Access Gap Cover for Frank members

From 1 May 2021, Frank will no longer provide Frank’s Gap Cover and will instead pay inpatient medical benefits in line with the Australian Health Service Alliance’s Access Gap Cover scheme.

If your medical specialist is registered for, and chooses to participate in, Access Gap Cover, Frank will pay higher medical benefits across a large number of procedures for you as an inpatient in hospital.

This means you’ll have more certainty around your out of pocket experience, giving you greater value on your health cover.

Frequently asked questions

  • In Australia, certain medical services provided by doctors have a Medicare Benefits Schedule (MBS) fee, set by the Government. This is called the 'scheduled fee'.
  • For medical services provided by a specialist while you are admitted as an inpatient in hospital, Medicare pays 75% of the scheduled fee and your health insurer pays the remaining 25%.
  • Specialists can charge whatever fee they deem appropriate for their services. If this fee is more than 100% of the scheduled fee, you will need to pay the difference. This is called a ‘medical gap’ or an out of pocket cost.
  • Frank is partnering with the Australian Health Service Alliance to give members access to Access Gap Cover.
  • Access Gap Cover is a billing system that provides higher benefits than the Government’s scheduled fee in most cases. It can reduce or even eliminate any gap for medical fees when treated as an inpatient in hospital.
  • Specialist doctors who are registered for, and use, the Access Gap Cover scheme will get a higher benefit from Frank (more than the standard 25%), in exchange for limiting the out of pocket cost they charge to you.
  • There are two scenarios for how you may be billed by your specialist doctor when they use the Access Gap Cover scheme:
    • No Gap – this is where there will be no gap for you to pay following the procedure
    • Known Gap – this is where you will be charged a maximum gap of $500 per specialist, per admission to hospital or a maximum of $800 for obstetrics services.
  • Access Gap Cover does not apply to pathology and radiology services, medical services outside of hospital and services not included in your policy.

Each individual specialist can choose if they will participate in Access Gap Cover on a case by case basis, so we recommend asking your specialist for Informed Financial Consent regarding your out of pocket costs before going into hospital.

  • Before deciding to have a procedure, you should discuss the cost of treatment with your specialist doctor. Your specialist must advise of any gap that you will have to pay and provide Informed Financial Consent, which is a written estimate of the fees for treatment, before you go into hospital.
  • You may also receive services from an assistant surgeon and anaesthetist for your procedure – they can also choose whether or not to participate in the Access Gap Cover scheme. You may have separate gaps to pay for their services.
  • Even if your specialist participates in Access Gap Cover, other out of pocket costs may arise for your in-hospital procedure such as costs associated with your hospital accommodation (including things like Excess and/or Co-Payments) and any prosthesis.
  • Specialists are free to choose to opt in or out of the Access Gap Cover scheme on a patient by patient and procedure by procedure basis – just because they are registered for the scheme doesn’t mean they always use it.
  • If you choose a doctor that does not participate in the Access Gap Cover scheme for your procedure, you will be covered by Medicare and Frank for the scheduled fee but will need to pay any gap.

Access Gap Cover does not cover services provided by pathologists and radiologists such as blood tests and diagnostic imaging. Medicare and Frank will cover the Medicare Benefits Schedule fee for these treatments and you'll only have an out of pocket cost if your doctor charges higher than the Medicare Benefits Schedule fee.

Access Gap Cover example table

Below is an example of how the current benefit structure works with Frank Gap Cover, compared to how it will work from 1 May 2021 for treatment in hospital for a knee reconstruction by a specialist in Victoria who chooses to participate in Access Gap Cover.

Knee reconstruction – current Frank Gap Cover 120% benefit structure
Knee reconstruction Medicare item numbers Specialist fees Total benefit (including Medicare and Frank Benefit) Out of pocket
49542 $2,559.10 $1,630.80 $928.30
Total $2,559.10 $1,630.80 $928.30
Knee reconstruction – Access Gap Cover benefit structure from 1 May 2021
Knee reconstruction Medicare item numbers Specialist fees Total benefit (including Medicare and Frank Benefit) Out of pocket
49542 $2,559.10 $2,159.10 $400.00
Total $2,559.10 $2,159.10 $400.00
The information provided in the table above is for example purposes only. Depending on your level of cover, you may still have out of pocket costs for other services, including for your anaesthetist and/or assistant surgeon.