3. Private Admitted Patients

3.3 Patient Election Procedures

Reference Public Hospital Circular 25 - September 2004

Hospitals should note that all eligible persons have the choice to be treated as either public or private patients. Election to be treated as a public or private patient must be made by the patient or their legally authorised representative before, at the time of, or as soon as practicable after admission. The patient or their legally authorised representative should sign a statement acknowledging that they have been fully informed of the consequences of their election, that they understand these consequences and that they have not been directed by a hospital employee to a particular decision.

Where admitted patients or their legally authorised representatives do not make a valid or actual election, these patients will be treated as public patients and the hospital will choose the doctor until such time as a valid election can be made. When a valid election is made, that election can be considered to be for the whole episode of care commencing from admission.

After admission and initial election, patient election status can only be changed in the event of unforseen circumstances. Examples of unforseen circumstances include, but are not limited to:

• Patients who are admitted for a particular procedure but are found to have complications requiring additional procedures;
• Patients whose length of stay has been extended beyond those originally and reasonably planned by an appropriate health professional; and
• Patients whose social circumstances change while in hospital (for example loss of job).

Inadequate private health insurance cover is not a sufficient reason for changing a patient’s election status.

In situations where a valid election is made, and then changed later because of unforseen circumstances, the change in patient status is effective from the date of change onwards and should not be retrospectively backdated to the date of admission.

Election forms

The admitted patient election form and information sheet included in the Fees and Charges Manual has been updated to reflect the requirements of the National Standards for Public Hospital Admitted Patient Election Processes (Schedule E of the Australian Health Care Agreement).

Hospitals can tailor election forms to meet individual hospital requirements. However, development of local election forms must be consistent with the National Standards and the Australian Health Care Agreement. The current practice of many Victorian hospitals, that do not use the information sheet from the Fees and Charges Manual but incorporate this information into other information provided to patients, is consistent with this approach.

All elections forms in use in Victorian public hospitals must comply with the National Standards. Hospitals are requested to review their election forms in light of the National Standards and make any required amendments. To assist you, the patient election form and the accompanying information sheet Victorian Public Hospitals-Information for Patients are provided as samples.

Multiple and Frequent admissions election forms

The Department is aware that some hospitals have developed election forms suitable to patients who require multiple or frequent admissions. This is appropriate provided that patients have the same information and choices as the single admission election form and the form is consistent with the National Standards and the Australian Health Care Agreement. Additionally, forms should be for a specified period, not exceeding six months, and nominate the hospital unit where the treatments will be provided.

The Fees and Charges Manual has been updated with this information http://www.health.vic.gov.au/feesman/fees2.htm.

Hospitals can obtain a copy of the Australian Health Care Agreement from the web link http://www.health.vic.gov.au/agreement/index.htm

Victorian Public Hospitals - Information for Patients

Download ( PDF File 54 KB)

The Medicare Agreement between the Commonwealth and State governments requires that YOU (or your agent) elect to be treated as a public (non-chargeable) or private (chargeable) patient upon admission to this hospital. Hospital employees cannot direct you towards making a particular decision.

Your election status (public or private) is valid from the commencement of your admission (admission date) through to the end of the admission.

You (or your agent), having made an informed election to be treated as a public or private patient upon admission to this hospital, cannot change your initial election status except in the event of unforeseen circumstances.

Examples of unforeseen circumstances include, but are not limited to:

• Patients who are admitted for a particular procedure but are found to have complications requiring additional procedures
• Patients whose length of stay has been extended beyond those originally and reasonably planned by an appropriate health care professional
• Patients whose social circumstances change while in hospital (for example loss of employment)

Inadequate private health insurance cover is not a sufficient reason for changing your election status.

In situations where a change is made to election status because of unforeseen circumstances, the change in patient status is effective from the date of the change onwards, and is not retrospectively backdated to the date of admission.

A Public Patient

• Must be eligible to receive treatment under Medicare
• Will be treated by doctors nominated by the hospital
• Cannot chose a specific doctor to provide his/her medical treatment, and
• Will not be charged for medical or hospital services.

You cannot choose to be a public patient if you:

• Elect to be treated by a doctor of your own choice
• Elect to occupy a bed in a single room, or
• Are not eligible to receive treatment under Medicare.

Note that single rooms are not available in all Victorian public hospitals. Where present, these are allocated first to patients with specific medical or clinical need for single room accommodation. Private patients desiring a single room will be allocated this accommodation only if the single room is not medically required for other patients.

A Private Patient

• Will be treated by his/her nominated doctor(s) provided that the doctor(s) has the right to practice at the hospital, and
• Will be responsible for the payment of the hospital accommodation fees, charges for all medical and diagnostic services, prosthesis, dental fees and other related services.

Private Health Insurance

• Does not stop you from electing to be a public patient
• Will cover full cost of shared ward accommodation but may not fully cover costs (depending on level of cover) if single room accommodation is chosen
• Medicare will cover 75% of the Commonwealth Medical Benefits Schedule fee for the medical services provided to private patients while in hospital and private health insurance will cover the remaining 25% of the fee
• Where a doctor charges a fee which exceeds the Commonwealth Medical Benefits Schedule fee, the patient will be responsible for paying the difference between the fee charged by the doctor and the Schedule fee.

