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What is Access Gap Cover?

The Access Gap Cover scheme is designed to reduce your out-of-pocket expenses when you receive a service in a hospital.

Under the Access Gap Cover scheme, participating medical practitioners can decide to accept up to the Territory Health Fund fee as full settlement of the account. This means you don’t have to make any additional payments for that particular service.

The doctor can also accept the fee as part of the payment and will inform you of any gap – called the known gap. The known gap is the additional out-of-pocket expenses you will need to pay.

If your doctor doesn’t participate in access gap, we will only cover the 25% between the 75% Medicare Rebate and the Medicare Benefits Schedule fee for inpatient services.

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What is an excess?

An excess is the amount you pay up front if you go to hospital or day surgery. The higher the excess, the less you pay for your regular premiums. The excess applies to all Members covered and is applied to the full cost of hospitalisation, including dependent children (*excluding exempt children as provided below) in both public and private hospitals and day surgery facilities.

In addition to your agreed excess, you may have other out-of-pocket costs associated with your hospital treatment.

The calculation of the excess amount will apply to hospitalisations in the order they are processed by Territory Health Fund. If the excess contribution on your first visit is less than your chosen excess option, and you’re admitted to hospital again in the same Membership Year you will be required to pay the remainder of your excess obligation.

The most you’ll have to pay each Membership Year for your excess payment is outlined below.

Excess level Maximum excess per Membership Year
  Single Couple/Family
$250 $250 $500
$500 $500 $1000
$750** $750 $1500

Once the excess has been paid, the rest of the hospital accommodation charges will be sent to us, so you can enjoy the full benefits of your private hospital cover. Of course your medical costs will be determined by your doctors’ participation with our gap scheme. See Access Gap section for more information.

*Under our Better Hospital (Silver+) cover, we don’t charge any excess on children aged 12 years or under if they need to be admitted to hospital for medical treatment.

** Only available on Vital Hospital (Bronze+) cover

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What is a pre-existing condition?

A pre-existing ailment, illness or condition is one where signs or symptoms of the condition were present at any time during the six months prior to applying for membership of Territory Health Fund or an upgrade of  your existing cover, determined by a Territory Health Fund appointed medical practitioner. You may have a pre-existing condition, ailment or illness without even being aware of it.

If we find that a pre-existing condition was present, you will need to serve a 12 month waiting period before claiming benefits for treatment. It isn’t necessary for the signs or symptoms to have been diagnosed by a doctor at the time of joining or upgrading your cover.

The 12 month waiting period for pre-existing ailments can be applied to all hospital (or hospital substitute) treatments for which we pay benefits. There are a couple of exceptions; a two month waiting period applies to the following services:

  • Approved rehabilitation treatment
  • Palliative care

The 12 month waiting period for the treatment of a pre-existing ailment can also apply to extras services.

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What are out-of-pocket expenses for hospital treatment?

Out-of-pocket expenses are the additional costs once all Medicare and private health insurance benefits have been expended. Usually, out-of-pocket expenses apply when you’re not fully covered for a particular treatment or service, or when a set benefit limit applies. Discovering you’ll be out of pocket can be a tough pill to swallow, especially after being discharged from hospital, or once your treatment is complete.

It’s your right to know if there are any out-of-pocket expenses that you might incur as part of your treatment, to avoid any surprises later. Knowing the cost of your medical treatment upfront is called Informed Financial Consent, and the Government has introduced a checklist, providing you with the questions you need to ask before going into hospital.

We recommend contacting us before going into hospital so that we can discuss what your policy provides cover for, and if any out-of-pocket expenses will apply. We’ll also supply you with a copy of the checklist. By talking to us before going into hospital, you’ll have the total picture and can avoid any unwanted surprises later.

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What is hospital cover?

Hospital cover protects you and your family if you need to go to hospital, by covering most of the major expenses that come with hospital treatment.

Having hospital cover means you don't need to be concerned about public hospital waiting periods, as well as giving you access to your choice of hospital and your choice of doctor in most cases.

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Do excesses apply to young children?

If you've got Better Hospital (Silver+) cover, we don't charge an excess for children up to and including the age of 12 if they need to go to hospital for treatment.

If you have Vital Hospital (Bronze+) cover, excesses still apply to children.

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What is an excluded benefit or service?

If a service is marked as "excluded", it means you won't be covered in a public or private hospital and we won't pay any benefits on that service. If you think you'll need treatment for any excluded service, we recommend you review our Better Hospital (Silver+) cover and see if it is right for you. 

If you're upgrading, don't forget that you'll need to serve a 12 month waiting period on those excluded or restricted services before you can claim.

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What is a restricted benefit or service?

If a service is covered as a restricted benefit, you will only be covered with your choice of doctor for shared ward accommodation in a public hospital. If you go to a private hospital or day facility for a service which has restricted benefits, you will pay large out-of-pocket expenses. Restricted benefits are amounts set by the Government and are not enough to cover accommodation costs in a private hospital. Although cover with restricted benefits entitles you to your choice of doctor in a public hospital, your doctor may not be willing, or able, to treat you in a public facility

Waiting periods may also apply to all restricted services.

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What is the Medicare Benefits Schedule?

