FAQ – What do changes to the Medical Gap Scheme mean for Bupa Members?

There has been a lot of discussion about changes Bupa has announced to the ‘Medical Gap Scheme’, with many of our customers asking what it means for their cover. Here are answers to some of the most common questions.

This information has since been updated.

What is the Bupa Medical Gap Scheme?

The Bupa Medical Gap Scheme is all about reducing the medical costs you need to pay for treatment in hospital. If your doctor uses our scheme, you’ll never pay more than $500 per specialist for your treatment.

We're changing the terms and conditions to the scheme to make it more transparent and to ensure our patients are never left with surprise out-of-pocket costs.

To provide context, this change only impacts non-contracted facilities. Currently, more than 95% of the total volume of private hospital services delivered to Bupa members (overnight, acute and day stay) are covered by contracts with Bupa. A list of specialists who participate in the Bupa Medical Gap Scheme can be found at www.bupa.com.au/find-a-provider.

Please note - these changes are different to changes Bupa is making to minimum benefits, find out more about those changes here.

So what’s actually changing with the Bupa Medical Gap Scheme?

Bupa has made some changes to what we refer to as ‘the Medical Gap Scheme’.

This change does not impact the majority of customers or services and applies to a very small number of hospitals and day-stay facilities.

The changes impact 2 areas;

1) the 4% of beds that are currently not contracted to Bupa in the private system.

At these locations, our Medical Gap Scheme will no longer be available, but Bupa will continue to make a contribution to your hospital stay in addition to the 25% payment towards the medical costs.

In many cases this will be exactly the same as what happens today, Bupa is just ensuring consistency of payments and experience for our customers everywhere.

Patients who go to hospitals and day-stay facilities which have chosen not to contract with Bupa are likely to experience out-of-pocket costs, as they do today.

We hope that this makes the system more transparent, and more importantly that our customers know up-front about any additional costs, when making a decision about where to go.

It is important to note that doctors often work at multiple hospitals, this includes the 96% of private hospital beds which have an agreement with us.

2) doctors in public hospitals (in some circumstances). Find out more about this here.

Bupa has recently announced two different changes. Firstly, changes to the ‘Medical Gap Scheme’ as discussed above, and secondly changes to ‘Minimum Benefits’. It’s important to note these are two very different things, both designed to improve transparency. Unfortunately in a number of conversations these have become confused.

The ‘Minimum Benefits’ changes only affects customers on some of our lowest levels of cover.  While Bupa is making these changes now, most other health funds made the same changes a number of years ago.

Our customers told us that they found these products and benefits confusing and of little value, which is why we decided to change. These changes also align to the government’s request for greater transparency and clarity for consumers. You can find out more about Bupa's changes to minimum benefits here.

Will I be covered if I go to a public emergency department?

Every Australian resident or permanent citizen can receive emergency care in public hospitals. That’s how the Medicare system works, and it’s available at no cost.

If you’re admitted to a public hospital as the result of an emergency, the public system is designed to cover you for this treatment.

When you’re admitted as a result of an emergency, you may not be getting all of the benefits you should under private cover, like your choice of doctor, and the ability to request a private room. We believe you shouldn’t be actively encouraged to use your cover in these situations.

We also believe that public hospitals shouldn’t choose to prioritise patients with private cover ahead of patients who don’t, considering all Australians should have fair access to treatment, regardless of their ability to pay for it.

What if I want to use my cover in a public hospital?

If you would like to use your cover in a public hospital, you still can. You’re still covered for 100% of the fee on the government’s list (called the MBS) for your medical costs.

Can my doctor use the Medical Gap Scheme in a public hospital?

If you’ve pre-booked your admission as a private patient in a public hospital, you can still use the gap scheme to keep your medical costs low, as long as:

  • The public hospital agrees not to charge you anything above what we pay for your hospital costs. For example, accommodation and theatre fees. And;

  • The hospital follows the same processes a private hospital does in checking what your policy covers you for, and providing information in relation to the services provided.

Does this mean health insurance in Australia is becoming a managed care system like in the US?

Absolutely not. Your doctor will always be the one who decides which treatment you need, and then you and your doctor together decide where you get that treatment.

The Australian health system does not require pre-approval for treatment from insurers, or any pre-authorisation, and this will not be changing.

Bupa is trying to protect its customers from unexpected costs and keep the overall cost of healthcare down, because that impacts the cost of premiums, something customers have told us is their number one priority.

Any claims that Bupa is moving towards a ‘US style system of managed care’ are completely incorrect, and scaremongering by a select group of people whose interests are probably more self-serving than customer centric.

Why are some doctors upset about this?

At the end of the day, some doctors are reacting to our changes because it means the out-of-pocket costs they choose to charge their customers will become very obvious.

It also means if they choose to send you to a non-contracted facility, potentially one they have an interest in, customers will be aware of the additional charges they will be faced with, as a result of the doctor’s decision.

Currently doctors are able to charge patients whatever they want, and may charge different customers different fees for the same thing. This is further explained here: 'Doctors charging up to 10 times more than medicare fees'.

Bupa believes greater transparency is required, and these changes support that.

By pushing to reduce gaps for our customers, it means doctors will have to be transparent about how much extra they’re charging patients as a result of their private cover.

Some doctors have also chosen to put out false or incorrect statements about these changes to deflect attention from the real issue; transparency.

The statements some are making about Australia becoming a ‘managed care’ system like the US, are simply incorrect.

Will I still be able to choose where I get treated?

Absolutely. Bupa customers do and still will be able to choose to be treated wherever they want.

This is, and will continue to be, a decision made between the doctor and the patient.

There’s nothing in the changes we’re making that takes away that choice. What we’re trying to do is to give our customers more transparency and protect them from unknown out of pocket costs that they could be charged, and that’s what these changes are about.

Do these changes mean Bupa can influence which hospital I can go to?

No. People can still choose to be treated wherever they like.

Bupa doesn’t own any hospitals or day stay facilities in Australia, so any suggestions around vertical integration does not make sense in this context and is factually incorrect.

Doctors and health professionals are the people who provide the care, but in some cases doctors can also have a financial interest in part or all of certain facilities.

Where a doctor has a financial interest in a facility, Bupa believes he or she should be declaring this to patients.

Ultimately customers are free to choose where they receive treatment, but Bupa believes it’s in the patient’s best interest to be fully informed about any extra cost up front.

Why bother having private health insurance when you still have to pay large out-of-pocket hospital costs?

These changes to the Medical Gap Scheme are designed to address exactly that concern. Bupa doesn’t want its customers to face unnecessary out-of-pocket costs, which is why we’re trying to do whatever we can to remove or reduce them.

While this change applies to only a very small number of private facilities, we need to remember that 96% of all private beds in Australia have entered into an arrangement with Bupa. This ensures little or no out-of-pocket costs which we believe is in the customers best interests.

However; where a customer chooses to go to a non-contracted facility, it means they’ll go there with full knowledge of their expected costs.


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