National Health Act 1953 Determination under Schedule 1, paragraph (bj) (Hib 01/2005) (Cth)

Commonwealth of Australia

NATIONAL HEALTH ACT 1953

Determination under Schedule 1, paragraph (bj)

(HIB 1/2005)

I, LINDA JANE ADDISON, delegate of the Minister for Health and Ageing acting under paragraph (bj) of Schedule 1 of the National Health Act 1953 (the Act):

AMEND the determination made under paragraph (bj) of Schedule 1 of the Act dated 30 June 1999 (as amended), by OMITTING Schedule 6 of that determination and SUBSTITUTING the attached Schedule 6.  This determination commences on the day after this determination is registered on the Federal Register of Legislative Instruments.

Dated this      21                day of       January  2005.

(Signed by)

LINDA JANE ADDISON

Assistant Secretary

Private Health Insurance Branch

Position No: 01202874

Delegate of the Minister for Health and Ageing

SCHEDULE 6 – SECOND TIER DEFAULT BENEFIT FOR OVERNIGHT AND DAY ONLY TREATMENT

Interpretation1.    

(1)     In this Schedule:

AN-SNAP rehabilitation classification system means the Australian National Sub-Acute and Non-Acute Patient (AN-SNAP) classification as described in Appendix 6 of Kathy Eagar et al, A national classification system and payment model for private rehabilitation services, University of Wollongong, 1999;

facility means a private hospital or private day hospital facility specified in clause 3;

HPPA means hospital-purchaser provider agreement;

rehabilitation episode of hospital treatment means an episode of hospital treatment in which the clinical intent or treatment goal is to improve the functional status of a patient with an impairment, disability or handicap. It is usually evidenced by a multi-disciplinary rehabilitation plan comprising negotiated goals and indicative time frames which are evaluated by a periodic assessment using a recognised functional assessment measure;

RHBO means registered health benefits organization; and

similar arrangement includes all agreements, except HPPAs, that have the effect of enabling payments to be made to a facility according to provisions (including pricing provisions) stated under these agreements.

(2)     In this Schedule, except in subclause 1(4), the Australian Capital Territory is taken to be part of the State of New South Wales and the Northern Territory is taken to be part of the State of South Australia.

(3)       In this Schedule, private hospitals are comparable if they fall within the same class from the following list:

(a)        private hospitals which provide psychiatric care for at least 50% of the episodes of hospital treatment;

(b)        private hospitals which provide rehabilitation care for at least 50% of the episodes of hospital treatment;

(c)private hospitals which do not fall into categories (a) or (b), with up to and including 50 licensed beds;

(d)        private hospitals which do not fall into categories (a) or (b) with more than 50 licensed beds and up to and including 100 licensed beds;

(e)        private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit;

(f)         private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, with either (or both) an accident and emergency unit or a specialised cardiac care unit.

Note: Some expressions used in this Schedule are defined in subsection 4(1) of the National Health Act 1953 (“Act”) or subsection 3(1) of the Health Insurance Act 1973 including:

§     day hospital facility;

§     hospital-purchaser provider agreement;

§     private hospital; and

§     registered health benefits organization.

(4)     In subclause 1(3), a reference to ‘licensed beds’ is a reference to the beds or patients that a private hospital is permitted, under State or Territory legislation in the State or Territory where the private hospital is located.

Minimum Level Of Benefit2.    

(1) The minimum level of benefit payable by a RHBO in respect of an episode of hospital treatment (excluding in situations of emergency) in a facility that does not have a HPPA (or a similar arrangement) with the RHBO, is that set by this clause 2, being the second tier default benefit, and not the minimum level of benefit set by Schedules 1, 2, 3, or 8 of the Determination made under paragraph (bj) of Schedule 1 of the Act.

Note 1:   Schedule 1 sets the minimum level of benefit payable for overnight shared ward accommodation in private hospitals in all States and Territories and overnight shared ward accommodation in recognised hospitals in Victoria and Tasmania.

Schedule 2 sets the minimum level of benefit payable for overnight shared ward accommodation in recognised hospitals in the Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia and Western Australia.

Schedule 3 sets the minimum level of benefit payable for same day accommodation in hospitals and day hospital facilities in all States and Territories.

Schedule 8 sets the minimum level of benefit payable for outreach services provided by, or on behalf of, specified hospitals and day hospital facilities.

Note 2: In situations of emergency paragraph (bi) of Schedule 1 of the Act applies.

