Doctor Information
How can my patients who want to stay with Bupa or AHSA health funds avoid additional out of pocket costs if ACHA goes out of contract?
VMOs can reduce the impact on patients who want to stay with Bupa or an AHSA fund by pre-booking their procedure before the notice period expires, any time up to and including 20 February 2025 for Bupa and 3 March 2025 for AHSA.
Who is communicating this to my patients who are Bupa or AHSA health fund members?
Bupa and AHSA are responsible for advising their members that they will be out of contract with ACHA unless a new agreement can be negotiated. VMOs should advise their patients who want more information to contact Bupa on 134 135 or their specific AHSA fund (visit https://ahsa.au/our-funds/ for details).
We are also providing support for patients by responding to any queries we receive, as well as providing information and updates for our hospital staff and VMOs.
Will this affect my ability to set my fees with Bupa or AHSA health fund patients?
No. Our health fund contracts do not contain any direct terms on VMOs and their rights to charge patients for their services.
Can I claim medical gap scheme rates for patients who are pre-booked?
Yes. VMOs will be entitled to medical gap scheme rates for pre-booked members. Bupa has its Medical Gap Scheme and the AHSA has its Access Gap Cover Scheme.
Can I claim medical gap scheme rates for patients who are not pre-booked?
- Bupa: No. Specialists will not be entitled to Bupa Medical Gap Scheme rates for members that are not prebooked at a ACHA facility when we are out of contract on and from 21 February 2025.
- AHSA funds: Yes. Specialists will be entitled to AHSA Access Gap Cover scheme rates for members that are not prebooked at a ACHA facility when we are out of contract on and from 4 March 2025.
What happens if a Bupa or AHSA health fund patient is admitted during the notice period and remains an inpatient after the notice period expires?
In this scenario, the patient’s episode of care is still funded at the contract rates. The terms and conditions of the contract will continue to apply for the duration of the admitted episode of care.
How will the transitional period affect my patients?
The below table outlines the circumstance and the duration in which the transitional period will apply to Bupa and AHSA health fund members.
| Treatment Type |
|---|
| Emergency (note inclusions/exclusions outlined in FAQs) |
| *Treatment commenced prior to termination date |
| Rehabilitation and mental health that started before termination date |
| Oncology and renal that started before termination date |
| No additional out-of-pocket fees for Treatment Types if patients are admitted in the periods noted below: (Treatments can occur at any time up to the end of the period noted below) |
|---|
| 3 months after termination date |
| Covered until discharge |
| 6 months after termination date |
| 6 months after termination date |
| Other Treatments (including elective surgery) |
|---|
| Pre-booked before termination date |
| No additional out-of-pocket costs if you are admitted in the periods noted below: |
|---|
| **Pregnancy and birth – 9 months after termination date |
| ***Other procedures – 6 months after termination date |
*Course of treatment: all patients undertaking a course of treatment (e.g., chemotherapy, dialysis, psychiatric rehabilitation) for a continuous period of up to six months. Course of treatment is not limited to the examples listed here.
*Maternity pre-bookings: if a booking has been received by the hospital prior to the contract termination date, including bookings notified by the doctor. If a pre-booked mother has a baby or multiple babies requiring admission to a special care nursery, this would be covered at the current contract rates. There may be exceptions where the baby requires ongoing treatment after being discharged from hospital. This would be deemed a separate admission and the rates payable would need to be confirmed with the AHSA.
**Non-maternity pre-bookings: if a booking is received by the hospital prior to the contract expiration date, including bookings notified by the doctor or where the patient has completed the necessary forms. Admission must occur within six months of the contract expiration date.
What happens for emergency admissions?
For emergency admissions, the current contract arrangements and payment schedules continue to apply for a continuous period of three months. Emergency admission (in absence of any agreement) will include any of the following:
- At risk of serious morbidity or mortality and requiring urgent assessment and resuscitation.
- Suffering from suspected acute organ or system failure.
- Suffering from an illness or injury where the viability of function of a body part or organ is acutely threatened.
- Suffering from a drug overdose, toxic substance, or toxin effect.
- Experiencing severe psychiatric disturbance whereby the health of the patient or other people is at immediate risk.
- Suffering from severe pain where the viability or function of a body part or organ is suspected to be acutely threatened.