Your authorisation is required by the hospital to enable release of a copy of your admitted patient election form to your health insurance fund (if this is requested by the fund). Failure to give this authorisation may result in the refusal of the health fund to provide benefits.

Compensable Patients

If you are, or may be, entitled to, (or have already received) compensation, damages or other benefits in respect of the injury, illness or disease for which you are receiving hospital care and medical treatment, all fees and charges may be met by your compensation. This includes, for example, compensation under the Accident Compensation Act 1985 (Vic), Transport Accident Act 1986 (Vic), Criminal Injuries Compensation Act 1983 (Vic), Safety Rehabilitation and Compensation Act 1988 (Cth), or a claim for damages at common law.

Veterans' Affairs Patients

Veterans' Affairs patients are those for whom the Department of Veterans' Affairs has agreed to accept responsibility for hospital charges for the condition for which you are being admitted.

Form of Election for Admission to a Public Hospital

Download ( PDF File 60 KB)

I (name)....................................................................................................................

of (address)................................................................................................................

elect for myself / or on behalf of (patient name).............................................................................

I understand that:

• All eligible persons have the right to choose to be treated as either public or private
• A person with private health insurance can elect to be treated as a public patient
• Provided I (or my agent) has made an independent informed decision, my initial election status cannot be changed except in unforeseen circumstances
• This election is valid for the entire episode of care in this hospital, commencing on my admission date.

Private (chargeable) Patient

Note that single rooms are not available in all Victorian public hospitals. Where present, these are allocated first to patients with specific medical or clinical need for single room accommodation. Private patients desiring single rooms will be allocated this accommodation only if available single rooms are not medically required for other patients.

Public (non-chargeable) Patient

Compensable/Veterans' Affairs Patients

3.4 New Prostheses Arrangements

The Australian Government introduced legislative amendments on 10 March 2005 necessary for the implementation of new prostheses arrangements.

The Commonwealth advise that new prostheses arrangements are aimed at making private health funds more efficient and to offer consumers better value private health insurance products and access to safe and clinically effective surgically implanted medical technologies and devices.

The Health funds currently meet, in relation to applicable hospital cover, 100 per cent of the cost of all surgically implanted prostheses and other medical devices listed on the Prostheses Schedule [Schedule 5 to the determination under paragraph (bj), Schedule 1 of the National Health Act 1953].

Under these arrangements, the Commonwealth advise the cost to funds of prostheses and medical devices has been growing at an unsustainable rate over the last decade, and is a significant driver of premium growth. There was an average 29 per cent increase in prostheses benefits paid in 2003-04 compared to 2000-01. The Commonwealth also advise that current arrangements are seen to be administratively cumbersome and limit consumer choice in whether they wish to purchase, for a lower premium, a health insurance product that may include co-payments or gaps for more expensive prosthetic items.

The Bill amends the Act to require registered health funds, to offer a no gap and gap permitted range of prostheses in relation to every admitted hospital procedure on the Medicare Benefits Schedule (MBS) for which they provide cover. The Bill amends the Act to allow the Minister to determine in writing:

• no gap prostheses - and the benefit amount for each no gap prosthesis;
• gap permitted prostheses - and the minimum and maximum benefit amounts for each gap permitted prosthesis.

The new arrangements will offer no-gap prostheses to health fund members for MBS procedures for which they have cover. At least one clinically appropriate no-gap prosthesis for each MBS admitted hospital procedure will be listed on the new Prostheses List.

The new prostheses arrangements will be implemented on 31 October 2005 and are preceded by the release of a new list on 31 August 2005. Although the August release of the Prostheses List will adopt the format of the new Prostheses List and will show benefit levels against each of the products the benefit levels will not become effective until the formal release of the List on 31 October. The two month delay is to allow time for health funds and hospitals to establish systems to support the new arrangements, and to ensure patients are properly informed by doctors, hospitals and health funds of the health fund benefit they can expect for their prostheses on or after 31 October.

In relation to Victorian public hospitals, prostheses fees charged are set by the State. A circular 22/2005 provides advice on this as well as an agreement reached at a national level between private health funds and States on reimbursement of public hospitals. This can be accessed at:http://www.health.vic.gov.au/hospitalcirculars/circ05/circ2205.htm

The following information has been prepared by the Commonwealth to notify all key stakeholders about the new arrangements, why changes have been made and the effect they may have.

(i) Circular PHI 46/05 August 2005 Benefits Payable for Prostheses and Human Tissues and Advance Release of the New Prostheses List & Circular PHI 51/05 Correction of errors in August 2005 Prostheses schedule and commencement of Prostheses List & Circular PHI 58/05 Amended Prostheses list - October 2005.
This can be accessed at: http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-privatehealth-providers-phicirculars2005-index1

ii) Circular PHI 63/05 Prostheses - Informed Financial Consent Guidelines
Further information on the new prostheses arrangements including the prostheses schedule can be accessed at: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-privatehealth-prostheseslist.htm#applications

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