Private Health Insurance (Reforms) Amendment Rules 2018 (Cth)
made under section 333‑20 of the
This is a compilation of the
The notes at the end of this compilation (the
The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register ( The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.
If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.
For more information about any editorial changes made in this compilation, see the endnotes.
If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.
If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.
Contents
This instrument is the
Private Health Insurance (Reforms) Amendment Rules 2018 .
(1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.
Sections 1 to 4 and anything in this instrument not elsewhere covered by this table | The day after this instrument is registered. | |
Schedule 1 | 1 April 2019 | 1 April 2019 |
Part 1 of Schedule 2 | 1 January 2019 | 1 January 2019 |
Part 2 of Schedule 2 | 1 April 2019 | 1 April 2019 |
Part 3 of Schedule 2 | 1 April 2020 | 1 April 2020 |
Part 1 of Schedule 3 | 1 April 2019 | 1 April 2019 |
Part 2 of Schedule 3 | 1 April 2020 | 1 April 2020 |
Schedule 4 | 1 January 2019 | 1 January 2019 |
Schedule 5 | 1 April 2019 | 1 April 2019 |
Schedule 6 | 1 April 2019 | 1 April 2019 |
Schedule 7 | The day after this instrument is registered. | |
Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.
(2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.
This instrument is made under section 333‑20 of the
Private Health Insurance Act 2007 .
Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.
Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, the following terms:
(a) adult;
(b) hospital cover.
Omit “(e)”, substitute “(ea)”.
Omit “The following costs are excluded from the calculation of net premium in subrule (4):”, substitute “For the purposes of this rule, disregard:”.
Insert:
; and (c) any age‑based discount that might apply in relation to the policy (see Part 2A).
Insert:
Note 1: See paragraphs 63‑10 (g) and 66‑5 (3) (ea) of the Act.
Note 2: Nothing in this Part requires a private health insurer to:
· make age‑based discounts available under any product; or
· if age‑based discounts are available under a product:
– make such discounts available for all ages between 18 and 29 (inclusive); or
– continue to make age‑based discounts available under the product.
Instead, an age‑based discount policy may specify the ranges of ages, between 18 and 29 (inclusive), for which such discounts will be available (see subparagraph 11B (c) (i)).
However, under this Part:
· if a person is receiving an age‑based discount, the person is entitled to continue to receive the full discount until the person turns 41 (unless the insurer chooses to discontinue age‑based discounts under the product, or the person transfers to a different insurance policy), and might be entitled to receive a reduced discount for a number of years after turning 41; and
· if age‑based discounts are available in relation to particular ages or particular ranges of ages for a particular product, they must be available in relation to those ages or ranges on the same terms and conditions for all insurance policies under that product (see section 63‑5 of the Act).
In this Part:
age‑based discount policy means an insurance policy that provides age‑based discounts.
discount assessment date , in relation to a person who is insured under an age‑based discount policy,means whichever of the following is applicable:
(a) subject to paragraph (c), if the policy provided age‑based discounts at the date the person became insured—that date;
(b) if the policy provided age‑based discounts at a date after the person became insured—the date the person was first eligible for an age‑based discount under the policy;
(c) if:
(i) the person transferred to the policy (the
new policy ) from another age‑based discount policy (theold policy ); and(ii) at the time of the transfer, the new policy was stated to be a retained age‑based discount policy; and
(iii) the person was not a dependent child under the old policy;
the person’s discount assessment date under the old policy.
eligible person , in relation to an age‑based discount policy, means a person to whom a discount applies in accordance with paragraph 11B (c).
retained age‑based discount policy means an insurance policy:
(a) that is an age‑based discount policy; and
(b) that states that it is a retained age‑based discount policy.
For paragraph 63‑10 (g) of the Act, an insurance policy must not provide for an age‑based discount (the
discount )unless:
(a) the policy covers:
(i) hospital treatment; or
(ii) hospital treatment and general treatment; and
(b) the discount will be a reduction in the amount that would otherwise be payable by the person for the policy, equal to the dollar amount calculated in accordance with rule 11C; and
(c) the discount will apply to each person insured under the policy who, on the discount assessment date for the person:
(i) was within one or more ranges of ages, between 18 and 29 (inclusive), that are specified in the policy as eligible for the discount; and
(ii) was not a dependent child under the policy; and
(d) while age‑based discounts are available under the policy, the discount will continue to apply until it is reduced, in accordance with rule 11C, to zero in relation to each such person insured under the policy; and
(e) the policy states whether it is a retained age‑based discount policy.
