Covering the Gap
Medical and 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 benefits paid by Navy Health.
The out-of-pocket expenses are assessed against the Medicare Benefits Schedule fees, which are set by the government. When you are admitted to hospital as a private patient, Medicare will pay 75% of the MBS fee, whilst Navy Health will pay the remaining 25% of the MBS fee. Doctors, surgeons, anaesthetists, pathologist or radiologists can charge for their services above the Medicare Benefit Schedule.
Navy Health can help reduce the extra expenses through our participation in the Access Gap Scheme and no-gap agreements.
Access Gap Scheme
|•||Helps minimise or eliminate associated costs (when the doctor chooses to participate, Navy Health is able to pay a further benefit towards the medical expenses above the MBS to an agreed level)|
|•||Encourage your treating doctor to participate as it can help alleviate any out of pocket expenses|
No Gap Agreements
If your treating doctor does not participate in the Access Gap scheme, Gap Medical benefits will apply. Under Gap Medical benefits, Medicare will cover 75% of the MBS and Navy Health will pay the remaining 25% of the MBS.
If the doctor charges more than the MBS fee, the member will be responsible for any ‘gap’ payment. The ‘gap’ is the difference between the MBS fee and the doctor’s fee.
As a private patient you are entitled to ask your treating doctors to give you Informed Financial Consent. This document will be given to you on request from your doctor and will tell you how much you will be “out-of-pocket” at the end of your planned hospitalization.
To search for a specialist in your area who have previously participated or have indicated their intention to participate in, as well as those who have agreed to alternative no gap arrangements, please refer to the Find a Specialist page.
How to Claim in patient medical services
Generally Access Gap accounts are forwarded to Navy Health by your Doctor and you will only need to pay your “gap” where applicable . If you receive an account that indicates it was intended to be payable by the Access Gap Scheme, please forward directly to Navy Health.
Please forward accounts directly to Medicare with a Medicare Two Way Claim Form. Medicare has an online claiming system which allows them to forward your claim to Navy Health for further benefits. If you are unable to utilise this service, please send your Medicare Statement of Benefit, along with a Medicare Two Way Claim Form to Navy Health and we will forward it to Medicare for you.
Private Hospital & Day Facilities
Navy Health has negotiated contracts with over 490 private hospitals and day facilities. Provided you are treated in a contracted hospital you will be covered 100% for all accommodation and theatre fee charges, minus your hospital excess where applicable. To search for agreement hospitals in your area, please go to Providers.
Non Contracted Facilities
It’s unlikely that you will be admitted to a non contracted private facility, but if you are we 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.
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