Co-Payment Rule Change - 1 July 2020

NOTIFICATION OF A NEW MAXIMUM PATIENT CO-PAYMENT (ALLOWABLE PATIENT GAP) EFFECTIVE 1 JULY 2020

Access Gap Cover enables you to charge your patients a co-payment if you wish to do so.

AHSA would like to give you 12 months’ notice regarding a change that we are making to AGC. The allowable patient co-payment (or maximum patient gap) will be changing from 1 July 2020.  From this date, each provider will be able to charge the patient a gap of up to $500 per episode.

Please ensure the relevant personnel within your facility are aware of this upcoming change.  It also provides you with the time to make any necessary system changes if they are required.  We will also send another reminder about this change closer to the effective date.

The following outlines the current gap rule as well as the new $500 rule.

The patient co-payment can be up to the difference between the AHSA benefit and the AMA fee but no more than $400 per item.

If the procedure does not have an AMA Fee, a maximum up to $400 may be charged to the patient.

For multiple procedures, the allowable gap will reduce by 50% on the second procedure and 25% for procedures thereafter.

Obstetricians may charge a co-payment up to $800 per confinement for items that relate to Management of Labour and Delivery as defined in the Medicare Benefits Schedule.

For any procedure or combination of procedures, if you decide to charge over and above the allowable AGC Patient co-payment amounts, then AGC benefits will not be payable.

Also note: You may not charge any fees to your patient such as ‘Booking Fees’ or ‘Hospital Facility Fees’ and the like.

Each individual medical provider in the admitted Episode* of care can choose to charge their patient an out-of-pocket cost of up to $500.

If you decide to charge over and above the allowable AGC patient co-payment, then AGC benefits will not be payable.

Note: If you choose to use AGC you must not charge any non-clinical fees to your patient such as ‘Booking Fees’, ‘Management Fees’, ‘Technology Fees’, ‘Administration Fees’, 'Insurance Levy Fees' or ‘Hospital Facility Fees’ and the like. This includes any hidden fees or fees not being a professional service described by an MBS item number. 

Please also note: The rule for Obstetricians will not change.  Obstetricians can choose to charge their patient an out-of-pocket cost of up to $800 per confinement for MBS items that relate to ‘Management of Labour and Delivery’ as defined in the MBS.