Health Legislation (Private Health Insurance Reform) Amendment Act 1995 (Cth)
[
The Parliament of Australia enacts:
AMENDMENTS COMMENCING ON 1 APRIL 1995 OR ROYAL ASSENT,
WHICHEVER IS LATER
Omit the paragraph.
Omit "Commonwealth medical benefits or fund benefits by contributors or registered persons", substitute "fund benefits by contributors".
Omit the paragraph, substitute:
"(a) is not an applicable benefits arrangement; and".
Omit the definition, substitute:
"
(a) premises that were, immediately before 1 April 1995, a day hospital facility (within the meaning of this section as in force at that time), other than premises in respect of which a declaration under subsection 5B(2) is in force; and
(b) premises in respect of which a declaration under subsection 5B(1) is in force;".
Insert:
"
Omit "shall, for the purposes of paragraph (da) of the definition of 'basic private table' or 'basic table' in subsection (1), be deemed", substitute "is taken, for the purposes of subparagraph (a)(ii) and paragraph (b) of the definition of 'applicable benefits arrangement' in subsection 5A(1), ".
Omit the subsection.
Omit the subsection.
(a) Omit "the basic table", substitute "an applicable benefits arrangement".
(b) Omit "that table", substitute "that arrangement or table".
Insert:
"5A.(1) A reference in this Act to an applicable benefits arrangement is a reference to an arrangement that a registered organization has entered into with some or all of the contributors to a health benefits fund conducted by the organization under which the contributors are covered (wholly or partly) for liability to pay fees and charges:
(a) in respect of:
(i) some or all hospital treatment provided to a patient by a hospital or a day hospital facility with which the organization has a hospital purchaser-provider agreement; and
(ii) all professional services that are rendered to the patient by a medical practitioner while that hospital treatment is being provided, and that are professional services in respect of which a medicare benefit is payable; or
(b) in respect of some or all professional services that are rendered to a patient by a medical practitioner while hospital treatment is provided to the patient in a hospital or a day hospital facility, and that are professional services in respect of which a medicare benefit is payable;
and includes a reference to a basic table of the organization.
"(2) For the avoidance of doubt, the application of subsection (1) is not affected by:
(a) the existence or non-existence of a medical purchaser-provider agreement between the organization and a medical practitioner referred to in that subsection; or
(b) the existence or non-existence of a hospital purchaser-provider agreement between the organization and a hospital or day hospital facility referred to in that subsection; or
(c) the existence or non-existence of a practitioner agreement between a hospital or day hospital facility referred to in that subsection and a medical practitioner referred to in that subsection.
"(3) In this section:
(a) an accredited dental practitioner; and
(b) a dental practitioner approved by the Minister for the purposes of the definition of 'professional service' in subsection 3(1) of the
Health Insurance Act 1973.
"5B.(1) The Minister may, in writing, declare premises specified in the declaration to be a day hospital facility for the purposes of this Act and the
"(2) The Minister may, in writing, declare premises specified in the declaration, being premises that were, immediately before the commencement of this section, a day hospital facility within the meaning of subsection 4(1) as in force at the time, not to be a day hospital facility for the purposes of this Act and the
"(3) A declaration under subsection (1) may be expressed to take effect from a day earlier than the day on which the declaration is made (not being a day earlier than the day on which the premises specified in the declaration were licensed, under the law of the State in which they are located, to operate as a day hospital facility).
"(4) A decision whether to make a declaration under this section must be in accordance with any guidelines in force under subsection (5).
"(5) The Minister may, by written instrument, make guidelines relating to the making of such decisions.
"(6) The guidelines are disallowable instruments for the purposes of section 46A of the
Omit the subsections.
Insert:
"
(a) Omit "subsections (1) and (2)", substitute "subsection (1)".
(b) Omit "subsection (1) or (2)", substitute "subsection (1)".
Omit "subsection (1) or (2) that the registration of an organization as a registered health benefit fund", substitute "subsection (1) that the registration of an organization".
Omit the subsection.
Insert:
"
Insert:
"73AB.(1) It is a condition of registration of a registered organization that it must, in accordance with this section, give to the Department and the Council:
(a) the information required under the Hospital Casemix Protocol; or
(b) so much of that information as is in the organization's possession or control;
except so far as the Secretary has agreed that the information need not be given.
"(2) The information must be provided in respect of:
(a) each period of one calendar month; or
(b) if the Secretary determines in writing that a longer period is to apply in relation to the organization—that longer period.
"(3) The information must be provided:
(a) not earlier than 3 months after the period under subsection (2) to which it relates; and
(b) not later than one week after the end of that 3 months.
"(4) The information must relate to each patient, in relation to whom the organization was given information by a hospital or day hospital facility under a hospital purchaser-provider agreement in compliance with a requirement of a kind referred to in paragraph 73BD(2)(c), who was discharged by the hospital or day hospital facility during the period under subsection (2) to which the information relates.
"(5) Information given under this section is taken, for the purposes of the
"73ABA. It is a condition of registration of a registered organization that it must expressly undertake not to discriminate against an eligible contributor on the grounds of race, sex or sexuality.".
Add at the end:
"(2) In Schedule 1, unless the contrary intention appears:
(a) an accredited dental practitioner; and
(b) a dental practitioner approved by the Minister for the purposes of the definition of 'professional service' in subsection 3(1) of the
Health Insurance Act 1973 ; and(c) a person on whose behalf a medical practitioner (within the meaning of subsection 3(1) of the
Health Insurance Act 1973 ), or a dental practitioner of a kind referred to in paragraph (a) or (b), renders a professional service.".
