Astute Simplicity Health members are eligible for covered on St.Lukes’s Gap Cover, from the underwriter, St.LukesHealth.
St.Lukes Gap Cover is designed to eliminate or reduce the ‘gap’ between the Medicare Benefits Schedule (MBS) fee and the doctor’s charge for hospital inpatient medical services provided by a participating doctor.
What is gap cover?
When you receive a medical service in hospital, Medicare will pay a benefit of 75% of the Medicare Benefits Schedule (MBS) fee. If you hold hospital cover you will also receive a further 25% of the MBS fee from Astute Simplicity Health. This means you will be fully covered up to the MBS fee. However, doctors can charge above the schedule fee and when they do, the difference between the MBS fee and the doctor’s charge is called the ‘gap’.
St.Luke’s Gap Cover is designed to eliminate or reduce this ‘gap’. If your doctor agrees to participate in St.Luke’s Gap Cover you will either be fully covered for your in-hospital medical services or your ‘gap’ will be significantly reduced. Your doctor 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 you will have no gap or out-of-pocket expense to pay.
A “Known Gap” provider agrees to charge no more than a specified known gap for each medical service, in which case your 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.
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.
If your doctor does not participate in the arrangement and charges over the MBS 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 Astute Simplicity Health.
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 Astute Simplicity Health 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. Astute Simplicity Health will send a statement of benefit paid to the patient in both circumstances.
Some participating doctors may still choose to give their account direct to you. If they do they will also provide you with a St. Luke’s Gap Cover claim form which must be presented to Astute Simplicity Health with the account for payment of Medicare and Fund benefit. The account should not be submitted direct to Medicare.
Who is eligible?
If you hold private hospital cover and have served all your waiting periods, you will be eligible for St.Luke’s Gap Cover benefits when treated by a participating doctor.
Only hospital in-patient medical services provided by a participating provider are eligible for St.Luke’s Gap Cover benefit. Out-patient services or services provided to patients who are not formally admitted to an approved hospital or day hospital facility, will not qualify for St.Luke’s Gap Cover benefit.
If you level of hospital cover carries an excess, this excess does not apply to the St.Luke’s Gap Cover benefit.
What should you do before receiving hospital treatment?
St.LukesHealth encourages all eligible members to check if their doctor participates in the St. Luke’s Gap Cover arrangement before commencing hospital treatment. If your doctor does not have information about the arrangement, ask them to contact Astute Simplicity Health for details.
We also encourage members to check which other medical providers will be involved in their hospital treatment and whether they too will be participating in the gap cover arrangement.
A list of participating doctors is provided on the St.LukesHealth web site. Even if your doctor does not appear on this list they may still participate in St. Luke’s Gap Cover.
If your doctor is a participating doctor you will need to provide them with your Astute Simplicity Health membership number.
If your doctor is not a participating doctor, ask them to consider billing you under this arrangement and ask what your out-of-pocket expenses are likely to be.