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  1. #1
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    Default private health insurance - "cap" on gap cover and/or "access gap"

    Hi everyone,


    We've had great help from this forum and have decided to sign up for private insurance company.
    Our choices were down to Medibank, Bupa, TUH (my husband is in education) and Peoplecare and have inquired to all of them and got quotes/plan details.


    One thing we are still confused and hoping to get some advice here is about the gap cover.


    Apparently, Medibank has this $500 cap system.
    Under this system, what we were told is that, given that the doctor/specialist is participating in gap cover, Medibank caps at $500 for out of pocket cost regardless what the doctor/specialist charges. (So the gap charge can be $30000 and you'd still only need to pay $500)
    This is per procedure and per doctor/specialist, not per item number.


    Other companies seem to have "access gap" system where we have been explained that the doctor/specialist (again, given that they are participating) can only charge up to $400 maximum out of pocket charge.
    This is per item number.


    So what we're trying to understand here is whether some cases can have multiple item numbers under 1 procedure or not.


    For example, could there be 5 item numbers under 1 procedure??


    Because in that case, there'll be maximum $500 that's out of pocket if with cap system, but $2500 if with access gap system, is that right?
    Or is it always 1 item number per 1 procedure?


    We've never had (and luckily never had to) private insurance, so all there item numbers and gap cover etc are new to us (and finding them quite confusing!), but we're hoping once we signed up with one company, we'll stay with them and not have to shop around again (at least for a while), so we want to make sure we don't misunderstand the information.




    Given that anything can happen anytime, this "cap" system with Medibank sounds really good, but we weren't sure if this was right....


    A) if 1 procedure has 1 item number and is performed by 1 doctor, and it costs $10000 above the government scheduled fee, we need to pay $500 out of pocket with Medibank but $400 with other companies who has "access gap".


    B) if 1 procedure is performed by 2 specialists and they have 3 item numbers each (if that's possible?), and it costs $10000 above the scheduled fee, it'll be $1000 ($500 per specialist) with Medibank but $2400 with other companies with access gap.


    Is above understanding correct??? (Feel like I'm back at school... and I was never good at math!!!)




    If anyone who's with medibank or/and with other companies that use this "access gap" could advise, that would be great.


    Sorry about a long/confusing post... thanks for all your help

  2. #2
    TheGooch's Avatar
    TheGooch is online now Winner 2014 - Newbie of the Year
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    Wow! Now I'm really confused! I'm changing from AHM after bub is born and adding my DP to my health insurance as combined, we will drop a tier compared with what I have to pay now...
    Back on topic. I'm not sure if this helps but when I go to the dentist for a general visit, my receipt has several item numbers. E.g 1 number for consultation, one for teeth clean and one for sensitivity test.
    My health fund then refunds me a bit for each item number. And each amount is different.
    That probably hadn't helped much. Private health is not something I. "Get" easily. I mainly have it to reduce Medicare at tax time!

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    From my understanding the Drs performing procedure have to agree to be part of the program. I've had put cover for 10 years but have never had to be admitted, only ever used extras.
    I'm now in need of an op, I have a $500 excess w medibank.
    The surgeon and anaesthetist won't take part in the gap/cap system. Medicare state the op (4 item #'s) as totaling $900.....cost from surgeon and anaes is $3200 so I'm out of pocket $2800!
    I'm having a 2nd opinion before agreeing. Luckily my op isn't an emergency and I have the time to seek another opinion. I've asked receptionist if this dr takes part in the program and she said he never has.

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    I have never known a specialist to charge only 1 item # and anaesthetists always charge several. So I hope that answers your multiple item number question.
    It's important to think about "participating" doctors. I live in a regional town and there are 0 participating dentists and optometrists (I'm with bupa). Try and find this out as well before committing. I'm pretty sure the HF should be able to give you a list in your area.

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    I'd be wary about the "participating doctors" thing. How are you covered if it's not a participating doctor? What is the list of participating doctor in your area?
    For anaesthetist you usually don't chose and get whoever is on call.

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    I think the service numbers are standard, not set by the doctor's surgery. I've had private health my entire adult life (I'm in my 30's now) and have never come across anything that bumps up the gap payment. Most specialists I've been to work with you to make sure your gap is at a minimum. I think it comes down to which doctor/service you use.

  7. #7
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    Good morning everyone and thank you for all your replies!!!

    Firsttimemum34, I know!!
    I am so sorry for confusing you too!! My head has been spinning this past few days. Neither my hubby nor I have ever been admitted to hospitals or had any surgeries etc ever, I think he hasn't even used his medicare card once in the last 10 years! so this has been a huge process learning all these things....
    But your reply definitely helped! That probably means that those 50%back or 60%back etc on extra applies on each item number, not per one visit's total.

    Mmumm, sorry you have to have an operation. Yes, you're definitely right. We've been advised from all the companies we inquired that the crucial thing is that the doctor/specialist you're going with is participating in the gap cover scheme. Because if he/she's not willing to participate, they can charge you whatever they want and it's all out of your pocket!!! and no matter which fund you're with, they can't help you. They all said, these days many doctors/specialists participate, as there are a lot of competitions and people can shop around, people can get second opinion and can choose to go with someone who's willing to participate. But they also said that, of course there are doctors/specialist who have more than enough patients and money that they don't care if they lose a few patients by not participating.
    Is there a particular reason that you want to go with your surgeon and anaesthetist? If it doesn't have to be them, since you have time, you may be able to find someone else...

    gnomesy, good point. We checked with all companies that the Private Hospital the OP who we want to go with uses has no gap. But for extras, we may also have to travel a bit to find the ones who are participating...

    Excusemyfrench, my understanding is that you're NOT covered if it's not participating doctor(s)! You're right, I think sometimes (or maybe often) you'd have no choice at all and have to go with whoever available, and if he/she's happens to be someone who doesn't participate, then it's all out of pocket, I think.

    lala77, I think whether it's the "cap" or the "access gap", these schemes are to reduce the out of pocket as much as possible, not to bump up, but it can only be applied if the doctor is participating. You're totally right, I think it really does come down to which doctor you use.


    Thanks everyone, good to understand that there's almost always more than 1 item numbers involved. So Medibank may be the go if this $500 "cap" really exists and it's not per item numbers but per procedure.

    Is there anyone who's with Medibank and experience with this cap???

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  9. #8
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    yep

    I wouldnt bother with gap cover as its unlikely to be worth it over a number of years.

    if you have to have an op - there will be extra costs, but its unlikely to add up to be more than the cost of the gap cover policy over a number of years.

    Especially as if you do have to have an op, its likely that some of your chosen specialists wont participate in the program anyway


 

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