National Health Act 1953 Determination under Schedule 1, paragraph (bj) (Hib 06/2005) (Cth)
Australian Government
NATIONAL HEALTH ACT 1953
Determination under Schedule 1, paragraph (bj)
(HIB 06/2005)
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 6 day of April 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 ofNew South Wales and theNorthern 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
Rji = charge for episode of hospital treatment type j in contract i
Rj = 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 AndFacilities Private Day Hospital (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 Albury Wodonga Private Hospital ALBURY NSW 2640 1125 Pemberton Road, WEST 2 Alpha Westmead Private Hospital 55 Burwood Road, NSW 2137 CONCORD 3 Baringa Private Hospital , COFFS HARBOUR NSW 2450 Mackays Road 4 Bega Valley Day Surgery Centre andPrivate Hospital , BEGA NSW 2550 31 Parker Street 5 Beleura Private Hospital , MORNINGTON VIC 3931 925 Nepean Highway 6 Berkeley Vale Private Hospital VALE NSW 2259 Lorraine Avenue ,BERKELEY 7 Bondi Junction Private Hospital 21 Spring Street, BONDI JUNCTION NSW 2022 8 Burnside War Memorial Hospital , TOORAK GARDENS SA 5065 120 Kensington Road 9 Cabrini Brighton 243 New Street, BRIGHTON VIC 318610 Cabrini Hospital , MALVERN VIC 3144 183 Wattletree Road 11 Cairns Private Hospital 1 Upward Street, QLD 4870 CAIRNS 12 Calvary Health Care – Campus Lenah Valley , LENAH VALLEY TAS 7008 49 Augusta Road 13 Calvary Health Care – Campus St Johns 30 Cascade Road, SOUTH HOBART TAS 700014 Calvary Health Care Riverina, WAGGA WAGGA NSW 2650 Hardy Avenue 15 Calvary Health Care Sydney Hurstville Community, HURTSVILLE NSW 2220 37 Gloucester Road 16 Calvary Health Care - St Lukes Campus Tasmania , LAUNCESTON TAS 7250 24 Lyttleton Street 17 Calvary Hospital -Adelaide 89 Strangways Terrace, NORTH SA 5006 ADELAIDE 18 Calvary Private Hospital ACT, BRUCE ACT 2617 Haydon Drive 19 Cedar Court Healthsouth Rehabilitation Hospital , CAMBERWELL VIC 3124 888 Toorak Road 20 Central District Private Hospital VALE SA 5112 25 Jarvis Road ,ELIZABETH 21 College Grove Hospital , WALKERVILLE SA 5081 18 North East Road 22 Donvale Rehabilitation Hospital , DONVALE VIC 3111 1119 Doncaster Road 23 Evesham Clinic Private Hospital , CREMORNE NSW 2090 3 Harrison Street 24 Fullarton Private Hospital , PARKSIDE SA 5063 295 Fullarton Road 25 Greenslopes Private Hospital , GREENSLOPES QLD 4120 Newdegate Street 26 Hollywood Private Hospital , NEDLANDS WA 6009 Monash Avenue 27 Hopetoun Rehabilitation Hospital , ELSTERNWICK VIC 3185 2-6 Hopetoun Street 28 Hunters Hill Private Hospital , HUNTERS HILL NSW 2110 9 Mount Street 29 Illawarra Private Hospital , FIGTREE NSW 2525 1 Suttor Place 30 Kahlyn Private Hospital , MAGILL SA 5072 40 Briant Road 31 Lake Macquarie Private Hospital , 3 Sydney Street GATESHEAD NSW 229032 Lawrence Hargrave Hospital , THIRROUL NSW 2515 72 Phillip Street 33 Maitland Private Hospital MAITLAND NSW 2323 173 Chisholm Road, EAST 34 Malvern Private Hospital , MALVERN VIC 3144 6 