Omit the subsection, substitute:
"(2) For the purposes of subsections (3), (4) and (8), if:
(a) benefits have been paid, or are payable, by a registered organization, in accordance with an applicable benefits arrangement or a supplementary hospital table, in respect of the provision of treatment, a service or another matter, for a person or persons, in relation to a particular day; and
(b) the person has not, or the persons have not, reached the prescribed age on that day;
then:
(c) if the matter was provided for one such person only—that day counts as one patient day of the contributor; or
(d) if such a matter was provided for 2 or more such persons—that day counts, subject to subsection (8), as a number of patient days of the contributor equal to the number of those persons.".
Omit "a basic table (whether or not modified by an election of the kind referred to in the condition set out in paragraph (ba) of the Schedule)", substitute "an applicable benefits arrangement".
Insert:
"(4A) For the purposes of subsection (4), the amount of a payment, made in accordance with an applicable benefits arrangement other than a basic table, in respect of a patient day is taken to be the amount of the payment divided by the episode duration in relation to the payment.".
Omit "a basic table (whether or not modified by an election of the kind referred to in the condition set out in paragraph (ba) of the Schedule)", substitute "an applicable benefits arrangement".
Insert:
"(6) For the purposes of subsection (5), the amount of a payment, made in accordance with an applicable benefits arrangement other than a basic table, is taken to be the amount worked out by:
(a) dividing the amount of the payment by the episode duration in relation to the payment; and
(b) multiplying the result by the number of days in the episode duration that occurred on or after the person reached the prescribed age.".
Insert:
"
means the number of days worked out in accordance with the information provided by the hospital or day hospital facility concerned to the registered organization under the Hospital Casemix Protocol.".
Insert:
"(11A) A reference in this section to an applicable benefits arrangement is a reference to an applicable benefits arrangement whether or not modified by an election of the kind referred to in the condition set out in paragraph (ba) of Schedule 1.".
Omit the paragraphs, substitute:
"(a) those benefits are taken to be hospital benefits; and
(b) those benefits are taken to be included in an applicable benefits arrangement of the organization.".
After "the Commonwealth" insert "and the States and Territories".
Insert:
"(4) Amounts received from the States or Territories for payment into the Fund form part of the Fund.".
Omit "in the financial year ending on 30 June 1989".
Insert:
"
"73BD.(1) A registered organization may enter into an agreement, with a hospital or a day hospital facility, that includes provisions to the effect that:
(a) except to the extent (if any) provided in the agreement, the hospital or day hospital facility agrees to accept payment by the organization in satisfaction of any amount that would, apart from the agreement, be owed to the hospital or day hospital facility, in relation to an episode of hospital treatment, by an eligible contributor (see subsection (3)); and
(b) payments by the organization to the hospital or day hospital facility in respect of episodes of hospital treatment are to be:
(i) casemix episodic payments (see subsection (4)); or
(ii) casemix episodic payments in respect of specified kinds of episodes of hospital treatment and, in respect of any other kind of episode of hospital treatment, payments made in accordance with the appropriate basic table or supplementary hospital table; or
(iii) payments made in accordance with the appropriate basic table or supplementary hospital table.
"(2) The agreement must also:
(a) specify the level of accommodation that the hospital or day hospital facility is to provide to eligible contributors (see subsection (3)) to a health benefits fund in respect of such episodes of hospital treatment; and
(b) require the hospital or day hospital facility to render, in respect of an episode of hospital treatment, a single account covering:
(i) all hospital services and related services; and
(ii) all professional services (if any) to which a practitioner agreement with the hospital or day hospital facility applies;
but not covering any professional services to which no such practitioner agreement applies; and
(c) require the hospital or day hospital facility to give to the organization, within the time specified in subsection (ii), the information specified in the Hospital Casemix Protocol prescribed by regulation made for the purposes of this paragraph, except so far as the Secretary has agreed that the information need not be given; and
(d) require the hospital or day hospital facility, in accordance with subsection (6), to inform any eligible contributor in respect of whom hospital treatment is to be provided at the hospital or day hospital facility of the amounts that the eligible contributor will be liable to pay to the hospital or day hospital facility in respect of the hospital treatment; and
(e) require the hospital or day facility to provide, in respect of an episode of hospital treatment, all reasonable assistance to the organization to enable the organization to verify:
(i) the essential variables for accurate casemix assignment; and
(ii) the payability of amounts by the organization under the agreement; and
(iii) the payability of other amounts by the organization relating to professional services rendered in connection with the hospital treatment.
"(3) For the purposes of paragraphs (1)(a), (2)(a) and (2)(d) and subsection (6), a person is an eligible contributor in relation to an episode of hospital treatment if:
(a) the person is a contributor to a health benefits fund conducted by the organization; and
(b) under the terms on which the person is a contributor, the person is covered (wholly or partly) in respect of the episode of hospital treatment.
"(4) For the purposes of paragraph (1)(b), a payment by the organization to the hospital or day hospital facility in respect of an episode of hospital treatment is a casemix episodic payment if:
(a) the episode of hospital treatment is an episode of a kind:
(i) specified in the List of Australian National Diagnosis Related Groups prescribed by the regulations; or
(ii) otherwise specified in the regulations; and
(b) the amount and structure of the payment is as set out in the agreement or may be worked out in accordance with the agreement.
"(5) Information referred to in paragraph (2)(c) must be given to the organization within 6 weeks after the patient to whom the information relates has been discharged from the hospital or day hospital facility in question.
"(6) For the purposes of paragraph (2)(d), the eligible contributor must be informed:
(a) where practicable, at any time before the admission for the hospital treatment in question; or
(b) otherwise—as soon after the admission as the circumstances reasonably permit.
"(7) Nothing in this section is to be taken as precluding natural persons from making arrangements for themselves, or for other natural persons wholly or partially dependent upon them, for the provision to them of hospital, medical or related services directly with hospitals.
