Bupa Medical Gap Scheme – what’s changed?
We've recently contacted specialists to let them know about changes made to the Bupa Medical Gap Scheme (Scheme) and Scheme Terms and Conditions from 1 December 2021. This is in response to customer and clinician feedback and changes from the Medicare Benefits Schedule (MBS) Review Taskforce.
See attached Letter to Providers
View new Medical Gap Scheme Terms and Conditions – effective 1 December 2021
View new Medical Gap Scheme Schedules – effective 1 December 2021 - (excel version updated to include 1 November 2021 MBS changes)
Frequently asked questions
(updated 13 October 2021)
What is Bupa doing?
Bupa is making changes to some of the benefits it pays to specialists for services through its Medical Gap Scheme. Bupa is introducing a nationally consistent Medical Gap Scheme model to pay specialists the same rate for the same item across all states and territories.
At the same time, it will further invest in a model that helps customers avoid out-of-pocket costs. Specialists will be offered a higher payment if they use Bupa's 'No Gap' Scheme rather than its 'Known Gap' Scheme.
Why are Bupa introducing a national rate?
Bupa currently pays specialists different amounts in different states or territories. To date, Bupa has maintained different state-based Medical Gap Scheme Schedules as a legacy of the mergers of the HBA, Mutual Community and MBF brands. As a result, specialists in some states or territories receive a different rate to their interstate peers for the same service. This is inconsistent with other major health insurers and potentially confusing for specialists.
Bupa's current Scheme also offers only a single rate for both 'Known Gap' or 'No Gap', so there is little incentive to offer a 'No Gap' experience for patients.
Where can I obtain a copy of the new national rates, applicable from 1 December 2021?
A copy of the new 'No Gap' and 'Known Gap' national Scheme Schedules are available here. An excel version of the new Scheme Schedules will be available closer to 1 December 2021.
Click here to view the new 'No Gap' and 'Known Gap' national Scheme Schedules. - (excel version updated to include 1 November 2021 MBS changes)
What does this mean in practice?
The national system aims to create consistency across all states and territories. Most specialists will see an increase or no change to the amount Bupa pays them. For some specialists, particularly in South Australia and Victoria, payments will be lower.
For context, they have for legacy reasons received payments substantially higher than those paid by other insurers and the national Bupa average. Specialists elsewhere, particularly in other states, are likely to see higher payments than today.
How will this impact the rates paid?
Bupa will aim to continue to pay specialists more for most inpatient services than any other major health insurer. While some may see a reduction, Bupa has increased the rates on many items with particular focus on incentives for 'No Gap' participation.
When do these come into effect?
The new Scheme arrangements will take effect from Wednesday 1 December 2021.
What is the difference between Bupa's 'No gap' or 'Known gap' Scheme?
Bupa will introduce a new 'Known Gap' rate for specialists who register and participate in the 'Known Gap' scheme. These providers can charge up to $500 Known Gap per patient per episode of care.
It is also introducing a higher 'No Gap' rate (higher than the new 'Known Gap' rate) for specialists who register and participate in our 'No Gap' Scheme. These providers accept the higher Medical Gap Scheme rate as full payment for the patient episode of care. No out-of-pocket (gap) costs can be charged.
Why is the maximum Known Gap I can charge limited to $500?
Specialists that participate in the Bupa Known Gap Scheme, can charge a Known Gap of up to $500 per episode of care.
Our customers tell us out-of-pocket costs are confusing so we've capped this amount to help provide certainty to Bupa customers that they will not be out-of-pocket more than $500 per Specialist if they use a Bupa Known Gap Scheme Specialist.
Of course, where appropriate, we apply indexation to the rates paid to providers but believe providing continued certainty for customers is important and as such, have maintained the Known Gap to a maximum of $500.
Do specialists have to participate in the Medical Gap Scheme?
