make sure that we always provide you with any updates as they happen, so you can make informed decisions about your health insurance.

• Why did these changes need to happen?
  It’s important for us to always be reviewing the benefits we pay, so that they stay up to date and relevant, and continue to provide the best coverage for you when you need to go to hospital. We want doctors to keep using Access Gap for you, so we need to make sure that the benefits we pay are reasonable in relation to what the doctors are charging – because we know no one wants to pay out-of-pocket gaps when they go to hospital.

• What if I’ve already received a quote from my doctor and or have surgery booked in after 1 July 2024?
  Please contact us and we can check your quote and the Access Gap benefits for you. The AHSA have contacted all Access Gap doctors and let them know about these changes, but you may also need to contact your doctor for an updated quote – we’ll let you know what you need to do.

• Feedback from your doctor?
  If you receive any feedback from your doctor or specialist, or if you have any concerns, please get in touch with us to discuss your admission in more detail – we’re all working through these changes together and appreciate any feedback you have.

This is what we know and where we can really help you out. As soon as you find out you’ll need a hospital admission contact us so you can be confident in what to expect.

We’ll talk you through minimising doctor’s fees and any other out-of-pocket costs as well as check your cover and discuss any pre or post hospital support programs and navigate any additional services that we may have available for you.

Let us help you, so you can focus on what’s important; we’re here for you.