Note: For paragraph (c), an insurer is not required to provide discounts for all ages between 18 and 29 (inclusive).
Note: This rule deals only with the calculation of the age‑based discount. The premium that is payable in respect of a particular insurance policy is also affected by other provisions of the Act (including Part 2‑3 of the Act, which deals with lifetime health cover) and rules made under the Act (including these Rules).
(1) For paragraph 11B (b), the total age‑based discount that applies under an age‑based discount policy for a particular period is equal to the sum of the applicable discounts to which each eligible person who is insured under the policy is entitled for that period.
(2) An eligible person is entitled to an
applicable discount calculated in accordance with the following formula:where:
applicable percentage , for a particular period, is the greater of:
(a) the person’s percentage for the period, determined in accordance with the table to subrule (3); and
(b) zero.
base rate for hospital cover is the amount of premiums that would be payable for hospital cover under the policy if:
(a) the premiums were not increased under Part 2‑3 of the Act (lifetime health cover); and
(b) there were no discounts of the kind allowed under subsection 66‑5 (2) of the Act (including under this Part of these Rules).
number of adults insured is the number of adults insured under the policy.
(3) For paragraph (a) of the definition of
applicable percentage insubrule (2), the table is:
18 or older, but under 41 | the person’s base percentage |
41 | the person’s base percentage minus 2 percentage points |
42 | the person’s base percentage minus 4 percentage points |
43 | the person’s base percentage minus 6 percentage points |
44 | the person’s base percentage minus 8 percentage points |
45 or older | zero |
(4) For subrule (3), a person’s
base percentage is equal to:
(a) for an eligible person under the policy—the percentage, as given by the following table, corresponding to the person’s age at the discount assessment date; and
Note: See paragraph 11B (c).
(b) otherwise—zero.
18 or older, but under 26 | 10% |
26 | 8% |
27 | 6% |
28 | 4% |
29 | 2% |
For paragraph 66‑5 (3) (ea) of the Act, a person is entitled to an age‑based discount for a particular period if:
(a) the person is insured under an age‑based discount policy during that period; and
(b) the person is an eligible person in relation to that policy; and
(c) the person’s applicable discount for that period, as calculated in accordance with subrule 11C (2), is not equal to zero.
Insert:
State , when used in Schedule 1, Schedule 2 or Schedule 3, means a risk equalisation jurisdiction.Note: The risk equalisation jurisdictions are set out in the
Private Health Insurance (Health Benefits Fund Policy) Rules 2015 . Under those rules, the area specified in each of the following paragraphs is a risk equalisation jurisdiction:(a) Australian Capital Territory, Norfolk Island and New South Wales;
(b) Northern Territory;
(c) Queensland;
(d) South Australia;
(e) Tasmania;
(f) Victoria;
(g) Western Australia and the Territory of Christmas Island and the Territory of Cocos (Keeling) Islands.
Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, “risk equalisation jurisdiction”.
Repeal the Part, substitute:
Note: This Part deals with:
· the information and form for standard information statements, for the purposes of subsection 93‑5 (1) of the Act, and methods by which standard information statements are made available; and
· information that must be provided to the Private Health Insurance Ombudsman relating to changes in premiums.
This Part does not limit the information that a private health insurer may give to an insured person.
Note: See rule 20 for a transitional provision relating to this rule that applies until 31 March 2020.
(1) For subsection 93‑5 (1) of the Act, the information to be contained in a standard information statement, and the form, for a product subgroup of a complying health insurance product, are:
(a) the information and form of words set out in Schedule 1; and
(b) if policies that belong to the product subgroup cover hospital treatment—the additional information, and the form of words, set out in Schedule 2; and
(c) if policies that belong to the product subgroup cover general treatment—the additional information, and the form of words, set out in Schedule 3.
(2) However, paragraph (1)(c) does not apply if the only general treatment provided is ambulance cover.
(1) This rule is made for the purposes of subsection 93‑5 (2) and paragraph 93‑15 (1) (a) of the Act.
(2) If:
(a) the standard information statement is accompanied by information additional to the information and form of words that are required by subrule 12 (1); and
(b) the standard information statement and the additional information are set out in the same document;
the additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).
Example: The document on which a standard information statement is provided might include information about ambulance cover that is additional to the information required by item 10 of the table to clause 2 of Schedule 1. The additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.
(1) This rule is made for the purposes of section 96‑25 of the Act.
