Access Gap Cover: Reduce Your Gap Fees

In short

Access Gap Cover can help reduce or eliminate gap fees, meaning you may pay less out of pocket for inpatient hospital admissions.

Huge differences in gap fees for the same surgery: why you should ask about Access Gap Cover

New research shows that Police Health's Access Gap Cover (Access Gap) can save you thousands of dollars in gap fees.

It follows Private Healthcare Australia analysing what people with health insurance were charged by surgeons for common operations in 2024-25.

The following variation was found:

Cataract surgery: The median or typical fee was $500 but 10 per cent of patients were charged more than $1,800
Knee replacement: The median fee was $1,080 but 10% of patients were charged more than $5,300
Hip replacement: The median fee was $1,240 but 10% of patients were charged more than $5,500
Gall bladder removal: The median was $600 but 10% of patients were charged more than $2,410
Children’s tonsil removal: The median fee was $850 but 10% of patients were charged more than $2,210
Children’s grommets: The median fee was $670 but 10% of patients were charged more than $1,320
Gastrointestinal endoscopy (gastroscopy): The median fee was $170 but 10% were charged more than $400

How Access Gap works and how to use it

Access Gap eliminates, or substantially reduces, the out-of-pocket expenses that are part of an inpatient hospital stay for people with private health insurance.

It's what some refer to as a ‘known gap scheme', and all you have to do is ask your treating specialist or surgeon if they'll treat you under Access Gap.

It is up to their discretion, but if they agree, the maximum you’ll pay is a known gap of up to $500 per doctor per hospital episode ($800 for obstetrics), or agree to no gap at all.

Specialists aren’t obliged to participate in the scheme, so if they won’t, you can keep looking.

It's available to Police Health members with Gold Hospital cover and Gold Combined cover*.

An example of how to use it

You can ask to use it when you're referred to a specialist for treatment or surgery as an inpatient being admitted to hospital.

Once you've got a referral for a specialist, follow these steps;

Use our ‘Find an Access Gap Doctor’ tool to call specialists in your area to ask about their fees before making an initial appointment. You can take a referral to any specialist, not necessarily the one named in your referral letter.
Ask your preferred specialist the following;
1. Would you treat me under Police Health's Access Gap arrangements?
2. Will I incur any personal out of pocket expenses for my treatment and if so, can you give me a written estimate of how much?
3. Will any assisting doctors also use Access Gap Cover? This refers to other specialists including anesthetists.
4. Are you prepared to send the bill to Police Health directly, so that they can claim my Medicare benefit on my behalf and send the payment back to you?

Find a specialist now

What is the gap in private health insurance?

When you go to hospital, there’s often a gap between what Medicare will pay and what the doctor charges.

This is because many doctors choose to charge more than the Medicare Benefit Schedule fee.

This means after Medicare and your health fund contribute, there’s still a difference. This is often called the “gap” or “out-of-pocket” costs.

Whilst a health fund pays a benefit towards it, that ‘gap’ can leave you with large out-of-pocket expenses to pay.

But with Access Gap, that gap can be eliminated, or substantially reduced.

Access Gap Cover FAQs

Access Gap Cover eliminates, or substantially reduces, the out-of-pocket expenses that are part of an inpatient hospital stay for people with private health insurance.

All you have to do is ask your treating specialist or surgeon if they'll bill you under Access Gap.

If they agree, the maximum you’ll pay is a known gap of up to $500 per doctor per hospital episode ($800 for obstetrics), or agree to no gap at all.