Document ID: chunk:federal_register_of_legislation:F2024L00144:reg:65:p36
Version: federal_register_of_legislation:F2024L00144
Segment Type: reg
Provision Reference: reg 65 (pt 36/38)
Character Range: 150621–153567

practitioner, within the meaning of that term in subsection 3 (1) of the Health Insurance Act 1973, and an insurer under which the practitioner agrees to accept payment by the insurer in satisfaction of the amount that would, apart from the agreement, be owed to the practitioner in relation to the treatment provided to the insured person.

No Gap Agreement         Means an agreement where the medical practitioner agrees to accept a payment by the insurer in full satisfaction of the amount owed so that there no gap, or no out of pocket expenses to be paid by the insured person.

Known Gap Agreement      Means an agreement where the medical practitioner agrees to accept a payment by the insurer in part satisfaction of the amount owed and the patient has provided informed financial consent so that the gap or out of pocket expenses to be paid by the insured person are known in advance.

No Agreement             Is where there is no agreement in place.

Amount charged           Is the amount accepted in full payment (if known), or the invoice amount.  For analytical purposes the amount charged and related data are collected in ranges with reference to the MBS where the amount charged is:

                         > MBS to 125% MBS Fee.
                         >125% to 150% MBS Fee.
                         >150% to 200% MBS Fee.
                         >200% MBS Fee.

Medicare benefit         Is the amount calculated by reference to the fees for medical services set out in the table of schedule fees.

                         Schedule fee, in relation to a professional medical service, means the fee specified in the table in respect of the service.

                         A Medicare benefit in respect of a professional service is:

                            (a)        in the case of a service provided:
                               (i)           as part of an episode of hospital treatment; or
                               (ii)          as part of an episode of hospital-substitute treatment in respect of which the person to whom the treatment is provided chooses to receive a benefit from a private health insurer; an amount equal to 75% of the Schedule fee.

Fund Benefit             Is the amount the fund pays in full or part satisfaction of the amount owed to the provider in excess of the Medicare benefit.

Gap                      Is the amount paid by the insured person, or their out of pocket expense, and is calculated as:

No of services           Is the number of medical services for the category.

% of services            Is the number of medical services for the category as a percent of the total number of medical services over all categories.

Amount charged % of MBS  Is the total amount charged in the category divided by the Medicare benefit schedule (MBS) fee. This is calculated as:

                         Note: that the Medicare benefit is 75% of the schedule fee.

Index