(2) This rule applies if the Minister has approved a proposed change to the premiums charged under a complying health insurance product of a private health insurer under subsection 66‑10 (3) of the Act.
(3) The private health insurer must notify the Private Health Insurance Ombudsman of:
(a) the premiums that applied before the approval; and
(b) the premiums that apply after the approval.
(4) The insurer must give this information to the Ombudsman by the earlier of:
(a) the day 14 days after the date of the Minister’s approval for the change; and
(b) 1 April of the year in which the Minister approved the change.
Insert:
Application of rule
(1) This rule applies until 31 March 2020.
Transitional provision
(2) A standard information statement that is in the old form is taken to contain the information, and be in the form, set out in these Rules.
(3) For this rule,a standard information statementis in the
old form if it contains the information, and is in the form, set out in these Rules as in force immediately before the commencement of Part 1 of Schedule 2 to thePrivate Health Insurance (Reforms) Amendment Rules 2018 .Note: Part 1 of Schedule 2 to the
Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 January 2019.
Repeal the Schedules, substitute:
In this Schedule, a reference to a
policy is a reference to a policy that forms part of the relevant product subgroup.
For paragraph 12 (1) (a) of these Rules, the information and form of words are set out in the following table:
1 | The name of the policy. |
2 | The trading or brand name of the private health insurer in the State in which the policy is being made available, together with any associated branding that the insurer elects to include. |
3 | If the policy is offered by a restricted access insurer—the following statement:
followed by the details. |
4 | A contact phone number and website address of the private health insurer. |
5 | The States in which the product is available, expressed as either:
|
6 | The total monthly premium payable before any rebate, loading or discount is applied. The following words must be inserted before or following the premium amount: “before any rebate, loading or discount”.
|
7 | If the policy is part of a corporate product—a statement to that effect, indicating either of the following, with the bracketed text replaced with the appropriate information:
|
8 | If the policy is closed so that it is no longer available to anyone except those persons who, at the time of closing, were insured under the policy—the following words:
|
9 | The insured groups that may be covered, expressed as whichever of the following is applicable:
|
10 | The following information:
|
11 | If, and only if, the policy is not yet available—the date from which the policy will be available. |
12 | The date on which the content of the statement was issued or updated, in the following format, with the bracketed text replaced with the appropriate information:
|
13 | The unique identifier for the standard information statement that is generated by the privatehealth.gov.au system. |
In this Schedule, a reference to a
policy is a reference to a policy that forms part of the relevant product subgroup.
For paragraph 12 (1) (b) of these Rules, the additional information and form of words are set out in the following table:
1 | If the policy is available only with a policy that covers general treatment—whichever of the following is applicable:
|
2 | Whichever of the following is applicable:
|
3 | An indication of:
|
4 | A list of all restrictions (if any) that apply. |
5 | The waiting periods that apply under the policy before a policy holder can claim, expressed either:
|
6 | Whichever of the following is appropriate:
|
7 | If there are no co‑payments—the statement “No co‑payments”. If there are co‑payments:
|
8 | The following statement:
|
9 | The following statement:
|
10 | A statement that indicates any other features of the policy that the insurer wishes to draw attention to. The statement must consist of at most 100 words.
|
Note: The information and form of words set out in this Schedule are not required if the only general treatment covered by the policy is ambulance cover.
In this Schedule, a reference to a
policy is a reference to a policy that forms part of the relevant product subgroup.
For paragraph 12 (1) (c) of these Rules, the additional information and form of words are set out in the following table:
1 | treatment—whichever of the following is applicable:
|
2 | Whichever of the following is appropriate:
|
3 | A complete list of treatments that are covered by the policy, expressed in terms of the following:
|
4 | A list of treatments that are not covered by the policy, expressed in terms of the treatments listed in item 3. |
5 | For each treatment that is covered by the policy—whichever of the following is applicable, with the bracketed text replaced with the appropriate text:
|
6 | For each treatment that is covered by the policy—if there is no annual limit on the benefits that can be paid, the statement “No annual limit”. Otherwise—the following statements, as applicable, with the bracketed text replaced with the appropriate figures or text:
|
7 | For each treatment listed in paragraphs (a) to (d) of item 3 (whether or not covered by the policy):
For paragraph (b) of this item:
|
8 | For each treatment covered by the policy, other than the treatments covered by item 7—examples of the maximum benefits that are payable when an insured person visits a practitioner who is not a preferred service provider, expressed using whichever of subparagraphs (b)(i) and (ii) of item 7 is applicable. For this item:
|
9 | A statement that indicates any other features of the policy that the insurer wishes to draw attention to. The statement must consist of at most 100 words.
|
Insert:
(1) This rule is made for the purposes of section 96‑25 of the Act.