Wilton Vale Crescent 35 Maryvale Private Hospital , MORWELL VIC 3840 McDonald Street 36 Mater Hospital North Sydney Rocklands Road, NORTH SYDNEY NSW 206037 Yeppoon Mater Hospital Cnr Cliff & Hutton Streets, YEPPOON QLD 4703 38 Mater Misericordia Private Hospital Brisbane 301 Vulture Street, SOUTH BRISBANE QLD 410139 Mater Misericordia Women’s & Children’s Private Health Service Cnr Raymond Terrace & Stanley Street, SOUTH BRISBANE QLD 410140 Mackay Mater Misericordiae Private Hospital , MACKAY QLD 4740 Gordon Street 41 Mater Misericordiae Private Hospital Gladstone Rossella Street, QLD 4680 GLADSTONE 42 Rockhampton Mater Misericordiae Private Hospital , ROCKHAMPTON QLD 4700 Ward Street 43 Mater Private Hospital Redland Weippin Street, QLD 4163 CLEVELAND 44 Mayo Private Hospital Lot 1,, Kolodong, VIA TAREE NSW 2430 Potoroo Drive 45 Mitcham Private Hospital , MITCHAM VIC 3132 27 Doncaster East Road 46 Mt Olivet Hospital , KANGAROO POINT QLD 4169 411 Main Street 47 Mt Wilga Private Hospital , HORNSBY NSW 2000 2 Manor Road 48 New Farm Clinic Private Hospital , NEW FARM QLD 4005 22 Sargent Street 49 North Eastern Community Hospital Lower North East Road, CAMPBELLTOWN SA 5074 50 North Shore Private Hospital , ST LEONARDS NSW 2065 Westbourne Street 51 Northside Clinic 2 Greenwich Road,NSW 2065 GREENWICH 52 Northside West Clinic , WENTWORTHVILLE NSW 2145 21-27 Lytton Street 53 Pendlebury Clinic 52 Pendlebury Road, NSW 2285 CARDIFF 54 Peninsula Private Hospital , FRANKSTON VIC 3910 49 McClelland Drive 55 Pinelodge Clinic Private Hospital , DANDENONG VIC 3175 1480 Heatherton Road 56 Poplars Private Hospital , EPPING NSW 2121 66 Norfolk Road 57 RiverCity Private Hospital , AUCHENFLOWER QLD 4066 401 Milton Road 58 South Eastern Private Hospital Cnr & Heatherton Roads, NOBLE PARK VIC 3174 Princes Highway 59 South Pacific Private Hospital , HARBORD NSW 2096 18 Beach Street 60 Southern Highlands Private Hospital , BOWRAL NSW 2576 Bowral Street 61 Spendelove House , 24 Spendelove Street SOUTHPORT QLD 421562 Sportsmed SA Hospital , STEPNEY SA 5069 32 Payneham Road 63 St Andrews Toowoomba Hospital , TOOWOOMBA QLD 4350 280 North Street 64 St Luke’s Hospital Complex , POTTS POINT NSW 2011 18 Rosalyn Street 65 St. Vincent ’s Hospital Toowoomba, TOOWOOMBA QLD 4350 Scott Street 66 St. Vincent’s Private Hospital 406 Stree, DARLINGHURST NSW 2010 Victoria 67 Sydney Adventist Hospital , WAHROONGA NSW 2076 185 Fox Valley Road 68 Tamara Private Hospital , 2-6 Dean Street TAMWORTH NSW 234069 The Clinic Adelaide 33-36 Park Terrace, GILBERTON SA 5081 70 The Clinic Albert Road VIC 3004 31-33 Albert Road ,MELBOURNE 71 The Valley Private Hospital Cnr Police & Gladstone Roads, MULGRAVE VIC 3170 72 Toronto Private Hospital Carey Street, NSW 2283 TORONTO 73 Vaucluse Private Hospital 82 Moreland Road, VIC 3056 BRUNSWICK 74 Wakefield Hospital 300 Wakefield Street,SA 5000 ADELAIDE 75 Wolper Jewish Hospital , WOOLLAHRA NSW 2025 8 Trelawney Street (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
Facilities Private Day Hospital