(2) This Schedule does not apply to episodes of hospital treatment referred to in Schedules 4, 5 and 7 of the Determination made under paragraph (bj) of Schedule 1 of the Act.

Note:    RHBOs must continue to pay benefits for:

§ nursing-home type patients as prescribed in Schedule 4 of the Determination made under paragraph (bj) of Schedule 1 of the Act;

§ surgically implanted prostheses, human tissue items and other medical devices as prescribed in Schedule 5 of the Determination made under paragraph (bj) of Schedule 1 of the Act; and

§ care plans and case conferencing in accordance with Schedule 7 of the Determination made under paragraph (bj) of Schedule 1 of the Act.

(3)(a) Subject to subclauses (6), and (8), the minimum level of benefit payable by a RHBO in respect of a non-rehabilitation episode of hospital treatment between 1 September of a particular year (“the first year”) and 31 August of the next year will be no less than 85% of the average charge for the equivalent episode of hospital treatment under that RHBO’s HPPAs (or similar arrangements) that were in force on 1 August of the first year with:

(i)    all comparable private hospitals in the State in which the facility is located (if treatment was provided in a facility that was a private hospital); or

(ii)   all private day hospital facilities in the State in which the facility is located (if the treatment was provided in a facility that was a private day hospital facility).

(b)      The formula for calculating the “average charge for the equivalent episode of hospital treatment” by a RHBO in each State is as follows:

Where:   j =     group of equivalent episodes of hospital treatment under the RHBO’s HPPAs (or similar arrangements)

i =     group of the RHBO’s HPPAs (or similar arrangements) in force on 1 August of the first year with comparable private hospitals, or with all private day hospital facilities, in the State

n=     the number of the RHBO’s HPPAs (or similar arrangements) in force on 1 August of the first year with comparable private hospitals, or with all private day hospital facilities, in the State

R_ji =  charge for episode of hospital treatment type j in contract i

R_j =   average charge for episode of hospital treatment type j

(4)     In subclause (3), each “episode of hospital treatment” must be identified using the patient classification system and payment structure in the majority of the relevant RHBO’s HPPAs (or similar arrangements) in force on 1 August of the first year with:

(a)       all comparable private hospitals in the State in which the facility is located (if treatment was provided in a facility that was a private hospital); or

(b)      all private day hospital facilities in the State in which the facility is located (if the treatment was provided in a facility that was a private day hospital facility).

(5)     In subclause (3), for the purpose of calculating the “average charge for the equivalent episode of hospital treatment” in a State:

(a)       the charge will include the sum of the amount payable by the RHBO under that RHBO’s HPPAs (or similar arrangements) and any excess or co-payment amounts payable by members, in accordance with the RHBO’s rules.

Note:      RHBO members’ financial obligations under such levels of cover will still apply.

(b)charges referred to within the RHBO’s HPPAs (or similar arrangements) for surgically implanted prostheses, human tissue items and other medical devices must not be included; and

(c)       charges referred to within the RHBO’s HPPAs (or similar arrangements) for hospital treatment provided to patients who are classified as nursing-home type patients (NHTPs) must not be included.

(6)    Subject to subclause (8), if a RHBO has less than five HPPAs (or similar arrangements) in force on 1 August of the first year with a particular class of comparable private hospitals in a State, then all of that RHBO’s HPPA’s with all classes of private hospitals in that State are to be used to calculate the minimum benefit payable.

(7)     Subject to subclause (8), the minimum level of benefit payable by a RHBO in respect of a rehabilitation episode of hospital treatment between 1 September of a particular year (“the first year”) and 31 August of the next year will be:

(a)        no less than 85% of the average charge for rehabilitation episodes of hospital treatment under all of that RHBO’s HPPAs (or similar arrangements) that were in force on 1 August of the first year with all comparable private hospitals in the State in which the facility is located if:

(i)     treatment was provided in a facility that was a private hospital; and

(ii)   the RHBO has directly linked the payment of benefits, under its HPPAs (or similar arrangements) with comparable private hospitals in the relevant State, for rehabilitation episodes of hospital treatment to the AN-SNAP rehabilitation classification system for the 12 months preceding and including 1 August of the first year; or

(b)      no less than 85% of the average charge for rehabilitation episodes of hospital treatment under all of that RHBO’s HPPAs (or similar arrangements) that were in force on 1 August of the first year with all private day hospital facilities in the State in which the facility is located if:

(i)    the treatment was provided in a facility that was a private day hospital facility); and

(ii)   the RHBO has directly linked the payment of benefits, under its HPPAs (or similar arrangements) with private day hospital facilities in the relevant State, for rehabilitation episodes of hospital treatment to the AN-SNAP rehabilitation classification system for the 12 months preceding and including 1 August of the first year; or

(c)       in any other case, an amount based on the AN-SNAP rehabilitation classification system negotiated by the RHBO and the facility.