(2) When giving an insured person a copy of a private health information statement in accordance with section 93‑15 or subsection 93‑20 (1) of the Act, the private health insurer must inform the person of the following:
(a) the name of each person who is covered by the policy;
(b) if the product subgroup to which the policy belongs covers hospital treatment—the following statements for each adult who is covered by the policy and to whom a lifetime health cover loading applies, with the bracketed text replaced with the appropriate amounts:
(i) “Your Lifetime Health Cover Loading is [Number]%.”;
(ii) “You have [the period of time expressed in years, months, days as appropriate] remaining until you have reached 10 continuous years of cover and your loading is removed.”.
(3) However, the insurer does not need to inform the person of the information referred to in subrule (2) more than once in any 12 month period.
(4) The information referred to in subrule (2) may be accompanied by either or both of the following:
(a) information additional to the information and form of words that are required by subrule 12 (1);
(b) other information about the policy and how it pertains to the person.
Example for paragraph (4) (b): An insurer may also inform an insured person of:
· the premium for hospital treatment and for general treatment that applies in relation to each adult insured under the policy, taking account of matters such as loadings, rebates and discounts; and
· the remaining portion (if any) of the waiting period for any or each treatment covered by the policy.
(5) If the private health information statement and the additional information referred to in subrule (2) and paragraphs (4)(a) and (b) are set out in the same document, the additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).
Example: The document on which a private health information statement is provided might include information about the monthly premium that is payable by the insured person under the policy that is additional to the information required by item 6 of the table to clause 2 of Schedule 1. That additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.
For subsection 93‑5 (2) of the Act, if a person asks an insurer for information about a complying health insurance product, the insurer must give the person a copy of the private health information statement for a product subgroup of that product:
(a) by post; or
(b) if the person has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the person.
Example: If requested by an insured person, a private health information statement may be provided in an electronic format, including via a web page.
Insert:
(1A) This rule does not apply in relation to an insurance policy that:
(a) covers hospital treatment (whether or not the policy also covers general treatment); and
(b) has “gold”, “silver”, “bronze” or “basic” in its name.
Repeal the subrule, substitute:
(3) For this rule,a private health information statementis in the
old form if it contains the information, and is in the form, for a standard information statement set out in these Rules as in force immediately before the commencement of Part 1 of Schedule 2 to thePrivate Health Insurance (Reforms) Amendment Rules 2018 .Note: Part 1 of Schedule 2 to the
Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 January 2019.
Repeal the item, substitute:
1 | The name of the policy.
|
Repeal the item, substitute:
3 | An indication of:
followed, in each case, by:
|
Repeal the item, substitute:
4 |
A list of all clinical categories (if any) that have restricted cover.
|
[13] Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, paragraph (b)) Omit “treatments”, substitute “clinical categories”.
[14] Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, after note 2) Insert:
Note 3: See rule 21 for a transitional provision relating to this item.
[15] Amendments of listed provisions — private health information statements
1 | Rule 4 (note at the end of the rule) | standard information statement | private health information statement |
2 | Paragraph 9AA(2)(a) | standard information statement | private health information statement |
3 | Part 3 (heading) | Standard information statements | Private health information statements |
4 | Part 3 (note to the Part heading, first bullet point) | standard information statements | private health information statements |
5 | Rule 12 (heading) | Standard information statements | Private health information statements |
6 | Subrule 12 (1) | standard information statement | private health information statement |
7 | Rule 13 (heading) | standard information statements | private health information statements |
8 | Paragraph 13 (2) (a) | standard information statement | private health information statement |
9 | Paragraph 13 (2) (b) | standard information statement | private health information statement |
10 | Subrule 13 (2) (example) | standard information statement | private health information statement |
11 | Rule 20 (heading) | standard information statements | private health information statements |
12 | Subrule 20(2) | standard information statement | private health information statement |
13 | Schedule 1 (heading) | standard information statement | private health information statement |
14 | Schedule 1, clause 2 (heading) | standard information statement | private health information statement |
15 | Schedule 1, clause 2 (table heading) | standard information statement | private health information statement |
16 | Schedule 1, clause 2, table item 13 | standard information statement | private health information statement |
17 | Schedule 2 (heading) | standard information statement | private health information statement |
18 | Schedule 3 (heading) | standard information statement | private health information statement |
Repeal the rule.