"73BDAA.(1) This section applies if:
(a) a hospital or a day hospital facility has entered into an agreement (the
'practitioner agreement' ) with a medical practitioner relating to the rendering of professional services by the medical practitioner at the hospital or day hospital facility; and(b) under the practitioner agreement, the medical practitioner agrees, except to the extent (if any) provided in the agreement, to accept payment by the hospital or day hospital facility in satisfaction of any amount that would, apart from the agreement, be owed to the medical practitioner in relation to professional services to which the agreement applies; and
(c) the practitioner agreement requires the medical practitioner, in accordance with subsection (3), to inform any eligible contributor (see subsection (4)) in respect of whom such professional services are rendered of any amounts that the eligible contributor will be liable to pay to the medical practitioner in respect of the professional services.
"(2) A hospital purchaser-provider agreement between a registered organization and the hospital or day hospital facility may include provisions to the effect that:
(a) except to the extent (if any) provided in the hospital purchaser-provider agreement, the hospital or day hospital facility agrees to accept payment by the organization in satisfaction of any amount that would, apart from the hospital purchaser-provider agreement, be owed to the hospital or day hospital facility, in relation to a professional service to which the practitioner agreement applies, by an eligible contributor (see subsection (4)); and
(b) the organization agrees to accept assignments under subsection 20A(2A) of the
Health Insurance Act 1973 of the medicare benefits payable in respect of the professional service.
"(3) For the purposes of paragraph (1)(c), the eligible contributor must be informed:
(a) where practicable, at any time before the professional service is rendered; or
(b) otherwise—as soon after the professional service is rendered as the circumstances reasonably permit.
"(4) For the purposes of paragraphs (1)(c) and (2)(a) and subsection (3), a person is an eligible contributor in relation to a professional service if:
(a) the person is a contributor to a health benefits fund conducted by the organization; and
(b) under the terms on which the person is a contributor, the person is covered (wholly or partly) in respect of the professional service.
"(5) A reference in this section to a professional service is a reference to a professional service:
(a) that is rendered to a patient by a medical practitioner while hospital treatment is provided to the patient in a hospital or a day hospital facility; and
(b) in respect of which a medicare benefit is payable.
"(6) In this section:
(a) an accredited dental practitioner; and
(b) a dental practitioner approved by the Minister for the purposes of the definition of 'professional service' in subsection 3(1) of the
Health Insurance Act 1973 ; and(c) a person on whose behalf a medical practitioner (within the meaning of subsection 3(1) of the
Health Insurance Act 1973 ), or a dental practitioner of a kind referred to in paragraph (a) or (b), renders a professional service.
"73BDA.(1) A registered organization may enter into an agreement, with a medical practitioner, that includes provisions to the effect that:
(a) except to the extent (if any) provided in the agreement, the medical practitioner agrees to accept payment by the organization in satisfaction of any amount that would, apart from the agreement, be owed to the medical practitioner, in relation to a professional service, by an eligible contributor (see subsection (4)); and
(b) the organization agrees to accept assignments under subsection 20A(2A) of the
Health Insurance Act 1973 of the medicare benefits payable in respect of the professional service;
and that specifies the amount that is payable by the organization to the medical practitioner under the agreement, or specifies the way in which such an amount is to be worked out.
"(2) The agreement must also:
(a) require the medical practitioner to forward to the organization all accounts for amounts of the kind referred to in paragraph (1)(a); and
(b) require the medical practitioner to specify in each such account any amounts that an eligible contributor (see subsection (4)) will be liable to pay to the medical practitioner in respect of the professional service in question; and
(c) require the medical practitioner, in accordance with subsection (5), to inform the eligible contributor in respect of whom the professional service is to be rendered of any amounts that the eligible contributor can reasonably be expected to pay to the medical practitioner in respect of the professional service.
"(3) The agreement may apply to all professional services rendered by the medical practitioner or may be limited to professional services of the kinds specified in the agreement.
"(4) For the purposes of paragraphs (1)(a), (2)(b) and (2)(c) and subsection (5), a person is an eligible contributor in relation to a professional service if:
(a) the person is a contributor to a health benefits fund conducted by the organization; and
(b) under the terms on which the person is a contributor, the person is covered (wholly or partly) in respect of the professional service.
"(5) For the purposes of paragraph (2)(c), the eligible contributor must be informed:
(a) where practicable, at any time before the professional service is rendered; or
(b) otherwise—as soon after the professional service is rendered as the circumstances reasonably permit.
"(6) A reference in this section to a professional service is a reference to a professional service:
(a) that is rendered to a patient by a medical practitioner while hospital treatment is provided to the patient in a hospital or a day hospital facility; and
(b) in respect of which a medicare benefit is payable.
"(7) In this section:
(a) an accredited dental practitioner; and
(b) a dental practitioner approved by the Minister for the purposes of the definition of 'professional service' in subsection 3(1) of the
Health Insurance Act 1973 ; and(c) a person on whose behalf a medical practitioner (within the meaning of subsection 3(1) of the
Health Insurance Act 1973 ), or a dental practitioner of a kind referred to in paragraph (a) or (b), renders a professional service.
"(8) Nothing in this section is to be taken as preventing natural persons from making arrangements for themselves, or for other natural persons wholly or partially dependent upon them, for the provision to them of medical or related services in a hospital, directly with a medical practitioner.
"
"73BDB. The following are not subject to any duty or charge under any law of a State or Territory, or any law of the Commonwealth that applies only in relation to a Territory:
(a) a hospital purchaser-provider agreement, to the extent that the agreement provides for payments of a kind referred to in paragraph 73BD(1)(a) or 73BDAA(2)(a) or assignments of medicare benefits of a kind referred to in paragraph 73BDAA(2)(b);
(b) a practitioner agreement, to the extent that the agreement provides for payments of a kind referred to in paragraph 73BDAA(1)(b);
(c) a medical purchaser-provider agreement, to the extent that the agreement provides for payments of a kind referred to in paragraph 73BDA(1)(a) or assignments of medicare benefits of a kind referred to in paragraph 73BDA(1)(b).
