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Medical & Hospital Benefits Explained

Navy Health aims to close the gap on out-of-pocket in-hospital expenses. A gap payment is the difference between the fee charged by the hospital or doctor and the benefit paid by Navy Health.

Gap payments may arise depending on the following:

Access Gap

When treated as a private patient in a hospital, members may face extra costs when the treating doctor charges more than the Medicare Benefits Schedule (MBS) allows for the service provided.

The Access Gap scheme is designed to help minimise or eliminate these costs. Where there is an agreement in place and the treating doctor chooses to participate in the Access Gap Scheme, the insurer will cover the cost above the MBS fee to an agreed level on the Access Gap fee. If the doctor’s fee is higher than the agreed Access Gap fee, the patient is responsible for paying the balance.

Access Gap

Access Gap Fee is limited to;

  • $400 above the Australian Health Services Alliance (AHSA) set fee for all items except obstetrics
  • $800 above the AHSA set fee for obstetrics only.

Gap Medical

If the member receives treatment as a private patient in a hospital from a doctor that chooses not to participate in the Access Gap Scheme, Gap Medical benefits will apply.

Under Gap Medical benefits, Medicare will cover 75% of the MBS fee for the service that has been provided. The insurer will pay the remaining 25% of the MBS fee.

If the doctor charges more than the MBS fee, the member will be responsible for any ‘gap’ payment. The ‘gap’ is defined as the monetary variation between the MBS fee and the doctor’s fee. 

Private Hospital & Day Facilities

Contracted Facilities

Prior to admission please check with your hospital as to whether or not your treatment or service is contracted. Contracted services relate to hospital fees such as accommodation and theatre.

Navy Health has been able to negotiate 100% benefits on most treatments and services at over 490 private hospitals and day facilities. Product excesses still apply. To search for agreement hospitals and specialists in your area, go here.

Prosthesis items are payable at 100% of the minimum Government recommended fee. There is at least one prosthesis item available for every surgery with no out-of-pocket expense to the patient.

Drugs prescribed for discharge and drugs not directly associated with the reason for admission are excluded from contracts and are the patient’s responsibility. In addition, if a patient chooses to stay in an executive suite, the patient will be required to pay the difference between the private room benefit and the executive suite charge.

Psychiatric Treatment & Rehabilitation Day Programs

Prior to your admission to a Psychiatric or Rehabilitation Day Program, please check with Navy Health as limits may apply. 

Private Hospital & Day Facilities

Non-Contracted Services

Prior to admission please check with your hospital as to whether or not your treatment or service is contracted. Contracted services relate to hospital fees such as accommodation and theatre. If you find that your impending hospital treatment or service is not contracted, we strongly recommend you contact our Member Services team to obtain benefit information prior to admission, as out-of-pocket expenses will apply. Product excesses may also apply.

Exclusions

Please be aware that sometimes service exclusions may apply for hospital services where Medicare does not pay a benefit. To be sure of coverage, please call Navy Health Member Services on 1300 306 289 prior to arranging admission.

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