Repeal the item, substitute:
1 | The name of the policy.
|
[18] Clause 2 of Schedule 2 (table item 3, column headed “Additional information and form of words”, note) Repeal the note.
[19] Clause 2 of Schedule 2 (table item 4, column headed “Additional information and form of words”, note) Repeal the note.
[20] Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, note 3) Repeal the note.
Insert:
basic policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers at least the treatments in all of the clinical categories indicated for a basic policy in Schedule 4; and
(c) is not a gold, silver or bronze policy.
bronze policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers at least the treatments in all of the clinical categories indicated for a bronze policy in Schedule 4; and
(c) is not a gold or silver policy.
clinical category , for hospital treatment, means a clinical category that is set out in Schedule 5.
gold policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers the treatments in all of the clinical categories indicated for a gold policy in Schedule 4.
MBS item means an item in any of the following:
(a) the general medical services table, made under section 4 of the
Health Insurance Act 1973 , as in force from time to time;(b) the diagnostic imaging services table, made under section 4AA of the
Health Insurance Act 1973 , as in force from time to time;(c) the pathology services table, made under section 4A of the
Health Insurance Act 1973 , as in force from time to time.
product tier means:
(a) for a gold policy—“gold”; and
(b) for a silver policy—“silver”; and
(c) for a bronze policy—“bronze”; and
(d) for a basic policy—“basic”.
silver policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers at least the treatments in all of the clinical categories indicated for a silver policy in Schedule 4; and
(c) is not a gold policy.
Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, “medical practitioner”.
Insert:
Note 1: This Part specifies additional requirements that an insurance policy must meet in order to be a complying health insurance policy, for the purposes of paragraph 63‑10 (g) of the Act.
Note 2: Nothing in this Part affects the operation of Division 72 of the Act (which relates to benefit requirements for policies that cover hospital treatment) or the operation of the Private Health Insurance (Benefit Requirements) Rules for the calculation of minimum benefits where restricted cover is allowed under rule 11G.
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
(2) The policy must be one of the following:
(a) a gold policy;
(b) a silver policy;
(c) a bronze policy;
(d) a basic policy.
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
Application of rule
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
Treatments that must be covered by policy
(2) The policy must cover:
(a) all hospital treatments that are within the scope of cover that is identified, in Schedule 5, for each clinical category in relation to which the policy provides cover (see subrules (5) and (6)); and
(b) all hospital treatments that are not within the scope of cover of such a clinical category, but that are:
(i) associated treatments for complications (see subrule (7)); or
(ii) associated unplanned treatments (see subrule (8)).
(3) However, the policy is not required to cover cosmetic surgery that is not medically necessary.
Treatments that may be covered by policy
(4) The policy may also provide either or both of the following:
(a) accident cover;
(b) benefits for travel or accommodation relating to a treatment referred to in subrule (2) or paragraph (a).
Interpretation
(5) For paragraph (2) (a), the scope of cover of a particular clinical category includes, but is not limited to:
(a) all hospital treatments involving the provision of an MBS item listed in Schedule 5 against that clinical category; and
(b) all hospital treatments:
(i) that are provided in relation to a treatment of a kind referred to in paragraph (2) (a) or (5) (a); and
(ii) involving the provision of an MBS item listed in:
(A) the common treatments list in Schedule 6; or
(B) the support treatments list in Schedule 7.
(6) Paragraph (5) (b) does not apply in relation to the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”.
(7) For subparagraph (2) (b) (i), a hospital treatment is an
associated treatment for complications if it is:
(a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and
(b) provided for a complication that arises during that episode.
(8) For subparagraph (2) (b) (ii), a hospital treatment is an
associated unplanned treatment if it is:
(a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and
(b) an unplanned treatment that:
(i) is provided as part of planned surgery performed during that episode; and
(ii) is, in the view of the medical practitioner who provides the unplanned treatment, medically necessary and urgent.
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
Gold policies
(1) A gold policy must provide unrestricted cover for all hospital treatments in all clinical categories.
Silver policies and bronze policies
(2) A silver policy or a bronze policy:
(a) must provide restricted cover or unrestricted cover for all hospital treatments in the following clinical categories:
(i) rehabilitation;
(ii) hospital psychiatric services;
(iii) palliative care; and
(b) must provide unrestricted cover for all hospital treatments in:
(i) the other clinical categories that a silver policy or a bronze policy, as appropriate, is required to cover; and
(ii) any other clinical categories that the policy covers.