"73BDC.(1) Subject to subsection (2), this Division does not affect the operation of the
"(2) Nothing in this Division is to be taken as specifically authorising or approving any act or thing for the purposes of subsection 51(1) of the
"73BDD.(1) There is established a panel, known as the Purchaser-Provider Panel, to monitor the operation of this Division, and of hospital purchaser-provider agreements and medical purchaser-provider agreements, and to report to the Minister as provided by this section.
(a) the Complaints Commissioner (who shall chair the panel);
(b) 2 members appointed by the Minister following consultation with the medical profession, including specialist practitioners;
(c) 2 members appointed by the Minister following consultations with organizations concerned with the provision of services by private hospitals;
(d) 2 members appointed by the Minister following consultations with registered organizations;
(e) 2 members appointed by the Minister following consultations with organizations concerned with the provision of services by public hospitals;
(f) 2 members appointed by the Minister following consultations with organizations representing consumers.
"(3) The performance of the functions of the panel is not affected by a vacancy or vacancies in the membership of the panel.
"(4) Members of the panel may be reappointed after a term of appointment has expired.
"(5) Any statistics, information or data provided to the panel in the course of its activities by a registered organization, hospital, medical practitioner, or agency of the Commonwealth shall not be in a form in which the personal or medical particulars of a patient or patients can be identified or inferred.
"(6) For the purposes of the
"(7) Unless both parties to a hospital or medical purchaser-provider agreement give their consent in writing, no agreements or provisions of an agreement may be required by the panel to be furnished to it.
"(8) Subject to subsection (9), no later than 1 October each year the panel shall provide to the Minister a written report on the operation of this Division, and of hospital purchaser-provider agreements and medical purchaser-provider agreements, during the immediately preceding financial year and such reports may contain any recommendations the panel thinks fit to make.
"(9) The Minister must cause a copy of each report received from the panel under subsection (8) to be presented to each House of the Parliament within 15 sitting days of that House after receiving it.
"(10) The panel will be disbanded no later than 30 June 1997.".
Omit "a basic table", substitute "an applicable benefits arrangement".
Omit "a basic table", substitute "an applicable benefits arrangement".
Omit "that table", substitute "that applicable benefits arrangement".
Omit "the table", substitute "the applicable benefits arrangement".
Omit "the table" (last occurring), substitute "the applicable benefits arrangement".
(a) Omit "a basic table", substitute "an applicable benefits arrangement".
(b) Omit "the basic table", substitute "the arrangement".
Omit "a basic table", substitute "an applicable benefits arrangement".
Omit "the table", substitute "the applicable benefits arrangement".
Omit "the table", substitute "the applicable benefits arrangement".
Insert:
''
Repeal the sections, substitute:
"73F.(1) The Minister may, by notice published in the
(a) informs people of what they could, as contributors, reasonably require from registered organizations, medical practitioners, hospitals and day hospital facilities; and
(b) advises people of matters to consider in making decisions about becoming contributors to such funds.
"(2) The Private Patients' Hospital Charter is a disallowable instrument for the purposes of section 46A of the
"73G.(1) No action (whether criminal or civil) lies against a person for breach of a duty of confidence, or breach of a similar obligation, in relation to the disclosure of information under a hospital purchaser-provider agreement in compliance with a requirement of a kind referred to in paragraph 73BD(2)(c) or (e).
"(2) No action (whether criminal or civil) lies against a hospital or a day hospital facility, or a person acting on behalf of a hospital or a day hospital facility, for breach of a duty of confidence, or breach of a similar obligation, in relation to the disclosure of information if the disclosure is reasonably necessary in connection with:
(a) making a payment under an applicable benefits arrangement or assessing whether or not to make such a payment; or
(b) any other matter relating to the operation of an applicable benefits arrangement.
"(3) This section has effect despite:
(a) any law (whether written or unwritten) of the Commonwealth, a State or a Territory; and
(b) any contract, arrangement or understanding;
to the contrary.".
Omit "section 73AA or 79", substitute "section 79".
Omit all the words after "the registered organization" (last occurring), substitute "must ensure that the Secretary receives notification of the change in accordance with this section.".
Insert:
"(1A) The notification must be received:
(a) if the change relates to rates of contribution by contributors—no later than 7 days, or such lesser period (if any) determined by the Minister on application from the organization, before the change is to come into effect; or
(b) in any other case—no later than 60 days, or such lesser period (if any) determined by the Minister on application from the organization, before the change is to come into effect.
"(1B) Within a reasonable time after receiving the notification, the Secretary must give the organization written acknowledgment of its receipt.
"(1C) The notification must be in writing in a form approved by the Minister.".
Omit "to contributors to the organization".
Insert:
"(l) to distribute copies of the Private Patients' Hospital Charter issued under section 73F to registered organizations for distribution and display by the organizations;
(la) to make copies of the Charter available to members of the public on request at each of its offices accessible to the public;
(lb) where appropriate, to publicise the existence and availability of the Charter in its brochures and other documents, concerning health insurance, made available to the public;".
Insert the following Division:
"
"132A.(1) The Minister is to establish an Aggregate Billing Advisory Committee.
