GapCover

If you have to go to hospital, your hospital cover will take care of the majority of costs for the medical services received while you’re in hospital as long as you’re eligible to be covered for that service and you’ve served all applicable waiting periods. However you can face extra expense if your doctor(s) or specialist(s) (doctor) charge above the Medicare Benefits Schedule (MBS) fee for their services.

ahm’s GapCover is designed to help remove or reduce out-of-pocket medical expenses so that you pay less or nothing at all for these services when you go to hospital.

If your doctor chooses to participate in GapCover

Ask your doctor to provide you with an estimate of medical fees so that you can see exactly how much you’ll have to pay before your treatment begins. Make sure they include the estimated costs of all the medical providers who will be involved in your treatment such as the anaesthetist and assistant surgeon. This estimate enables you to make a fully informed decision about the cost of your treatment before giving consent to your doctor.

  • If your doctor chooses to participate in the GapCover scheme with ahm, the maximum out-of-pocket medical expenses you’ll pay is $500 per claiming provider ie. per doctor’s account for each hospital stay. In some cases you may not have to pay anything extra at all.
  • Your doctor will bill ahm directly, so there’s no need to worry about filling in any claim forms.
  • Your doctor can choose to participate on a case by case basis. If they decline to participate or if they charge over the maximum $500 gap amount, the scheme can’t be used and you’ll have to pay the difference between the MBS fee and the doctor’s charge.

If your doctor chooses not to participate in GapCover

  • You should still ask your doctor to provide you with an estimate of medical fees prior to your treatment
  • We’ll only be able to pay up to the MBS fee set by the Government and you’ll have to pay the amount above the MBS fee
  • Doctors involved in your treatment will each bill you separately.

How it works

GapCover scheme
Doctor charges MBS Fee
Medicare pays 75% ahm pays 25%
Doctor charges above MBS

Medicare pays 75%of the MBS fee.

ahm pays 25 % of MBS fee and additional
amount  up to the GapCover agreed fee

 Member pays up to $500
per claiming provider
Doctor charges more than $500 above the
GapCover agreed fee
Medicare pays 75% and ahm pays 25% of the MBS fee.
Member pays balance above MBS fee 

Search for your doctor

We offer a search facility so you can quickly find if your doctor has previously participated in GapCover.

Search for your doctor »

(Note: Doctors can choose to participate on a case by case basis. Inclusion on this list doesn’t guarantee that they’ll agree to participate for your treatment.)

Need more information? If you have any further questions about the change or if you’re planning to go to hospital, call us on 134 246.

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