Basic policies
(3) A basic policy must provide restricted cover or unrestricted cover for all hospital treatments in:
(a) all of the clinical categories that a basic policy is required to cover; and
(b) any other clinical categories that the policy covers.
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
(2) The policy must include a name that contains the policy’s product tier.
(3) If the policy covers one or more clinical categories additional to those required for a policy of that product tier in Schedule 4, the name may also contain “plus” or “+”.
(4) The name must not contain:
(a) the name of any other metal; or
(b) the name of any gemstone or any semi‑precious stone; or
(c) unless permitted by subrule (3)—either “plus” or “+”.
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers general treatment only.
(2) The policy must include a name that does not contain:
(a) the name of any metal; or
(b) the name of any gemstone or any semi‑precious stone; or
(c) either “plus” or “+”.
Insert:
Application of rule
(1) This rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
(2) This rule applies until 31 March 2020.
Transitional provisions
(3) If the policy does not have any of the following:
(a) “gold”, “silver”, “bronze” or “basic”;
(b) the name of any other metal;
(c) the name of any gemstone or semi‑precious stone;
in its name, the policy need not comply with Part 2B.
(4) If the policy:
(a) does not have any of the words referred to in subrule (3) in its name; and
(b) does not use the clinical categories to indicate the treatments it covers;
each of the following:
(c) item 1 of clause 2 of Schedule 1;
(d) item 3 of clause 2 of Schedule 2;
(e) item 4 of clause 2 of Schedule 2;
(f) item 5 of clause 2 of Schedule 2;
as in force immediately before the commencement of Part 2 of Schedule 2 to the
Private Health Insurance (Reforms) Amendment Rules 2018 applies in relation to the policy.Note: Part 2 of Schedule 2 to the
Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 April 2019.
Add:
Note: See rule 4 and Part 2B.
For the definition of
gold policy ,silver policy ,bronze policy andbasic policy in rule 4, and for rule 11H, the following table sets out the clinical categories that are indicated for policies of each product tier.
Rehabilitation | ||||
Hospital psychiatric services | ||||
Palliative care | ||||
Brain and nervous system | ||||
Eye (not cataracts) | ||||
Ear, nose and throat | ||||
Tonsils, adenoids and grommets | ||||
Bone, joint and muscle | ||||
Joint reconstructions | ||||
Kidney and bladder | ||||
Male reproductive system | ||||
Digestive system | ||||
Hernia and appendix | ||||
Gastrointestinal endoscopy | ||||
Gynaecology | ||||
Miscarriage and termination of pregnancy | ||||
Chemotherapy, radiotherapy and immunotherapy for cancer | ||||
Pain management | ||||
Skin | ||||
Breast surgery (medically necessary) | ||||
Diabetes management (excluding insulin pumps) | ||||
Heart and vascular system | ||||
Lung and chest | ||||
Blood | ||||
Back, neck and spine | ||||
Plastic and reconstructive surgery (medically necessary) | ||||
Dental surgery | ||||
Podiatric surgery (provided by a registered podiatric surgeon) | ||||
Implantation of hearing devices | ||||
Cataracts | ||||
Joint replacements | ||||
Dialysis for chronic kidney failure | ||||
Pregnancy and birth | ||||
Assisted reproductive services | ||||
Weight loss surgery | ||||
Insulin pumps | ||||
Pain management with device | ||||
Sleep studies |
The clinical category must be covered on an unrestricted basis. | |
The clinical category may be offered on a restricted cover basis in Basic, Bronze and Silver product tiers only. | |
Restricted cover permitted: indicates the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories on a restricted or unrestricted basis. | |
A blank cell indicates that the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories; however it must be on an unrestricted basis. |
Note 1: Rule 11F is the principal provision that deals with what must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 6 and Schedule 7.
Note 2: The treatments that must be covered are any hospital treatments that are in the scope of cover of a clinical category in relation to which the policy provides cover. The scope of cover includes, without limitation:
· any hospital treatment involving the provision of an MBS item number listed in column 3 below; and
· except for the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”—any hospital treatment:
– that is provided in relation to a treatment within the scope of cover of a particular clinical category or that involves the provision of an MBS item number listed in column 3 below; and
– that involves the provision of an MBS item number listed in Schedule 6 (common treatments) or Schedule 7 (support treatments).