"(2) The Committee is to consist of the following members:
(a) the Secretary to the Department (who shall chair the Committee);
(b) a member nominated by each of the following:
(i) the Australian Medical Association;
(ii) the Australian Private Hospitals Association;
(iii) the Australian Catholic Hospitals Association;
(iv) the Australian Hospitals Association;
(v) the Australian Health Insurance Association;
(vi) the Council of Procedural Specialists;
(c) a member jointly nominated by the Australian Consumers' Association and the Consumers' Health Forum;
(d) 2 other members nominated by the Minister, only one of whom may be an employee of the Department.
"(3) If the person referred to in paragraph (2)(b) is not available to serve as a member, that person may nominate a person to be a member of the Committee in his or her place.
"(4) The Minister is to determine the terms and conditions of appointment, including remuneration and allowances, if any, of a person who is a member of the Committee. Arty such remuneration or allowances are to be paid out of monies appropriated by the Parliament for the purpose.
"(5) The functions of the Committee are:
(a) to investigate the most appropriate way of moving to a system of aggregate billing for an episode of hospital treatment (covering all hospital services and related services including medical services); and
(b) to recommend to the Minister the most appropriate method of achieving aggregate billing by 1 July 1998.
"(6) The recommendation referred to in paragraph (5)(b):
(a) must be made not later than 1 January 1997; and
(b) must be tabled in each House of the Parliament within 15 sitting days of that House of being received by the Minister.
"(7) Following tabling of the recommendation the Minister may determine that the Committee is no longer required and may terminate the membership of the persons referred to in subsection (2).".
Omit "the basic table", substitute "an applicable benefits arrangement".
Omit the paragraph, substitute:
"(b) Subject to the condition set out in paragraph (ba), the organization will permit:
(i) any contributor to a health benefits fund conducted by it; and
(ii) any person who is eligible to become such a contributor;
to contribute for benefits in respect of the contributor and the contributor's dependants (if any), or in respect of the person and the person's dependants (if any), in accordance with any applicable benefits arrangement of the organization.".
Omit "the basic table", substitute "an applicable benefits arrangement of the organization".
Omit "the basic table" (last occurring), substitute "that arrangement".
Omit the subparagraph, substitute:
"(i) in relation to benefits in respect of a matter related to an ailment or illness the signs or symptoms of which, in the opinion of a medical practitioner appointed by the organization, existed at any time during the 6 months preceding the day on which the contributor made the election—12 months; or".
Insert:
"(bd) The organization will have in force an applicable benefits arrangement under which contributors are entitled to contribute for benefits in respect of:
(i) all episodes of hospital treatment to which paragraph 73BD(4)(a) applies; and
(ii) all professional services rendered to a patient, while hospital treatment is provided to the patient in a hospital or a day hospital facility, being professional services in respect of which a medicare benefit is payable; and
(iii) all episodes of hospital treatment to which a basic table of the organization could apply,
(be) The organization will permit all contributors to a health benefits fund conducted by the organization, and all persons who are eligible to become such contributors, to contribute for benefits in accordance with that applicable benefits arrangement.".
Insert:
"(ca) The organization will not refuse or fail to enter into a hospital purchaser-provider agreement with a hospital or a day hospital facility solely because of one or more of the following:
(i) the number of beds that the hospital or day hospital facility has;
(ii) the range of hospital treatments that the hospital or day hospital facility provides;
(iii) the fact that a particular person, or a person of a particular kind, owns or has an interest in the hospital or day hospital facility;
(iv) the fact that a particular person, or a person of a particular kind, does not own or have an interest in the hospital or day hospital facility.".
Omit the paragraph, substitute:
"(d) The amount of fund benefit payable by the organization in respect of hospital treatment for a person who is not a nursing-home type patient will not exceed the fees or charges incurred in respect of that hospital treatment.".
Omit "to a contributor".
Insert:
"(ea) The amount of benefit payable by the organization in respect of a professional service that:
(i) is rendered to a patient while hospital treatment is provided to the patient in a hospital or a day hospital facility; and
(ii) is a professional service in respect of which a medicare benefit is payable;
must be an amount at least equal to:
(iii) if the medical expenses incurred in respect of the service are greater than or equal to the Schedule fee (within the meaning of Part II of the
Health Insurance Act 1973 ) in respect of the service—25% of that Schedule fee; or(iv) if medical expenses incurred in respect of the service are less than that Schedule fee—the amount (if any) by which the medical expenses exceed 75% of that Schedule fee;
but, if the service is rendered by or on behalf of a medical practitioner with whom the organization does not have a medical purchaser-provider agreement that applies to that service, the amount of benefit payable must not exceed the amount referred to in subparagraph (iii) or (iv) (whichever is applicable).".
Omit "a basic table", substitute "an applicable benefits arrangement of the organization".
Omit "a basic table", substitute "an applicable benefits arrangement of the organization".
Omit "the basic table", substitute "that arrangement".
Insert:
"(ha) The organization will make freely available to the contributors to a health benefits fund conducted by it up-to-date lists of:
(i) the hospitals and day hospital facilities with which it has hospital purchaser-provider agreements; and
(ii) the persons with whom it has medical purchaser-provider agreements.
(hb) The organization will, at the request of a contributor to a health benefits fund conducted by it, give to a hospital, day hospital facility or medical practitioner such information that the organization has that will enable or assist:
(i) the hospital or day hospital facility to comply, in relation to the contributor, with any requirements of the kind referred to in paragraph 73BD(2)(d) that are included in a hospital purchaser-provider agreement between the organization and the hospital or day hospital facility; or
(ii) the medical practitioner to comply, in relation to the contributor, with any requirements of the kind referred to in paragraph 73BDAA(1)(c) that are included in a practitioner agreement between the medical practitioner and a hospital or day hospital facility; or
(iii) the medical practitioner to comply, in relation to the contributor, with any requirements of the kind referred to in paragraph 73BDA(2)(c) that are included in a medical purchaser-provider agreement between the organization and the medical practitioner;
as the case requires,
(he) The organization will:
(i) make copies of the Private Patients' Hospital Charter issued under section 73F available to contributors to any health benefits funds conducted by it; and
(ii) at each of its business premises accessible to the public, make copies of the Charter available to members of the public on request; and
(iii) at each such premises, display at least one copy of the Charter; and
(iv) where appropriate, publicise the existence and availability of the Charter in its brochures and other documents, concerning health insurance, made available to the public".
