|
Prior to the introduction of Gap Cover Schemes, medical charges for services provided in hospital could only be covered up to the Medicare Benefits Schedule (MBS) fee set by the Federal Government. If a doctor charged more than the MBS fee, the 'gap' would have to be paid by the patient.
In June 2000, St.LukesHealth introduced St. Luke's Gap Cover, a medical gap cover arrangement designed to eliminate or reduce the 'gap' or out-of-pocket expense on hospital in-patient medical services provided to eligible St.LukesHealth members by participating doctors.
St. Luke's Gap Cover provides a schedule of fees that doctors may choose to use when treating eligible St.LukesHealth members. A doctor who participates in the St. Luke's Gap Cover arrangement can participate either as a 'No Gap' provider, or as a 'Known Gap' provider. A 'No Gap' provider agrees to charge no more than the St. Luke's Gap Cover schedule fee, in which case there will be no gap or out-of-pocket expense for the patient. A 'Known Gap' provider agrees to charge no more than a specified known gap for each medical service, in which case the patient's out-of-pocket expense will be reduced.
Doctors who charge a 'known gap' under the St. Luke's Gap Cover arrangement, will be required to inform the patient of the out-of-pocket expense that applies to their treatment.
A key feature of the gap cover arrangement is a simplified billing process for services provided by participating doctors. The doctor can send patient accounts direct to St.LukesHealth for payment of both the Medicare benefit and the Fund benefit. Patients treated by a 'No Gap' participating doctor, will not receive an account for services provided by that doctor. Patients treated by a 'Known Gap' participating doctor, will only receive an account for the agreed out-of-pocket charge. St.LukesHealth will send a statement of benefit paid to the patient in both circumstances.
Some doctors may still choose to give their account direct to the patient. If they do they will also provide a St. Luke's Gap Cover claim form which must be presented to St.LukesHealth with the account for payment of Medicare and Fund benefit. The account should not be submitted direct to Medicare.
Not all medical services provided during a course of hospital treatment will necessarily be covered by the St. Luke's Gap Cover arrangement. As doctor participation is voluntary, it is possible for only some services to be covered by the arrangement if multiple providers are involved in your treatment.
Participation in the St. Luke's Gap Cover arrangement remains the choice of the individual doctor. If your doctor does not participate in the arrangement and charges over the Medicare Benefits Schedule fee, you will have to pay the gap or out-of-pocket expense for the difference between the amount charged and the MBS fee. Patients using non-participating doctors will be billed directly by the doctor and will still be able to claim the 25% gap between the Medicare benefit and the MBS fee from St.LukesHealth.
|