(8) If the minimum level of benefit payable under subclauses (3), (6), or (7) in respect of an episode of hospital treatment is below the level set in Schedules 1, 2, 3 or 8 of the Determination made under paragraph (bj) of Schedule 1 of the Act, then the minimum level of benefit payable under this Schedule 6 is that set in Schedules 1, 2, 3 or 8 of the Determination made under paragraph (bj) of Schedule 1 of the Act for that episode of hospital treatment.

3.  Specified Private Hospitals And Private Day Hospital Facilities

(1)     Table A specifies private hospitals for the purpose of the definition of “facility” in subclause 1(1) of this Schedule 6.

Table A: Specified Private Hospitals

Item	Facility Name	Address
1	Alpha Westmead Private Hospital	55 Burwood Road, CONCORD   NSW   2137
2	Albury Wodonga Private Hospital	1125 Pemberton Road, WEST ALBURY   NSW   2640
3	Baringa Private Hospital	Mackays Road, COFFS HARBOUR   NSW   2450
4	Bega Valley Day Surgery Centre and Private Hospital	31 Parker Street, BEGA   NSW   2550
5	Beleura Private Hospital	925 Nepean Highway, MORNINGTON   VIC   3931
6	Berkeley Vale Private Hospital	Lorraine Avenue, BERKELEY VALE   NSW   2259
7	Burnside War Memorial Hospital	120 Kensington Road, TOORAK GARDENS   SA   5065
8	Cabrini Brighton	243 New Street, BRIGHTON   VIC   3186
9	Cabrini Hospital	183 Wattletree Road, MALVERN   VIC   3144
10	Cairns Private Hospital	1 Upward Street, CAIRNS   QLD   4870
11	Calvary Health Care – Lenah Valley Campus	49 Augusta Road, LENAH VALLEY   TAS   7008
12	Calvary Health Care – St Johns Campus	30 Cascade Road, SOUTH HOBART   TAS   7000
13	Calvary Health Care Riverina	Hardy Avenue, WAGGA WAGGA   NSW   2650
14	Calvary Health Care Sydney Hurstville Community	37 Gloucester Road, HURTSVILLE   NSW   2220
15	Calvary Health Care Tasmania - St Lukes Campus	24 Lyttleton Street,  LAUNCESTON   TAS   7250
16	Calvary Hospital - Adelaide	89 Strangways Terrace, NORTH ADELAIDE   SA   5006
17	Calvary Private Hospital ACT	Haydon Drive, BRUCE   ACT   2617
18	Cedar Court Healthsouth Rehabilitation Hospital	888 Toorak Road, CAMBERWELL   VIC   3124
19	Central District Private Hospital	25 Jarvis Road, ELIZABETH VALE   SA   5112
20	College Grove Hospital	18 North East Road, WALKERVILLE   SA   5081
21	Donvale Rehabilitation Hospital	1119 Doncaster Road, DONVALE   VIC   3111
22	Evesham Clinic Private Hospital	3 Harrison Street, CREMORNE   NSW   2090
23	Fullarton Private Hospital	295 Fullarton Road, PARKSIDE   SA   5063
24	Greenslopes Private Hospital	Newdegate Street, GREENSLOPES   QLD   4120
25	Hollywood Private Hospital	Monash Avenue, NEDLANDS   WA   6009
26	Hopetoun Rehabilitation Hospital	2-6 Hopetoun Street, ELSTERNWICK   VIC   3185
27	Hunters Hill Private Hospital	9 Mount Street, HUNTERS HILL   NSW   2110
28	Illawarra Private Hospital	1 Suttor Place, FIGTREE   NSW   2525
29	Kahlyn Private Hospital	40 Briant Road, MAGILL   SA   5072
