National Health Act 1953 Determination under Schedule 1, paragraph (bj) (HIB 1/2006) (Cth)
Australian Government
NATIONAL HEALTH ACT 1953
Determination under Schedule 1, paragraph (bj)
(HIB 1/2006)
I, LINDA JANE ADDISON, delegate of the Minister for Health and Ageing acting under Schedule 1, paragraph (bj) of the National Health Act 1953 (the Act):
AMEND the determination made under Schedule 1, paragraph (bj) of the Act dated
24 June 2005 (HIB 11/2005) (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 5th day of January 2006
Linda Addison
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 and 7 of the Determination made under paragraph (bj) of Schedule 1 to the Act, and the Determination made under subsections 73AAG(6) and (7) 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;
§ no gap prostheses and gap permitted prostheses determined under subsections 73AAG(6) and (7) 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 no gap prostheses and gap permitted prostheses determined under subsections 73AAG(6) and (7) of the Act 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.
Facilities Hospital Day Private And Hospitals Private3. Specified
(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 1125 Pemberton Road, WEST ALBURY NSW 2640 2 Alpha Westmead Private Hospital Corner Mons & Darcy Roads, WESTMEAD NSW 2145 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 Blackwood Hospital Group 13 Laffers Road, BELAIR SA 5052 8 Bondi Junction Private Hospital 21 Spring Street, BONDI JUNCTION NSW 2022 9 Brisbane Private Hospital 259 Wickham Tce, BRISBANE QLD 4000 10 Burnside War Memorial Hospital 120 Kensington Road, TOORAK GARDENS SA 5065 11 Cabrini Brighton 243 New Street, BRIGHTON VIC 3186 12 Cabrini Hospital 183 Wattletree Road, MALVERN VIC 3144 13 Cairns Private Hospital 1 Upward Street, CAIRNS QLD 4870 14 Calvary Health Care – Lenah Valley Campus 49 Augusta Road, LENAH VALLEY TAS 7008 15 Calvary Health Care – St Johns Campus 30 Cascade Road, SOUTH HOBART TAS 7000 16 Calvary Health Care Riverina Hardy Avenue, WAGGA WAGGA NSW 2650 17 Calvary Health Care Sydney Hurstville Community 37 Gloucester Road, HURTSVILLE NSW 2220 18 Calvary Health Care Tasmania - St Lukes Campus 24 Lyttleton Street, LAUNCESTON TAS 7250 19 Calvary Hospital - Adelaide 89 Strangways Terrace, NORTH ADELAIDE SA 5006 20 Calvary Private Hospital ACT Haydon Drive, BRUCE ACT 2617 21 Castle Hill Hospital 72-74 Cecil Avenue, CASTLE HILL NSW 2154 22 Cedar Court Healthsouth Rehabilitation Hospital 888 Toorak Road, CAMBERWELL VIC 3124 23 Central District Private Hospital 25 Jarvis Road, ELIZABETH VALE SA 5112 24 Coastal Private Hospital 221 Willmott Drive. WAIKIKI WA 6169 25 College Grove Hospital 18 North East Road, WALKERVILLE SA 5081 26 Delmont Private Hospital 298 Warrigal Road, GLEN IRIS VIC 3146 27 Donvale Rehabilitation Hospital 1119 Doncaster Road, DONVALE VIC 3111 28 Evesham Clinic Private Hospital 3 Harrison Street, CREMORNE NSW 2090 29 Fullarton Private Hospital 295 Fullarton Road, PARKSIDE SA 5063 30 Greenslopes Private Hospital Newdegate Street, GREENSLOPES QLD 4120 31 Hawkesbury District Health Service Level 2, 16-18 Bridge Street, EPPING NSW 2121 32 Hollywood Private Hospital Monash Avenue, NEDLANDS WA 6009 33 Holy Spirit Northside 627 Rode Road, CHERMSIDE QLD 4032 34 Hopetoun Rehabilitation Hospital 2-6 Hopetoun Street, ELSTERNWICK VIC 3185 35 Hunters Hill Private Hospital 9 Mount Street, HUNTERS HILL NSW 2110 36 Illawarra Private Hospital 1 Suttor Place, FIGTREE NSW 2525 37 Kahlyn Private Hospital 40 Briant Road, MAGILL SA 5072 38 Lake Macquarie Private Hospital 3 Sydney Street, GATESHEAD NSW 2290 