Note 3: MBS items are mentioned in the table below against a clinical category, or in the common treatments or support treatments lists in Schedules 6 and 7. Where an MBS item is mentioned for a clinical category in column 3 in the table below, the treatment including that MBS item is most likely to be provided under that clinical category, or a clinical category in the same or a higher product tier (according to Schedule 4). However, the mention of an MBS item against a particular category does not mean it is only covered under that clinical category.
In this Schedule, the scope of cover of a particular clinical category is taken not to include any treatment that is, or treatments that are, expressly stated to be listed separately under another clinical category.
For rule 4, and Part 2B, the clinical categories are set out in the following table.
Hospital treatment for physical rehabilitation for a patient related to surgery or illness. For example: inpatient and admitted day patient rehabilitation, stroke recovery, cardiac rehabilitation. | ||
Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders. For example: psychoses such as schizophrenia, mood disorders such as depression, eating disorders and addiction therapy. | Treatments involving the provision of the following MBS items: 170 171 172 289 297 320 322 324 326 328 342 344 346 348 350 352 364 366 367 369 370 855 857 858 861 864 866 2700 2701 2712 2713 2715 2717 2721 2723 2725 2727 6018 6019 6023 6024 6025 6026 6028 6029 6031 6032 6034 6035 6037 6038 6042 14224 80000 80001 80005 80010 80011 80015 80020 80021 80100 80101 80105 80110 80111 80115 80120 80121 80125 80126 80130 80135 80136 80140 80145 80146 80150 80151 80155 80160 80161 80165 80170 80171 82000 82015 | |
Hospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain. | Treatments involving the provision of the following MBS items: 3003 3005 3010 3014 3015 3018 3023 3028 3032 3040 3044 3051 3055 3062 3069 3074 3078 3083 3088 3093 | |
Hospital treatment for fertility treatments or procedures. For example: retrieval of eggs or sperm, Treatment of the female reproductive system is listed separately under Pregnancy and birth‑related services are listed separately under | Treatments involving the provision of the following MBS items: 13200 13201 13202 13203 13206 13209 13212 13215 13218 13221 13251 13260 13290 13292 14203 14206 37605 37606 | |
Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion. For example: sciatica, prolapsed or herniated disc, and spine curvature disorders such as scoliosis, kyphosis and lordosis. Joint replacements are listed separately under Joint fusions are listed separately under Spinal cord conditions are listed separately under Management of back pain is listed separately under Chemotherapy and radiotherapy for cancer is listed separately under | Treatments involving the provision of the following MBS items: 30672 44133 50600 50604 50608 50612 50616 50620 50624 50628 50632 50636 50640 50644 51020 51021 51022 51023 51024 51025 51026 51031 51032 51033 51034 51035 51036 51041 51042 51043 51044 51045 51051 51052 51053 51054 51055 51056 51057 51058 51059 51061 51062 51063 51064 51065 51066 51071 51072 51073 51102 51103 51110 51111 51112 51113 51114 51115 51120 51130 51131 51140 51141 51145 51150 51160 51165 51170 51171 | |
Hospital treatment for the investigation and treatment of blood and blood‑related conditions. For example: blood clotting disorders and bone marrow transplants. Treatment for cancers of the blood is listed separately under | Treatments involving the provision of the following MBS item: 13700 | |
Hospital treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system. For example: carpal tunnel, fractures, hand surgery, joint fusion, bone spurs, osteomyelitis and bone cancer. Chest surgery is listed separately under |
Spinal cord conditions are listed separately under
Spinal column conditions are listed separately under
Joint reconstructions are listed separately under
Joint replacements are listed separately under
Podiatric surgery performed by a registered podiatric surgeon is listed separately under
Management of back pain is listed separately under
