We’re committed to delivering market leading health insurance at an affordable price. That’s why we’ve introduced our Access Gap Cover initiative, which is designed to help minimise or, in some cases, eliminate out-of-pocket expenses when you go to hospital.

For most hospital services, Medicare sets an amount known as the Medicare Benefit Schedule fee (MBS). When you go into hospital, this is the amount you’re guaranteed will be covered - Medicare covers 75% of the MBS fee, and we cover the other 25%.

Some doctors, however, charge more than the MBS fee. We try and make treatment more affordable by offering Access Gap cover, if your doctor participates in what’s called the Access Gap scheme.

The Access Gap Benefit is an agreed maximum amount we’ll pay up to for your doctor’s services if they’re part of the scheme. Your doctor may choose to accept this amount as full payment for your treatment, which means no out-of-pockets for you. But, if your doctor’s fee is higher than the Access Gap Benefit, you'll unfortunately have out of pocket expenses to pay.

Some doctors don’t participate in the Access Gap scheme at all, and some participate on a patient-by-patient basis. If your doctor doesn’t participate, we’ll only cover the 25% between the Medicare rebate and MBS fee. To make sure you’re fully aware of all fees to be charged prior to treatment, we recommend contacting your treating doctor to find out if they will participate in the Access Gap scheme for your treatment and to discuss fees upfront. That way, you’ll be fully prepared and aware of any out-of-pocket expenses before you go to hospital.

Effective 1 July 2024, the Australian Health Service Alliance (AHSA), which oversees the scheme for Territory Health Fund and other Australian health insurers, will be amending certain items on the Access Gap Cover (AGC) schedules. Find out more

You can also find doctors who may participate in the Access Gap scheme by visiting the AHSA website.