Item Facility Name Address
1 Aesthetic Day Surgery , KOGARAH NSW 2217 14 Kensington Street 2 Albury Day Surgery ALBURY NSW 2640 4 Baker Street, WEST 3 Avenue Day Surgery 20 The Avenue, VIC 3181 WINDSOR 4 Ballina Day Surgery , BALLINA NSW 2478 46 Tamar Street 5 Broadmeadow Day Surgery 1st Floor (Suite 1), , 18 Lambton Road
BROADMEADOW NSW 22926 Buderim Gastroenterology Centre , BUDERIM QLD 4556 139 King St 7 Calvary Day Procedure Centre329,31, , WAGGA WAGGA NSW 2651 333 Edward Street 8 Capital Day Surgery Centre Calvary Clinic, Mary Potter Circuit, BRUCE ACT 26179 Chasely Day Surgery Wesley Medical Centre, 40 Chasely Street,
AUCHENFLOWER QLD 406610 Day Surgical Centre Coffs Harbour , COFFS HARBOUR NSW 2450 69 Albany Street 11 Day Surgery Colin Street 51 Colin Street, WEST WA 6005 PERTH 12 Epping Surgery Centre , Suite 3, Oxford Place 44-46 Oxford Street
EPPING NSW 212113 Day Procedure Centre Griffiths Road , WARATAH NSW 2298 182 Christo Road 14 Day Surgery Harley Place , Suite 605, BONDI JUNCTION NSW 2026 251 Oxford Street 15 Healthwoods Specialist Centre , GRANVILLE NSW 2142 53 Cowper Street 16 Inner West Endoscopy Centre , MARRICKVILLE NSW 2204 311 Marrickville Road 17 Kew Private Dialysis Centre, WANTIRNA VIC 3152 303 Mountain Highway 18 Endoscopy Services Logan Unit , BROWN PLAINS QLD 4118 2/32 76 Beaudesert Road 19 Maroubra Day Surgery , MAROUBRA NSW 2035 225 Maroubra Road 20 Mater Misericordiae Day Unit Mackey , MACKAY QLD 4740 1 Wellington Street 21 Montserrat Day Hospital 383 – , GAYTHORNE QLD 4051 391 Samford Road 22 (Indooroopilly) Montserrat Day Hospital 12 Riverview Tce, INDOOROOPILLY QLD 4068 23 (Spring Hill) Montserrat Day Hospital Level 2, 35 Astor Rce, QLD 4000 BRISBANE 24 Orange Day Surgery Centre NSW 2800 60-62 McNamara Street ,ORANGE 25 Pacific Day Surgery , FORTITUDE VALLEY QLD 4006 38 Misterton Street 26 Payneham Dialysis Centre , PAYNEHAM SA 5070 2 Portrush Road 27 Perfect Vision Eye Surgery , Suite 3, HORNSBY NSW 2077 25 –29 Hunter Street 28 QFG Day Theatres Level , SPRING HILL QLD 4000 4/33 North Street 29 Day Surgery Randwick 2 Eurimble Avenue, NSW 2031 RANDWICK 30 Day Surgery Roderick Street , 23 Roderick Street IPSWICH QLD 430531 Rosebud SurgiCentre , ROSEBUD WEST VIC 3940 1537 Point Nepean Road 32 Solander Day Surgery QLD 4870 182 Grafton St ,CAIRNS 33 Digestive Disease Centre South Coast , BUNDALL QLD 4217 86 Ashmore Road 34 South Western Endoscopy Centre , 20-22 Bigge Street LIVERPOOL NSW 217035 Sydney IVF – Liverpool , 173-175 Biggs Street LIVERPOOL NSW 217036 Sydney IVF Clinic 4 O’Connell Street, NSW 2000 SYDNEY 37 Sydney Retina Clinic & Day Surgery Level 13, 187 Macquarie Street, NSW 2000 SYDNEY 38 Terrace West Endoscopy Centre , 18 Limestone Street IPSWICH QLD 430539 The CAPS Clinic John James Memorial Hospital Strickland Crescent
DEAKIN WEST ACT 260040 The Eye Institute Level 4, , CHATSWOOD NSW 2057 270 Victoria Ave 41 The Hills Parenting Centre , CASTLE HILL NSW 2154 103-108 Showground Road 42 Vista Laser Eye Clinics1 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.
0
0
0