Omit "a basic table", substitute "an applicable benefits arrangement of the organization".
(a) Omit "a basic table" (first occurring), substitute "an applicable benefits arrangement of the organization".
(b) Omit ", being ailments of a kind that are determined by the Minister by writing signed by him or her, to be ailments to which this condition applies".
(a) Omit "a basic table", substitute "an applicable benefits arrangement of the organization".
(b) Omit "that basic table", substitute "that arrangement".
Insert:
"(ka) If:
(i) an applicable benefits arrangement to which a waiting period referred to in paragraph (j) or (k) applies had wholly or partly replaced another applicable benefits arrangement of the organization (the
'previous benefits arrangement' ); and(ii) immediately before the replacement, the contributor had been a contributor for benefits in accordance with the previous benefits arrangement; and
(iii) immediately before the replacement, the contributor had served the whole or a part of another waiting period in relation to the previous benefits arrangement;
the organization must count the contributor's service of the other waiting period towards the waiting period referred to in paragraph (j) or (k), at least so far as the first-mentioned arrangement entitles the contributor to benefits equivalent to the benefits to which he or she was entitled under the previous benefits arrangement.
(kb) If:
(i) an applicable benefits arrangement to which a waiting period referred to in paragraph (j) or (k) applies had wholly or partly replaced a supplementary hospital table of the organization; and
(ii) immediately before the replacement, the contributor had been a contributor for benefits in accordance with the supplementary hospital table; and
(iii) immediately before the replacement, the contributor had served the whole or a part of another waiting period in relation to the supplementary hospital table;
the organization must count the contributor's service of the other waiting period towards the waiting period referred to in paragraph (j) or (k), at least so far as the arrangement entitles the contributor to benefits equivalent to the benefits to which he or she was entitled under the supplementary hospital table,
(kc) For the purposes of paragraph (k), a pre-existing ailment is an ailment or illness the signs or symptoms of which, in the opinion of a medical practitioner appointed by the organization, existed at any time during the 6 months preceding the day on which the contributor began contributions to the organization for:
(i) benefits in accordance with the applicable benefits arrangement or supplementary hospital table referred to in that paragraph; or
(ii) if applicable, benefits in accordance with the previous benefits arrangement referred to in paragraph (ka) or the replaced supplementary hospital table referred to in paragraph (kb).
(kd) In forming an opinion referred to in subparagraph (bc)(i) or paragraph (kc), the medical practitioner appointed by the organization must have regard to any information relating to the ailment or illness that was given to him or her by the medical practitioner who treated the ailment or illness.".
Omit the paragraph, substitute:
"(la) For the purposes of the conditions set out in paragraphs (ld) and (le), a person (the 'relevant person') is a transferred contributor in relation to a benefit (the 'relevant benefit') included in an applicable benefits arrangement or a supplementary hospital table or other table of the organization if the following conditions are satisfied:
(i) the relevant person is, in relation to the organization, a contributor for benefits in accordance with the arrangement or table;
(ii) at the time of becoming such a contributor, or within 7 days or such longer period as the rules of the organization allow before that time, the relevant person was, in relation to another health benefits organization, a contributor for benefits in accordance with a comparable benefits arrangement (see paragraph (laa));
(iii) the comparable benefits arrangement included a benefit (the 'comparable benefit') that was comparable to the relevant benefit;
(iv) at the time of becoming a contributor for benefits in accordance with the applicable benefits arrangement, supplementary hospital table or other table, the person had paid all contributions due to the other organization.
(1aa) The reference in subparagraph (la)(ii) to a comparable benefits arrangement is a reference to:
(i) if the relevant benefit is included in an applicable benefits arrangement (other than a basic table), whether or not modified by an election of the kind referred to in the condition set out in paragraph (ba)—an applicable benefits arrangement (other than a basic table), whether or not modified by such an election, of the other health benefits organization; or
(ii) if the relevant benefit is included in a basic table, whether or not modified by an election of the kind referred to in the condition set out in paragraph (ba)—a basic table, whether or not modified by such an election, of the other health benefits organization; or
(iii) if the relevant benefit is included in a supplementary hospital table—a supplementary hospital table of the other health benefits organization; or
(iv) if the relevant benefit is included in a table other than a basic table or a supplementary hospital table—a table other than a basic table or a supplementary hospital table of the other health benefits organization.".
Omit "applicable table", substitute "applicable benefits arrangement, supplementary hospital table or other table".
Omit "to a basic table" (wherever occurring).
Omit "the table", substitute "an applicable benefits arrangement of the organization".
Omit the paragraphs, substitute:
"(o) The organization will comply with any request by the Commission for access to any document in the possession or under the control of the organization that relates directly or indirectly to payment of a medicare benefit to the organization because of subsection 20A(2A) of the
Health Insurance Act 1973. (p) The organization will retain such a document for the period of 2 years starting:
(i) if the document relates to payment of a medicare benefit in respect of professional services for which one claim for an amount of benefit was lodged with the organization—on the day on which that claim was lodged; or
(ii) if the document relates to payment of a medicare benefit in respect of professional services for which 2 or more claims for an amount of benefit were lodged with the organization—on the day on which the last of those claims was so lodged.".
Omit "paragraph (da) of the definition of 'basic private table' or 'basic table' in subsection 4(1)", substitute "subparagraph (a)(ii) and paragraph (b) of the definition of 'applicable benefits arrangement' in subsection 5A(1)".