- Suffering acute significant haemorrhaging and requiring urgent assessment and treatment.
- Patient requires immediate admission to avoid imminent morbidity or mortality and where a transfer to another facility is impractical.
What support will ACHA provide for VMOs?
We will continue to provide information including for your patients, and your hospital General Manager will be in regular contact with you.
Additional support will include:
- Opportunities for VMOs to attend online briefings with ACHA.
- ACHA frontline staff provided with additional training to respond to patient queries.
- Information for your practice team including a briefing sheet that can be given to patients.
We will also seek feedback from you and your practice about how this is working and what else you need.
If you go back into contract with Bupa or AHSA health funds during the patient’s admission, will any additional costs be refunded?
No. The patient would still have to pay the out of pocket fees for the time spent in hospital where the contract was not in place.
What happens if a Bupa or AHSA health fund patient’s admission type changes during their stay (e.g. medical to surgical, surgical to rehab, same day to overnight)?
Patients must receive full informed financial consent on their expected out of pocket costs and this should include all scenarios which have been detailed above. Patient eligibility checks must be completed to ensure that a patient is covered for a procedure, especially if there is a change to care type or new presenting illness during their admission. There should be no change to current process, in that a second eligibility check must be undertaken to ensure that the patient is covered for the new presenting condition.
Will non-prosthetic medical devices, prosthesis, pharmacy, pathology and radiology be covered during a Bupa or AHSA health fund patient’s stay after the transitional period ends and ACHA is out of contract with Bupa and AHSA health funds?
- Current high-cost medical disposables listed in the contract will likely no longer be paid by PHI, and will need to be passed on to the patient.
- There is no change to a prosthesis payment. If it is a listed prosthesis, it is still payable by PHI.
- Pharmacy that is intrinsic to a patient’s episode of care should not be passed on to the patient, with the exception of high cost drugs which may need to be passed on to the patient. Bupa and the AHSA health funds do not have to consider ex-gratia requests for high-cost drugs when there is no contract with the hospital. However, this is at the discretion of the fund.
- There is no change to pathology and radiology as these services are not covered by ACHA’s contract with Bupa or AHSA health funds.
Do you expect me to tell my patients about the impact on them of this?
ACHA has communicated to all pre-booked patients who are members of either Bupa or AHSA health funds. It is your choice as to how you tell your patients about this situation. We have provided you with a letter explaining the situation that you or your practice manager can share with your impacted patients to help them make an informed choice
If my patients stays with Bupa or AHSA health funds what will their future out-of-pocket costs be?
Patients who are Bupa and AHSA health fund members may need to pay additional out of pocket costs if they do not meet the criteria of the transitional arrangements or once those transitional arrangements no longer apply. We won’t know the exact out of pocket costs until Bupa and the AHSA funds advise us what level of funding they intend to keep paying us for their members’ care in our hospitals Under guidelines set by the Private Health Insurance Ombudsman, doctors, hospitals and health funds are expected to work together to provide information to patients about the costs associated with treatment, and any private health insurance benefits payable, prior to their admission to hospital.
What do I do if my patient asks me if it is possible to change health funds?
If a patient asks about switching funds and you are happy to talk about this, we recommend you provide them with the following information:
Australia’s private health insurance laws allow members to move their cover to another health fund without re-serving waiting periods when transferring to a comparable product. Bupa and AHSA health fund members can avoid additional fees if they switch to a comparable product with another fund that has the same level of benefits and same conditions as their current product. ACHA has agreements in place with all other major Australian health insurers including HCF, Medibank, NIB and St Lukes Health.
If you choose to discuss switching with patients, we also recommend you advise them of the following:
* Private health insurance is complex and it can be difficult to compare health insurance products. You should discuss your health insurance needs with the fund you are proposing to switch to so that you understand the new product, how it differs from your current product and can confirm that the product is right for you.
Make sure you consider the products excess, co-payment, full cost and all out of pocket expenses that will apply in the event you require treatment at a hospital. You should also consider if you are obtaining a comparable product. If you switch to a comparable product with another fund that has the same level of benefits and same conditions as your current product, you will not have to re-serve any waiting periods that have already been served.
You can compare funds for free at www.privatehealth.gov.au and choose a fund that is not affected.