30	Lake Macquarie Private Hospital	3 Sydney Street, GATESHEAD   NSW   2290
31	Lawrence Hargrave Hospital	72 Phillip Street, THIRROUL   NSW   2515
32	Malvern Private Hospital	6 Wilton Vale Crescent, MALVERN   VIC   3144
33	Maryvale Private Hospital	McDonald Street,   MORWELL   VIC   3840
34	Mater Hospital North Sydney	Rocklands Road, NORTH SYDNEY   NSW   2060
35	Mater Misericordia Private Hospital Brisbane	301 Vulture Street, SOUTH BRISBANE   QLD   4101
36	Mater Misericordia Women’s & Children’s Private Health Service	Cnr Raymond Terrace & Stanley Street, SOUTH BRISBANE   QLD   4101
37	Mater Private Hospital Redland	Weippin Street, CLEVELAND   QLD   4163
38	Mayo Private Hospital	Lot 1, Potoroo Drive, Kolodong, VIA TAREE   NSW   2430
39	Mitcham Private Hospital	27 Doncaster East Road, MITCHAM   VIC   3132
40	Mt Olivet Hospital	411 Main Street, KANGAROO POINT   QLD   4169
41	Mt Wilga Private Hospital	2 Manor Road, HORNSBY   NSW   2000
42	New Farm Clinic Private Hospital	22 Sargent Street, NEW FARM   QLD   4005
43	North Eastern Community Hospital	Lower North East Road, CAMPBELLTOWN   SA   5074
44	North Shore Private Hospital	Westbourne Street, ST LEONARDS   NSW   2065
45	Northside Clinic	2 Greenwich Road, GREENWICH   NSW   2065
46	Northside West Clinic	21-27 Lytton Street, WENTWORTHVILLE   NSW   2145
47	Peninsula Private Hospital	49 McClelland Drive, FRANKSTON   VIC   3910
48	Pinelodge Clinic Private Hospital	1480 Heatherton Road, DANDENONG   VIC   3175
49	Poplars Private Hospital	66 Norfolk Road,   EPPING   NSW   2121
50	South Eastern Private Hospital	Cnr Princes Highway & Heatherton Roads, NOBLE PARK   VIC   3174
51	South Pacific Private Hospital	18 Beach Street,   HARBORD   NSW   2096
52	Southern Highlands Private Hospital	Bowral Street, BOWRAL   NSW   2576
53	Spendelove House	24 Spendelove Street, SOUTHPORT   QLD   4215
54	Sportsmed SA Hospital	32 Payneham Road,   STEPNEY   SA   5069
55	St Andrews Toowoomba Hospital	280 North Street, TOOWOOMBA   QLD   4350
56	St Luke’s Hospital Complex	18 Rosalyn Street,   POTTS POINT   NSW   2011
57	St. Vincent’s Hospital Toowoomba	Scott Street,  TOOWOOMBA   QLD   4350
58	St. Vincent’s Private Hospital	406 Victoria Stree, DARLINGHURST   NSW   2010
59	Sydney Adventist Hospital	185 Fox Valley Road,   WAHROONGA   NSW   2076
60	Tamara Private Hospital	2-6 Dean Street, TAMWORTH   NSW   2340
61	The Adelaide Clinic	33-36 Park Terrace, GILBERTON   SA   5081
62	The Albert Road Clinic	31-33 Albert Road, MELBOURNE   VIC   3004
63	The Valley Private Hospital	Cnr Police & Gladstone Roads, MULGRAVE   VIC   3170
64	Toronto Private Hospital	Carey Street, TORONTO   NSW   2283
65	Vaucluse Private Hospital	82 Moreland Road,   BRUNSWICK    VIC   3056
66	Wakefield Hospital	300 Wakefield Street, ADELAIDE   SA   5000
67	Wolper Jewish Hospital	8 Trelawney Street,   WOOLLAHRA   NSW   2025

(2)     Table B specifies private day hospital facilities for the purpose of the definition of “facility” in subclause 1(1) of this Schedule 6.