Omit "paragraph (da) of the definition of 'basic private table' or 'basic table' in subsection 4(1)", substitute "subparagraph (a)(ii) and paragraph (b) of the definition of 'applicable benefits arrangement' in subsection 5A(1)".
Add at the end:
"(2) Subsection (1) does not apply if:
(a) the rendering of the professional service is covered by a medical purchaser-provider agreement; and
(b) the amount payable under the agreement for the professional service is not determined on a fee for service basis.".
Insert:
"(2A) Where:
(a) a medicare benefit would, apart from this section, be payable to an eligible person in respect of a professional service rendered to a patient while hospital treatment is provided to the patient in a hospital or a day hospital facility; and
(b) the eligible person has entered into an arrangement with a registered organization under which he or she is covered (wholly or partly) for liability to pay fees and charges in respect of that professional service; and
(c) either:
(i) the organization has a medical purchaser-provider agreement with the medical practitioner by whom or on whose behalf the professional service was rendered; or
(ii) the organization has a hospital purchaser-provider agreement with the hospital or day hospital facility, and the hospital or day hospital facility has a practitioner agreement, with the medical practitioner by whom or on whose behalf the professional service was rendered, that applies to the professional service; and
(d) the agreement applies to the professional service;
the eligible person is taken, for the purposes of this Act, to have assigned his or her right to the payment of the medicare benefit to the organization.
"(2B) Despite subsection (4), in subsection (2A):
(a) an accredited dental practitioner; and
(b) a dental practitioner approved by the Minister for the purposes of the definition of 'professional service' in subsection 3(1); and
(c) a person on whose behalf a medical practitioner (within the meaning of subsection 3(1)), or a dental practitioner of a kind referred to in paragraph (a) or (b), renders a professional service.".
(a) Before "The Minister may" in subsection (1), insert "Subject to subsection (4)".
(b) After subsection (3) insert the following subsection:
"(3A) For the purposes of this Act and the
National Health Act 1953, a declared private hospital must provide data specified in the Hospital Casemix Protocol:(a) in a patient identifiable state, to a registered private health insurance organization which has an applicable benefits agreement with the patient; and
(b) in a patient de-identified state to a data bureau established, no later than 1 January 1996, by statute, for the purpose of receiving and disseminating such data; and
(c) the role and responsibilities of the data bureau shall be defined by statute after appropriate consultations with registered organizations, hospitals and medical practitioners, and with due reference to the data requirements of the Hospital Casemix protocol.".
Add at the end:
"(4) A decision whether to make a declaration under this section must be in accordance with any guidelines in force under subsection (5).
"(5) The Minister may, by written instrument, make guidelines relating to the making of such decisions.
"(6) The guidelines are disallowable instruments for the purposes of section 46A of the
Omit "a basic table", substitute "an applicable benefits arrangement".
Omit "the basic table", substitute "an applicable benefits arrangement".
AMENDMENTS COMMENCING ON 1 OCTOBER 1995
Omit "a health benefits fund", substitute "the health benefits fund".
Omit "a health benefits fund", substitute "the health benefits fund".
Omit "or health benefits funds".
Omit the definition, substitute:
"
(a) that starts on the day on which the contributor becomes a contributor for benefits in accordance with an applicable benefits arrangement, supplementary hospital table or other table of benefits of the organization; and
(b) during which, under the rules of the organization, the contributor is not entitled to fund benefits in accordance with that arrangement or table.".
Omit the subsection.
Repeal the section.
Omit "a health benefits fund", substitute "the health benefits fund".
Omit the subsections.
Add at the end the following note:
"Note: Subsections (5) and (6) deal with the application of this definition in respect of employee health benefits schemes.".
Insert:
"
(a) is a minor or incidental part of the employer's business; or
(b) does not require the employee to pay any contributions; or
(c) does not require the employee to pay contributions that reflect the value of the benefits that the employer is providing under the arrangement; or
(d) provides for the employer to make payments in relation to hospital treatment, or an ancillary health benefit, provided to a person other than the employee; or
(e) confers on the employer or another person a discretion whether to make payments;
but does not include:
(f) an arrangement that is the subject of an agreement to which Part VIB of the
Industrial Relations Act 1988 applies, being an agreement:(i) that has been certified by, or the implementation of which has been approved by, the Australian Industrial Relations Commission under that Part before 1 January 1995; and
(ii) a copy of which has been given to the Minister; or
(g) an arrangement that the Minister determines in writing not to be an employee health benefits scheme;".
Add at the end:
"(5) Subject to subsection (6), an employee health benefits scheme is not precluded from constituting a health insurance business within the meaning of this section, even though it does not constitute a business of undertaking liability by way of insurance, if:
(a) the employer is a body corporate to which paragraph 51(xx) of the Constitution applies; or
(b) the employer is a body corporate incorporated in a Territory; or
(c) the employer carries on business in a Territory.
"(6) Subsection (5) does not apply in relation to an employee health benefits scheme to the extent (if any) that the scheme constitutes State insurance within the meaning of paragraph 51(xiv) of the Constitution.
"(7) The Minister must not make a determination under paragraph (g) of the definition of 'employee health benefits scheme' in subsection (4) in relation to an arrangement that is the subject of an agreement to which Part VIB of the
Omit the subsections.
Omit "in a State".
Omit "in respect ofthat State".
Omit "in that State" and all the words from and including "and if, in accordance with those rules" to and including "in the Northern Territory".
Omit the subparagraph, substitute:
"(ii) costs incurred by the organization wholly or exclusively in the carrying on
of business as a registered health benefits organization;".
Omit "in that State" and all the words from and including "or if, in accordance with the rules" to and including "in the Northern Territory".