39 Lawrence Hargrave Hospital 72 Phillip Street, THIRROUL NSW 2515 40 Maitland Private Hospital 173 Chisholm Road, EAST MAITLAND NSW 2323 41 Maryvale Private Hospital McDonald Street, MORWELL VIC 3840 42 Mater Hospital North Sydney Rocklands Road, NORTH SYDNEY NSW 2060 43 Mater Hospital Yeppoon Cnr Cliff & Hutton Streets, YEPPOON QLD 4703 44 Mater Misericordia Private Hospital Brisbane 301 Vulture Street, SOUTH BRISBANE QLD 4101 45 Mater Misericordia Women’s & Children’s Private Health Service Cnr Raymond Terrace & Stanley Street, SOUTH BRISBANE QLD 4101 46 Mater Misericordiae Hospital Bundaberg Bourbong Street, BUNDABERG QLD 4670 47 Mater Misericordiae Private Hospital Mackay Gordon Street, MACKAY QLD 4740 48 Mater Misericordiae Private Hospital Gladstone Rossella Street, GLADSTONE QLD 4680 49 Mater Misericordiae Private Hospital Rockhampton Ward Street, ROCKHAMPTON QLD 4700 50 Mater Private Hospital Redland Weippin Street, CLEVELAND QLD 4163 51 Mayo Private Hospital Lot 1, Potoroo Drive, Kolodong, VIA TAREE NSW 2430 52 Mercy Private Hospital 159 Grey Street, EAST MELBOURNE VIC 3002 53 Mitcham Private Hospital 27 Doncaster East Road, MITCHAM VIC 3132 54 Mt Lawley Private Hospital 14 Alvan Street, MOUNT LAWLEY WA 6050 55 Mt Olivet Hospital 411 Main Street, KANGAROO POINT QLD 4169 56 Mt Wilga Private Hospital 2 Manor Road, HORNSBY NSW 2000 57 Murray Valley Private Hospital Nordsvan Drive, WODONGA,VIC 3690 58 New Farm Clinic Private Hospital 22 Sargent Street, NEW FARM QLD 4005 59 North Eastern Community Hospital Lower North East Road, CAMPBELLTOWN SA 5074 60 North Shore Private Hospital Westbourne Street, ST LEONARDS NSW 2065 61 Northside Clinic 2 Greenwich Road, GREENWICH NSW 2065 62 Northside West Clinic 21-27 Lytton Street, WENTWORTHVILLE NSW 2145 63 Pendlebury Clinic 52 Pendlebury Road, CARDIFF NSW 2285 64 Peninsula Private Hospital 49 McClelland Drive, FRANKSTON VIC 3910 65 Peninsula Private Hospital (Harbord) 12 McDonald Street, HARBORD NSW 2096 66 Perth Clinic 29 Havelock St, WEST PERTH WA 6005 67 Poplars Private Hospital 66 Norfolk Road, EPPING NSW 2121 68 RiverCity Private Hospital 401 Milton Road, AUCHENFLOWER QLD 4066 69 South Eastern Private Hospital Cnr Princes Highway & Heatherton Roads, NOBLE PARK VIC 3174 70 South Pacific Private Hospital 18 Beach Street, HARBORD NSW 2096 71 Southern Highlands Private Hospital Bowral Street, BOWRAL NSW 2576 72 Spendelove House 24 Spendelove Street, SOUTHPORT QLD 4215 73 Sportsmed SA Hospital 32 Payneham Road, STEPNEY SA 5069 74 St Andrews Toowoomba Hospital 280 North Street, TOOWOOMBA QLD 4350 75 St Luke’s Hospital Complex 18 Rosalyn Street, POTTS POINT NSW 2011 76 St. Vincent’s Hospital Toowoomba Scott Street, TOOWOOMBA QLD 4350 77 St. Vincent’s Private Hospital 406 Victoria Street, DARLINGHURST NSW 2010 78 St. Vincent’s Private Hospital 59 Victoria Parade, FITZROY VIC 3065 79 Sydney Adventist Private Hospital 185 Fox Valley Road, WAHROONGA NSW 2076 80 Tamara Private Hospital 2-6 Dean Street, TAMWORTH NSW 2340 81 The Adelaide Clinic 33-36 Park Terrace, GILBERTON SA 5081 82 The Albert Road Clinic 31-33 Albert Road, MELBOURNE VIC 3004 83 The Bays Hospital Mornington Campus 262 -272 Main Street, MORNINGTON VIC 3931 84 The Valley Private Hospital Cnr Police & Gladstone Roads, MULGRAVE VIC 3170 85 Toronto Private Hospital Carey Street, TORONTO NSW 2283 86 Toowong Private Hospital 496 Milton Rd, TOOWONG QLD 4066 87 Vaucluse Private Hospital 82 Moreland Road, BRUNSWICK VIC 3056 88 Wakefield Hospital 300 Wakefield Street, ADELAIDE SA 5000 89 Westmead Rehabilitation Centre 7 Coleman Street, MERRYLANDS NSW 2160 90 Westside Private Hospital 55 Burwood Road