Table B: Specified Private Day Hospital Facilities

Item	Facility Name	Address
1	Aesthetic Day Surgery	14 Kensington Street,   KOGARAH   NSW   2217
2	Albury Day Surgery	4 Baker Street,   WEST ALBURY   NSW   2640
3	Ballina Day Surgery	46 Tamar Street,   BALLINA   NSW   2478
4	Broadmeadow Day Surgery	1st Floor (Suite 1), 18 Lambton Road, BROADMEADOW   NSW   2292
5	Buderim Gastroenterology Centre	139 King St, BUDERIM   QLD   4556
6	Calvary Day Procedure Centre	329,31,333 Edward Street, WAGGA WAGGA   NSW  2651
7	Capital Day Surgery Centre	Calvary Clinic,   Mary Potter Circuit, BRUCE   ACT   2617
8	Castle Hill Day Surgery	Corner of Cecil Avenue and Terminus Streets, CASTLE HILL   NSW   2154
9	Chasely Day Surgery	Wesley Medical Centre, 40 Chasely Street, AUCHENFLOWER   QLD   4066
10	Coffs Harbour Day Surgical Centre	69 Albany Street, COFFS HARBOUR   NSW   2450
11	Colin Street Day Surgery	51 Colin Street,   WEST PERTH   WA   6005
12	Epping Surgery Centre	Suite 3, Oxford Place, 44-46 Oxford Street EPPING   NSW   2121
13	Griffiths Road Day Procedure Centre	182 Christo Road,   WARATAH   NSW   2298
14	Harley Place Day Surgery	Suite 605, 251 Oxford Street, BONDI JUNCTION   NSW   2026
15	Inner West Endoscopy Centre	311 Marrickville Road, MARRICKVILLE   NSW   2204
16	Kew Private Dialysis Centre	303 Mountain Highway, WANTIRNA   VIC   3152
17	Logan Endoscopy Services	Unit 2/32 76 Beaudesert Road, BROWN PLAINS   QLD   4118
18	Maroubra Day Surgery	225 Maroubra Road,   MAROUBRA   NSW   2035
19	Montserrat Day Hospital	383 – 391 Samford Road, GAYTHORNE   QLD   4051
20	Montserrat Day Hospital (Indooroopilly)	12 Riverview Tce, INDOOROOPILLY   QLD   4068
21	Montserrat Day Hospital (Spring Hill)	Level 2, 35 Astor Rce, BRISBANE   QLD   4000
22	Orange Day Surgery Centre	60-62 McNamara Street, ORANGE   NSW   2800
23	Pacific Day Surgery	38 Misterton Street, FORTITUDE VALLEY   QLD   4006
24	Payneham Dialysis Centre	2 Portrush Road, PAYNEHAM   SA   5070
25	Pendlebury Clinic	52 Pendlebury Road, CARDIFF   NSW   2285
26	Perfect Vision Eye Surgery	Suite 3,   25 –29 Hunter Street, HORNSBY   NSW   2077
27	QFG Day Theatres	Level 4/33 North Street, SPRING HILL   QLD   4000
28	Randwick Day Surgery	2 Eurimble Avenue,   RANDWICK   NSW   2031
29	Roderick Street Day Surgery	28 Roderick Street,   IPSWICH   QLD   4305
30	Rosebud SurgiCentre	1537 Point Nepean Road, ROSEBUD WEST   VIC   3940
31	Solander Day Surgery	182 Grafton St,   CAIRNS   QLD   4870
32	South Coast Digestive Disease Centre	86 Ashmore Road, BUNDALL   QLD   4217
33	South Western Endoscopy Centre	20-22 Bigge Street,   LIVERPOOL   NSW   2170
34	Sydney IVF – Liverpool	173-175 Biggs Street,   LIVERPOOL   NSW   2170
35	Sydney IVF Clinic	4 O’Connell Street,   SYDNEY   NSW   2000
36	Sydney Retina Clinic & Day Surgery	Level 13,   187 Macquarie Street, SYDNEY   NSW   2000
37	Terrace West Endoscopy Centre	18 Limestone Street,   IPSWICH   QLD   4305
38	The Eye Institute	Level 4, 270 Victoria Ave, CHATSWOOD   NSW   2057
39	The Hills Parenting Centre	103-108 Showground Road, CASTLE HILL   NSW   2154
40	Vista Laser Eye Clinics	1 Mclaren Street, NORTH SYDNEY   NSW   2060

4.  Transitional provision for facilities no longer specified in clause 3

(1) If a determination is made removing a facility from clause 3, the facility is deemed to remain specified in clause 3 only for such period of time and for such purposes as are necessary to allow members of RHBOs to receive the benefit of the second tier default benefit, in relation to episodes of hospital treatment for which those members were admitted patients at the facility or booked for hospital treatment at the facility (as opposed to merely being on the facility’s waiting list) prior to the date the determination removing the facility from clause 3 took effect.

(2)   If, because of a name or address change, a facility is no longer specified in clause 3, the facility is deemed to remain specified in clause 3 only for such period of time and for such purposes as are necessary to allow members of RHBOs to receive the benefit of the second tier default benefit, in relation to episodes of hospital treatment for which those members were admitted patients at the facility or booked for hospital treatment at the facility (as opposed to merely being on the facility’s waiting list) prior to the date the facility changed its name or address.