Don't be deceived by scaremongering: here's why Bupa is changing the Medical Gap Scheme

The scaremongering around ‘managed care’ could not be further from the truth. 

This information has been updated.

Bupa will continue to pay all benefits in-line with our mandatory obligations at non-contracted facilities, ensuring 100% of the Medicare rate is paid.

That said, we believe where we are making additional contributions over and above minimum requirements, these funds should primarily be going to our customers, to eliminate out-of-pocket costs.

Why is Bupa's Medical Gap Scheme changing?

Firstly, it's important to understand what the Medical Gap Scheme is.

Recently there's been a strong focus on both the affordability and transparency of private health insurance, by governments and media alike. This is not just in in relation to medical costs, but for hospital episodes too.

The changes to the Medical Gap Scheme are designed to improve affordability and transparency, as we have been promising to do.

Unfortunately, and in all too many cases, customers have not been told when being booked into a hospital or day facility that it's not contracted with Bupa.

When this is combined with ad hoc use of the medical gap scheme by treating doctors, customers have been left with large out-of-pocket costs which they weren't expecting.

This is exactly the lack of transparency that people have been talking about, and that Bupa is committed to fixing.

It’s also important to know this change only impacts a very small portion of Bupa claims, with more than 96% of all Bupa claims for private same-day and overnight admissions currently going through contracted facilities.

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I've heard claims Bupa is moving to a managed care system similar to the US, is this true?

The direct answer is absolutely not.

Australia does not require customers or doctors to seek pre-approval prior to treatment. This continues to be the case today.

Doctors, never health insurers, will always determine patients’ treatment and care options as they do today; nothing has changed.

However, customers have been asking for greater clarity on costs especially at locations where mixed arrangements were in place, and this change to the medical gap scheme is designed to support this.

Managed care cannot and will not occur in Australia. This is complete misinformation.

Those pushing out these statements are doing so to cloud what the change actually means.

The only change, applicable only at a very small number of locations, actually means that doctors must advise a patient if they are going to a contracted hospital or not, and then must advise what their medical costs will be for the service.

The patient then will have full informed consent and can decide how they wish to proceed either at the recommended non-contracted facility or anywhere else they choose to go.

Of course, most doctors have multiple admitting rights across Australia and if they operate at a contracted facility, which they can choose to do, then not only will the hospital bill be covered but also they can also use the gap scheme to help customers minimise their medical costs.

The change is designed to help the customer gain full informed consent, something that was not previously occurring.

How will this affect Bupa Health Insurance customers?

In making these changes we know there are three possible consequences, all of which are good for our health insurance customers;

  1. The customer is informed up-front about all costs involved and chooses to have the treatment in the non-contracted facility. Whilst a gap will exist, the customer has made a decision to go there regardless, with full informed consent.

  2. The customer requests to be treated at a contracted facility where not only is the hospital cost fully covered (excluding any excess if applicable) but they can also gain access to the medical gap scheme, with informed financial consent.

  3. The customer decides they want to stay with the treating doctor and go to the hospital and chooses to transfer health funds and receive treatment with a reduced out-of-pocket.

All of these scenarios are good for the consumer and are aided by Bupa providing clarity around which benefits are paid at a non-contracted facility.

These changes are designed to support the customer, the only person we should all be advocating on the behalf of.

READ MORE: We answer some of the most Frequently Asked Questions around changes to Bupa's Medical Gap Scheme, including why some doctors aren't happy about it, and whether it will impact which hospital you can recieve treatment at.