What Is Access Gap Cover? (AGC) — A Simple Guide for see-u by HBF Members
Access Gap Cover (AGC) helps reduce or even eliminate out-of-pocket costs when you’re treated in a private hospital. This simple guide explains what Access Gap Cover is, how it works, and how it helps keep your private hospital costs predictable.
Important: Not all doctors use Access Gap Cover and not all health funds offer it. At see-u by HBF, we do. Always ask your doctor if they will treat you under AGC before your procedure.
Want the simple version before getting into the details? Our Mind the Gap blog has you sorted.
How Access Gap Cover Works
Access Gap Cover is designed to reduce the medical gap — the difference between what your doctor charges and what Medicare + your private health insurer cover.
At see-u by HBF, we choose to participate in AGC because it helps keep private hospital costs fair and transparent for our members. We partner with the Australian Health Services Alliance (AHSA) to offer AGC across Australia.
The simple explanation
When a doctor participates in Access Gap Cover for your treatment:
- They agree to charge within a set fee limit
- see-u by HBF pays a higher benefit behind the scenes to help close that gap
- You may end up with no out-of-pocket cost or a small, capped gap
Each doctor involved decides case by case whether they will participate in AGC.
Benefits of Access Gap Cover
- Lower or no out-of-pocket hospital costs
- Clearer fee estimates before your procedure
- Reduced paperwork (your doctor can bill us directly)
- A smoother, more predictable hospital experience
AGC does not apply to pathology, radiology, out-of-hospital services or treatments excluded from your policy.
One see-u member saved over $40,000 in out-of-pocket costs by asking about Access Gap Cover before surgery.
Access Gap Cover Billing: No Gap vs Known Gap
When a doctor participates in AGC, they choose between two billing options:
- No Gap (You Pay $0)
Your doctor charges an amount equal to the AGC benefit (Medicare + see-u by HBF).
This means you pay nothing out-of-pocket.
- Known Gap (A Small, Capped Fee)
Your doctor charges slightly more, but the amount you pay is capped at:
- $500 per hospital episode, per provider (surgeon, anaesthetist, assistant surgeon), or
- $800 per obstetric service
If a doctor does not participate in Access Gap Cover, we can only pay the standard Medicare Benefits Schedule (MBS) fee and you pay the rest.
Other Fees Under Access Gap Cover
Doctors treating you under AGC cannot charge administrative or booking fees.
Only services linked to an MBS item number can be billed.
If you’re unsure whether a charge is allowed, ask your doctor or call us for support.
How to Find Doctors Who Use Access Gap Cover
Not all doctors use AGC for every procedure, so it’s important to check early.
You can use the see-u by HBF Provider Search to find doctors who often participate in Access Gap Cover. Because participation is case-by-case, always confirm directly with your doctor.
When to Ask Your Doctor About Access Gap Cover
Discuss AGC before you agree to a procedure or sign your Informed Financial Consent.
Checklist to ask each provider
- Do you participate in Access Gap Cover for this procedure?
- Will I have any out-of-pocket costs?
- Can I get a written estimate or quote?
- Are there any other fees linked to this treatment?
- Could these fees change, and how will you let me know?
- Do I need to pay anything upfront?
- Will you bill see-u by HBF directly?
Member tip: A two-minute conversation about AGC can save you hundreds — or in some cases, tens of thousands.
Need Help Understanding Access Gap Cover?
If you’re planning a hospital procedure and want someone to talk you through Access Gap Cover, fee estimates or how to check doctor participation, the see-u crew is here to help.
We’re committed to keeping your cover simple, transparent and affordable.