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St.LukesHealth Medical Gap

St.LukesHealth Medical Gap

Astute Simplicity Health members are eligible for covered on St.LukesHealth Medical Gap, from the underwriter, St.LukesHealth.

St.LukesHealth Medical Gap is designed to eliminate or reduce the gap between the Medicare Benefits Schedule fee and the fee a doctor charges for hospital inpatient medical service, provided your doctor is participating in the St.LukesHealth Medical Gap arrangement. If your doctor chooses to participate in St.LukesHealth Medical Gap, you will either be fully covered for your in-hospital medical treatment or your gap or out-of-pocket expense will be significantly reduced. 

If you hold private hospital cover and have served all your waiting periods, you are eligible for St.LukesHealth Medical Gap benefits when treated by a participating doctor.  Only hospital in-patient medical services are eligible for the 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 the benefit. If your level of hospital cover includes an excess, the excess does not apply to the St.LukesHealth Medical Gap benefit.

Your doctor can participate as a “No Gap” provider or a “Known Gap” provider. A “No Gap” provider agrees to charge no more than the St.Luke’s Gap schedule fee, meaning you will have no gap or out-of-pocket expense to pay. Members treated by a “No Gap” doctor will not receive an account for services provided by that doctor.

A "Known Gap' provider may charge a maximum $500 out-of-pocket for each episode of care, in which case your out-of-pocket expense will be known.

St.LukesHealth will send a statement of benefit paid to the member in both circumstances.

Some participating doctors may choose to give their account to you. If they do, they will also provide a St.LukesHealth Medical Gap claim form, which you must present to St.LukesHealth with the account for payment of Medicare and fund benefit. This account should not be submitted direct to Medicare.

Not all medical services provided during a course of hospital treatment will be covered by the St.LukesHealth Medical Gap 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 Medicare Benefits Schedule, you must pay the gap or out-of-pocket expense for the difference between the amount charged by your doctor and the Medicare Benefits Schedule fee. Members using non-participating doctors will be billed directly by the doctor and will still be able to claim the 25 per cent gap between the Medicare Benefit and the Medicare Benefit Schedule Fee from St.LukesHealth.

What should I do before receiving hospital treatment?

St.LukesHealth encourages all eligible members to check if their doctor participates in the St.LukesHealth Medical Gap arrangement before commencing hospital treatment. We also encourage members to check which other medical providers will be involved in their hospital treatment and whether they participate in the St.LukesHealth Medical Gap arrangement.

If your doctor does not appear on this list, they may still participate in St.LukesHealth Medical Gap. If your doctors does participate, you will need to provide them with your St.LukesHealth 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 costs are likely to be.

Further information regarding medical providers can be found here.

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