Add at the end "or".
Omit "; or".
Omit the subparagraph.
Omit "specifying, or applies to carry on business as a registered health benefits organization in, the State concerned", substitute ", or applies to carry on business as a registered health benefits organization,".
Omit the subsection.
Omit "in any State".
Omit ", or for permission to carry on business".
Omit "or for permission to carry on business".
Omit", or permission to carry on business as a registered health benefits organisation, as the case requires, ".
Omit all the words from and including "or for permission to carry on business" to and including "shall also take into account", substitute ", and the Minister, in exercising the Minister's powers with respect to such an application, must consider whether the organization is eligible to be registered and must also take into account".
Omit "relevant fund or funds", substitute "fund".
Omit "or those funds".
Omit "or each of those funds".
Omit "or to carry on business" and "or a relevant fund".
Omit the paragraph.
Omit the subsections.
Add at the end:
"(3) Determinations made under paragraph (bga) of the conditions set out in Schedule 1 are disallowable instruments for the purposes of section 46A of the
Omit ", where it conducts only one health benefits fund, the value of the assets of that fund shall", substitute "the value of the assets of the health benefits fund conducted by it must".
Omit the subsections.
Omit "a health benefits fund", substitute "the health benefits fund".
Omit "; and".
Omit the subparagraph.
Omit the paragraphs, substitute:
"(f) The amount of benefit payable by an organization in respect of hospital treatment must be an amount that is payable under an applicable benefits arrangement.".
Omit the paragraph, substitute:
"(k) If the rules of the organization provide for a waiting period in relation to contributors for benefits in accordance with an applicable benefits arrangement of the organization (whether or not modified by an election of the kind referred to in the condition set out in paragraph (ba)) in respect of pre-existing ailments, the waiting period will not exceed the period of 12 months commencing on the date on which a contributor commenced to contribute for benefits in accordance with that arrangement.".
Omit the paragraph.
Omit "or supplementary hospital table".
Omit "or the replaced supplementary hospital table referred to in paragraph (kb)".
Omit "supplementary hospital table or other".
Omit ", supplementary hospital table or other", substitute "or".
Omit "(other than a basic table)" (wherever occurring).
Omit the subparagraphs.
Omit "other than a basic table or a supplementary hospital table" (wherever occurring).
Omit ", supplementary hospital table or other", substitute "or".
1.
No. 95, 1953, as amended. For previous amendments, see No. 68, 1955; Nos. 55 and 95, 1956; No. 92, 1957; No. 68, 1958; No. 72, 1959; No. 16, 1961; No. 82, 1962; No. 77, 1963; No. 37, 1964; Nos. 100 and 146, 1965; No. 44, 1966; Nos. 14 and 100, 1967; No. 100, 1968; No. 102, 1969; No. 41, 1970; No. 85, 1971; No. 114, 1972, Nos. 49 and 202, 1973; No. 37, 1974; Nos. 1, 13 and 93, 1975; Nos. 1, 60, 91, 99, 108, 157 and 177, 1976; Nos. 98 and 100, 1977; Nos. 36, 88, 132 and 189, 1978; Nos. 54, 91 and 122, 1979; Nos. 117 and 131, 1980; Nos. 40, 74, 92, 118, 163 and 176, 1981; Nos. 49, 80 and 112, 1982; Nos. 35, 54 and 139, 1983; Nos. 46, 63, 72, 120, 135 and 165, 1984; Nos. 24, 53, 65, 70, 95, 127 and 167, 1985; Nos. 28, 75, 94 and 115, 1986; Nos. 22, 44, 72, 118, 131 and 132, 1987; Nos. 79, 87, 99 and 155, 1988; No. 95, 1989; Nos. 3, 84, 106 and 141, 1990; Nos. 6, 68, 70, 73, 83, 84, 115, 116, 119, 122, 141, 169, 175, 208 and 211, 1991; Nos. 70, 81, 88, 136, 192, 200 and 204, 1992; Nos. 28, 61, 76 and 106, 1993; Nos. 12, 22, 23, 63, 78, 80, 85, 116 and 174, 1994; and No. 24, 1995.
2.
No. 42, 1974, as amended. For previous amendments, see No. 58, 1975; Nos. 59, 91, 101, 109 and 157, 1976; No. 75, 1977; Nos. 36, 89 and 133, 1978; Nos. 53 and 123, 1979; No. 132, 1980; Nos. 118 and 176, 1981; Nos. 49, 80 and 112, 1982; Nos. 54 and 139, 1983; Nos. 15, 46, 63, 120, 135 and 165, 1984; Nos. 24, 65, 70, 95 and 167, 1985; Nos. 28, 75 and 94, 1986; Nos. 44, 131, 132 and 141, 1987; Nos. 85, 87, 99 and 155, 1988; Nos. 59, 84, 95 and 164, 1989; Nos. 3, 106 and 141, 1990; Nos. 6, 57, 68, 70, 73, 84, 116, 141, 171, 172, 175, 190, 193 and 211, 1991; Nos. 88, 136, 192, 204, 226, 229 and 230, 1992; No. 76, 1993; and Nos. 12, 22, 60, 85, 116 and 174, 1994.
3.
No. 41, 1974, as amended. For previous amendments, see Nos. 61, 91 and 100, 1976; Nos. 36 and 134, 1978; No. 53, 1979; Nos. 54 and 115, 1983; No. 63, 1984; Nos. 65 and 167, 1985; No. 75, 1986; Nos. 75 and 99, 1988; Nos. 119 and 122, 1991; Nos. 94 and 136, 1992; No. 29, 1993; and Nos. 80, 84 and 174, 1994.
[
House of Representatives on 2 February 1995
Senate on 28 February 1995 ]
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