HBF Schedules

HBF Schedules

HBF has several different schedules.

For all states except WA

On 13 February 2017, HBF joined the AHSA Gap Cover system for all states except WA. Cutting Edge will load the appropriate state AHSA schedule.
Copayments rules are in the the AHSA guidelines.

In Western Australia 

There are 3 HBF schedules for WA providers.
  1. Full Cover is the No Gap schedule paying a higher rebate - no out of pocket of any sort is permitted.
  2. Full Cover - Specialist Anaesthetists is the schedule for WA anaesthetists and is also a no-gap schedule.
  3. Known Gap is the basic schedule and has several option.

For claims prior to 1st October 2023

Opt in – pays at the lower Known Gap rates but without the ability to charge a gap. 
Opt in – Known Gap can charge a gap up to the HBF Full Cover schedule, HBF pays rebates at Known Gap level. With this option, the maximum gap is not fixed, it’s the difference between the schedules. 
Opt - out can charge any gap, HBF pays rebates at MBS level.

When using the HBF known-gap schedule, the maximum gap allowable is just 10% above the HBF fee. This means that the maximum charge using this system is equal to the no-gap fee. If a higher copayment is charged, the fund will pay only the 25% rebate up to the Medicare schedule fee.

All outstanding Known Gap claims from prior to 1 October 2023, must be submitted before 31 December 2023.

For claims from 1st October 2023

The Fully Covered schedule will continue and the Known Gap agreement will be replaced by the simpler Provider Choice schedule. WA Providers must elect to use one of these.
1. Fully Covered - this is the No Gap schedule. No out of pocket is permitted
2. Provider Choice which allows the Practitioner the flexibility case by case to choose between 
      (i) Opt In Option using the Provider Choice Schedule, no out of pocket but at a lower rate than the Fully Covered schedule
      (ii) Opt Out Option charging a gap exceeding the Provider Choice Schedule. HBF pays Minimum Benefit only (100% of MBS) with the patient paying the gap.

For more details see the HBF website


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