When you go to hospital, your doctor, surgeon and anaesthetist all charge for their services separately to your hospital accommodation costs. Their fees are known as medical expense. These medical expenses are assessed against the Medicare Benefts Schedule (MBS) fees, which are set by the government. If you're admitted to hospital as a private patient, Medicare will pay 75% of the MBS fee for your medical expenses. We then pay the remaining 25% of the MBS fee.

However, some doctors charge more than the MBS fee, which can mean big out-of-pocket expenses for you. Our private hospital cover can help reduce or avoid these extra expenses through our Access Gap agreement.

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What benefits do you pay for hearing aids?

Hearing aids are covered on our Better Hospital (Silver+) product. A benefit amount is provided to use over a period of three (3) Membership years based on the date on which the purchase of a hearing aid/s is made. The benefit limit is applied based on your length of membership with Territory Health Fund.

  • Up to 10 years - $1,000
  • 10-15 years - $1,500
  • 15 years + - $2,000

Benefits per person are calculated at 85% of the cost of hearing aids up to the appropriate limit of benefits.

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What is a waiting period?

Waiting periods are exactly what their name suggests; the length of time a policy holder needs to wait before being able to make claims on services.

They apply when you join any health fund for the very first time, or when you upgrade to a higher level of cover.

Waiting periods are designed to keep health cover fair for everyone, by protecting the fund and Members against people who join intentionally to make big claims, and then cancel their membership.

If you're transferring from another fund and take out an equivalent level of cover, or if you've previously been covered by your parents' membership, we recognise that you've already served the waiting periods, so you can claim straight away. If you upgrade to a higher level of cover when you switch, you'll only need to serve the waiting period on the increased benefits.

Our table below outlines the waiting periods that apply to hospital and extras:

Item/Service

2 month waiting period appliesHospital

  • For all hospital treatments or services where there are no pre-existing conditions (excluding accidental injury ^)
  • Rehabilitation - eg. inpatient rehabilitation, stroke recovery, cardiac rehabilitation
  • Hospital psychiatric services
  • Palliative care

Extras

  • Dental
    • Diagnostic – includes examinations & consultations
    • Preventative – includes cleaning and scaling, fluoride treatment etc.
    • Simple extraction
    • Restorative – composite and amalgam fillings
    • General services – includes mouth guards and occlusal splints
  • Optical
  • Acupuncture
  • Audiology
  • Chiropractor
  • Remedial massage therapy/myotherapy
  • Osteopathy
  • Chinese Medicine
  • Dietician
  • Occupational therapy
  • Orthoptic therapy
  • Physiotherapy
  • Exercise physiology
  • Podiatry
  • Psychology
  • Speech therapy
  • Healthy Living benefits
  • Foot orthoses and orthopaedic shoes
  • Pharmaceuticals
  • School accidents^
  • Sporting accidents^

12 month waiting period appliesHospital

  • Pre-existing conditions (excluding rehabilitation, hospital psychiatric services and palliative care)
  • Pregnancy and birth
  • Mechanical aids and appliances
  • Surgery for assisted fertility programs such as IVF or GIFT, sterilisation or vasectomy, elective surgery
  • Mammograms and bone density tests
  • Hearing aids
  • Australian Hearing Services Card
  • Nursing Services
  • Mamograms and bone density tests
  • Hospital boarder
  • Nursing home type patients

Extras

  • Major dental services
    • Periodontics – specialised gum treatment
    • Surgical extraction – includes wisdom tooth extraction
    • Endodontic services – includes root canal therapy
    • Crowns and bridges
    • Prosthodontics – dentures
    • Orthodontics – braces etc.
    • Supply of hearing aids
  • Childbirth education

Emergency Ambulance

A one day waiting period applies to emergency ambulance treatment

^ Two month waiting periods apply for most other items or services. Cover for an accident is immediate provided it is not recoverable from another source such as Workers Compensation, third party or other liability provision. Sporting accidents sustained by sportspeople in activities relating to their fulltime employment as a sporting professional, including training and competition have a two month waiting period.

 

 

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Can I upgrade my cover?

If you're on one of our lower or medium levels of cover, you can choose to upgrade at any time by contacting us on 1800 623 893.

Upgrading could include:

  • Increasing the level of cover - for example, going from Intermediate to Value Plus Hospital
  • Adding a new cover - for example, adding extras cover
  • Reducing your excess - that is, going from $750 (Vital Hospital (Bronze+)) or $500 excess to $250

If you're upgrading, you may need to serve waiting periods on the upgraded portion of your cover. While you're waiting, we'll still honour the benefits of your previous cover. Conditions also apply to hospitalisation if you're changing your excess.

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Can I downgrade my cover?

If things are a bit tight financially, or if you want to change to a level of cover that's more practical, you can choose to downgrade your cover.

Downgrading may include:

  • Reducing the level of cover - for example, going from Better Hospital (Silver +) to Vital Hospital (Bronze+) cover
  • Removing a current cover - for example, dropping extras cover
  • Increasing your excess - going from a $250 to $500 excess or $750 for Vital Hospital (Bronze+)

If you choose to downgrade, you won't need to serve additional waiting periods, and your new excess applies to inpatient hospital services immediately.