Access Gap Cover has been designed to help eliminate or reduce your out-of-pocket medical costs (sometimes refer to as your gap) while you are an admitted patient of any registered hospital or day procedure centre.

Medicare pays 75% of the Commonwealth Medical Benefits Scheme (CMBS) fee for professional services while you’re in hospital. Westfund cover the rest of the CMBS fee.

Where the charge exceeds the CMBS fee, we will pay an additional benefit that will eliminate or reduce any out-of-pocket medical gap expenses if the doctor participates in our Access Gap Cover Scheme.

Doctors are independent of Westfund Health Insurance and can choose whether they take part in this scheme on a case-by-case basis. You should ask your doctor to explain the costs of your hospital admission including any prostheses gap amount, their own fees and any other expenses involved. You should also ask any other doctors involved such as assistant surgeons and anaesthetists for their costs. If there are any gaps for you to pay, ask for a written cost estimate. This is known as ‘informed financial consent’.


The Access Gap Advantage


Financial Certainty due to Informed Financial Consent

If your doctor charges you an out-of-pocket (gap) expense, they should inform you in writing in advance of the treatment or as soon as practicable in cases of emergency. Under Access Gap Cover, you will receive a written quote or an estimate of medical fees from your doctor if there will be a gap.


No need to make a claim from Medicare or Westfund

The doctor will bill Westfund directly and we settle the claim on your behalf. We even take care of the Medicare claim for you.


Doctor Search Facility

This is designed to let you know about doctors who have participated in Access Gap Cover before (or indicated that they will) as well as those who have agreed to alternative no-gap arrangements.

Find a doctor using our online search, however, please be guided by the referral process initiated by your GP. If you have been referred to a doctor and that doctor’s name does not appear on this search facility, remember to check with your doctor to see if they will participate in Access Gap Cover for you.

If your doctor chooses not to treat you as an Access Gap Cover patient, we recommend that your discuss the charge with your doctor, before you are admitted to hospital if possible, and request full disclosure of any out-of-pocket expenses.

Your ability to afford the procedures should be discussed with your doctor. If you need to find an alternate doctor, ask your GP.


Doctor-Patient Relationship

Westfund will not interfere in the independent relationship between you and your doctor.

Frequently Asked Questions


How will I know if my doctor will participate?

Doctors can choose to participate in Access Gap Cover on a patient-by-patient basis. It’s important that you ask your doctor whether they will participate in Access Gap Cover for you.

Ask these 3 questions:

  • Will you treat me under Access Gap Cover?
  • Will I have any out-of-pocket expenses and, if so, can you provide a written estimate of how much?
  • Will any assisting doctors also use Access Gap Cover and, if so, how can I obtain a quote for their services?

How can I encourage my doctor to participate?

Participation in Access Gap Cover is open to all doctors who perform inpatient services. It is best to consult with your doctor and ask if they are willing to participate in your case.

Doctors can contact the Australian Health Service Alliance (AHSA) to register their interest to participate in Access Gap Cover.

All doctors can choose to use Access Gap Cover to bill Westfund for inpatient medical treatment. You can ask your doctor to recommend that any assisting specialists (such as an anaesthetist) use Access Gap Cover for the billing of their services too.

If the doctor chooses to use Access Gap Cover, they will need to submit the bill to Westfund on your behalf. They cannot give the bill to you to give to Westfund.


What if my doctor won’t treat me with Access Gap Cover?

An enormous number of doctors throughout Australia have been invited to provide their services using Access Gap Cover however, there are some doctors not willing to do so.

If your doctor chooses not to treat you as an Access Gap Cover patient, we recommend that your discuss the charge with your doctor, before you are admitted to hospital if possible, and request full disclosure of any out-of-pocket expenses.

Your ability to afford the procedures should be discussed with your doctor. If you need to find an alternate doctor, ask your GP.