CONCORD NSW 213791 Wolper Jewish Private 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 Avenue Day Surgery 20 The Avenue, WINDSOR VIC 3181 3 Ballina Day Surgery 46 Tamar Street, BALLINA NSW 2478 4 Bankstown Primary Health Care Day Surgery Grnd Floor, 67 Rickard Road, BANKSTOWN NSW 2200 5 Broadmeadow Day Surgery 1st Floor (Suite 1), 18 Lambton Road,
BROADMEADOW NSW 22926 Buderim Gastroenterology Centre 139 King St, BUDERIM QLD 4556 7 Calvary Day Procedure Centre 329,31,333 Edward Street, WAGGA WAGGA NSW 2651 8 Capital Day Surgery Centre Calvary Clinic, Mary Potter Circuit, BRUCE ACT 2617 9 Carringbah Day Surgery 42 President Avenue, CARRINGBAH NSW 2229 10 Chasely Day Surgery Wesley Medical Centre, 40 Chasely Street,
AUCHENFLOWER QLD 406611 Chesterville Day Hospital 28 Chesterville Road, CHELTENHAM VIC 3192 12 Coffs Harbour Day Surgical Centre 69 Albany Street, COFFS HARBOUR NSW 2450 13 Colin Street Day Surgery 51 Colin Street, WEST PERTH WA 6005 14 Coolenberg Clinic 60 Lake Rd, PORT MACQUARIE NSW 2444 15 Epping Surgery Centre Suite 3, Oxford Place, 44-46 Oxford Street
EPPING NSW 212116 Griffiths Road Day Procedure Centre 182 Christo Road, WARATAH NSW 2298 17 Harley Place Day Surgery Suite 605, 251 Oxford Street, BONDI JUNCTION NSW 2026 18 Healthwoods Specialist Centre 53 Cowper Street, GRANVILLE NSW 2142 19 Inner West Endoscopy Centre 311 Marrickville Road, MARRICKVILLE NSW 2204 20 Liverpool Day Surgery 105-119 Longstaff Avenue, MOOREBANK NSW 2170 21 Logan Endoscopy Services Unit 2/32 76 Beaudesert Road, BROWN PLAINS QLD 4118 22 Mater Misericordiae Day Unit Mackey 1 Wellington Street, MACKAY QLD 4740 23 Montserrat Day Hospital 383 – 391 Samford Road, GAYTHORNE QLD 4051 24 Montserrat Day Hospital (Indooroopilly) 12 Riverview Tce, INDOOROOPILLY QLD 4068 25 Montserrat Day Hospital (Spring Hill) Level 2, 35 Astor Rce, BRISBANE QLD 4000 26 Ophthalmic Surgery Centre Suite 6, 12-14 Malvern Avenue, CHATSWOOD NSW 2067 27 Orange Day Surgery Centre 60-62 McNamara Street, ORANGE NSW 2800 28 Pacific Day Surgery 38 Misterton Street, FORTITUDE VALLEY QLD 4006 29 Peninsula Eye Centre 47 Redcliffe Parade, REDCLIFFE QLD 4020 30 Perfect Vision Eye Surgery Suite 3, 25 –29 Hunter Street, HORNSBY NSW 2077 31 QFG Day Theatres Level 4/33 North Street, SPRING HILL QLD 4000 32 Randwick Day Surgery 2 Eurimble Avenue, RANDWICK NSW 2031 33 Roderick Street Day Surgery 23 Roderick Street, IPSWICH QLD 4305 34 Rosebud SurgiCentre 1537 Point Nepean Road, ROSEBUD WEST VIC 3940 35 Solander Day Surgery 182 Grafton St, CAIRNS QLD 4870 36 South Coast Digestive Disease Centre 86 Ashmore Road, BUNDALL QLD 4217 37 South Western Day Surgery Centre 20-22 Bigge Street, LIVERPOOL NSW 2170 38 Sydney Day Surgery 213-219 Darlinghurst Road, DARLINGHURST NSW 2010 39 Sydney IVF – Liverpool 173-175 Biggs Street, LIVERPOOL NSW 2170 40 Sydney IVF Clinic 4 O’Connell Street, SYDNEY NSW 2000 41 Sydney Oculoplastic Surgery 229 Macquarie St, SYDNEY NSW 2000 42 Sydney Retina Clinic & Day Surgery Level 13, 187 Macquarie Street, SYDNEY NSW 2000 43 Terrace West Endoscopy Centre 18 Limestone Street, IPSWICH QLD 4305 44 The CAPS Clinic John James Memorial Hospital
Strickland Crescent
DEAKIN WEST ACT 260045 The Eye Institute Level 4, 270 Victoria Ave, CHATSWOOD NSW 2057 46 The Hills Parenting Centre 103-108 Showground Road, CASTLE HILL NSW 2154 47 The San Day Surgery 1a Northcote Road, HORNSBY NSW 2077 48 Vista Laser Eye Clinics 1 Mclaren Street, NORTH SYDNEY NSW 2060 49 Western Plains Day Surgery 62 Windsor Parade, DUBBO NSW 2830
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.
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