No. Whilst Bupa encourages specialists to use the Scheme for all customers, Bupa appreciates there may be occasions where a specialist chooses not to accept the Scheme rate.
On these occasions, the specialists must:
- obtain full Informed Financial Consent (IFC) from the eligible Bupa customer at the first consultation leading to the episode of care; and
- bill the patient directly.
In these cases, Bupa will pay the customer 25% of the MBS Fee.
If a specialist does choose to participate in the Scheme, they must register each of their unique practice location with Bupa as either a 'No Gap' specialist or, a 'Known Gap' specialist. The specialist can choose to use the Scheme for inpatient admissions, as a private patient in a public hospital or, in a private hospital, which has an agreement with Bupa.
Can I register for both 'No gap' and 'Known Gap'?
Specialists must register for EITHER 'No Gap' or 'Known Gap' for each unique practice location. You can differentiate which scheme you use at different practice locations, but you cannot register for both schemes at the same practice location. Should you wish to switch between these Schemes, you must submit a change of details form. Please allow up to 30 days for your Scheme status to be updated.
If a specialist registers for 'No Gap':
- They will be promoted as a 'No Gap' specialist
- A higher 'No Gap' benefit is payable
- They agree to accept the 'No Gap' benefit as full payment for the episode of care
- They can opt out of the Scheme on a case-by-case basis
If a specialist registers for 'Known Gap':
- They will be promoted as a 'Known Gap' specialist
- They will receive the 'Known Gap' benefit
- They can charge the patient a gap of up to $500 per episode of care
- They can opt out of the Scheme on a case-by-case basis
What do specialists need to do?
You don't need to do anything if you want to remain on your current registration status, i.e.: in this scenario, your current Scheme registration status will continue to apply from 1 December 2021, if it is not updated.
To change any practice Scheme registration status and ensure claims aren't impacted, please log into the portal at providers.bupa.com.au using your unique code located in the email or letter we sent you before 10 November 2021. You can change your practice Scheme status at any time after this date by contacting us on firstname.lastname@example.org or calling us on 1800 931 194 and we'll aim to process your request as soon as possible. Please ensure you have your Bupa Practice Identification (ID) number available, as this will assist us to identify your practice.
Has Bupa updated its Terms and Conditions?The Scheme changes take effect from 1 December 2021. The updated Terms and Conditions will apply from 1 December 2021. Bupa recommends all its providers familiarise themselves with these new Terms and Conditions. Providers continual use of the Scheme after 1 December 2021 constitutes their agreement to comply with the amended Terms and Conditions.
Will this change what my patient is covered for?
No. There is no change to Bupa's health insurance policies for customers.
What happens if I have an admission booked on or after 1 December 2021?
For pre-booked admissions on or after 1 December 2021 our new medical gap scheme rates will apply.
How will my status as a participating Scheme specialist be promoted?
To assist Bupa customers and referring specialists to be able to identify specialists who are registered under the Scheme, Bupa may promote details of your practice including contact details, information about your participation in the Scheme, and the location(s) at which you practice.
This information may appear in any Bupa approved media or materials, including on any Bupa website or Mobile App, via call centres and retail centres or affiliated partner websites.
Bupa may also advise customers to ask you about the Scheme and any Known Gaps when they contact you.
Who can I talk to at Bupa about this?
For any questions, please contact us on email@example.com or call us on
1800 931 194. Please ensure you have your Bupa Practice Identification (ID) number available, as this will assist us to identify your practice.
New Medical Gap Scheme Terms and Conditions – effective 1 December 2021
New Medical Gap Scheme Schedules – effective 1 December 2021 (excel version updated to include 1 November 2021 MBS changes)
Medical Gap Scheme Terms and Conditions – 1 August 2018
Medical Gap Scheme Schedules – 1 July 2021
You will be able to access the Provider Portal to change your registration status using the following browsers: Internet Explorer (Version 11 only), Microsoft Edge, Safari and Chrome