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 18350 18351 18353 18354 18360 18361 18365 30103 30107 30111 30114 30226 30229 30232 30235 30238 30241 30244 32036 39331 43500 43503 43506 43509 43512 43515 43518 43521 43524 43876 43879 44325 44328 44331 44334 44338 44342 44346 44350 44354 44358 44359 44361 44364 44367 44370 44373 44376 45605 45788 45851 45855 45857 45859 45861 45863 45867 45869 45871 45873 45875 45945 45978 45981 45987 45993 45996 46300 46303 46306 46307 46327 46330 46333 46336 46339 46342 46348 46351 46354 46357 46360 46363 46366 46369 46372 46375 46378 46381 46384 46387 46390 46393 46396 46399 46402 46405 46459 46462 46464 46465 46468 46471 46474 46477 46480 46483 47000 47003 47006 47009 47012 47015 47018 47021 47024 47027 47030 47033 47036 47039 47042 47045 47048 47051 47054 47057 47060 47063 47066 47069 47072 47301 47304 47307 47310 47313 47316 47319 47348 47351 47354 47357 47361 47362 47364 47367 47370 47373 47378 47381 47384 47385 47386 47387 47390 47393 47396 47399 47402 47405 47408 47411 47414 47417 47420 47423 47426 47429 47432 47435 47438 47441 47444 47447 47450 47451 47453 47456 47459 47462 47465 47466 47467 47468 47471 47474 47477 47480 47483 47486 47489 47492 47495 47498 47501 47504 47507 47510 47513 47516 47519 47522 47525 47528 47531 47534 47537 47540 47543 47546 47549 47552 47555 47558 47561 47564 47565 47566 47567 47570 47573 47576 47579 47582 47585 47588 47591 47594 47597 47600 47603 47606 47609 47612 47615 47618 47621 47624 47627 47630 47633 47636 47639 47642 47645 47648 47651 47654 47657 47663 47666 47672 47678 47726 47729 47732 47753 47756 47762 47765 47768 47771 47774 47777 47780 47783 47786 47789 47900 47903 47920 47921 47924 47927 47930 47933 47936 47948 47951 47954 47957 47960 47963 47966 47969 47972 47975 47978 47981 47982 48200 48203 48206 48209 48212 48215 48218 48221 48224 48227 48230 48233 48236 48239 48242 48400 48403 48406 48409 48412 48415 48418 48421 48424 48427 48500 48503 48506 48509 48512 48912 48936 48939 48942 48945 48954 49100 49106 49109 49118 49200 49203 49206 49212 49218 49300 49303 49306 49360 49363 49366 49500 49509 49512 49545 49566 49569 49700 49712 49718 49721 49724 49727 49728 49800 49803 49806 49809 49812 49815 49818 49821 49824 49827 49830 49833 49836 49837 49838 49845 49848 49851 49854 49860 49863 49866 49878 50100 50102 50103 50104 50109 50112 50115 50118 50121 50130 50200 50201 50203 50206 50209 50212 50215 50218 50221 50224 50227 50230 50233 50236 50239 50300 50303 50306 50309 50312 50315 50318 50321 50324 50327 50330 50336 50339 50342 50345 50348 50349 50351 50352 50353 50354 50357 50360 50363 50366 50369 50372 50375 50378 50381 50384 50387 50390 50393 50394 50396 50399 50402 50405 50408 50426 50450 50451 50455 50456 50460 50461 50465 50466 50470 50471 50475 50476 50500 50504 50508 50512 50516 50520 50524 50528 50532 50536 50540 50544 50548 50552 50556 50560 50564 50568 50572 50576 50580 50584 50588 50650 50654 50658 52056 52057 52058 52059 52060 52061 52062 52063 52064 52066 52069 52072 52073 52075 52078 52081 52084 52087 52090 52092 52094 52095 52096 52097 52098 52099 52102 52105 52114 52126 52129 52130 52131 52180 52182 52184 52186 53200 53203 53206 53209 53212 53215 53218 53220 53221 53224 53225 53226 53227 53230 53233 53236 53239 53400 53403 53406 53409 53410 53411 53412 53413 53414 53415 53416 53418 53419 53422 53423 53424 53425 53427 53429 53439
Hospital treatment for the investigation and treatment of the brain, brain‑related conditions, spinal cord and peripheral nervous system.
For example: stroke, brain or spinal cord tumours, head injuries, epilepsy and Parkinson’s disease.
Treatment of spinal column (back bone) conditions is listed separately under
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 6004 6007 6009 6011 6013 6015 6016 14227 14230 14233 14236 14239 14242 18377 35000 35003 35006 35009 35012 35412 35414 39003 39006 39009 39012 39013 39015 39018 39300 39303 39306 39309 39312 39315 39318 39321 39324 39327 39330 39333 39500 39503 39600 39603 39606 39609 39612 39615 39640 39642 39646 39650 39653 39654 39656 39658 39660 39662 39700 39703 39706 39709 39712 39715 39718 39721 39800 39803 39806 39812 39815 39818 39821 39900 39903 39906 40000 40003 40006 40009 40012 40015 40018 40100 40103 40106 40109 40112 40115 40118 40600 40700 40701 40702 40703 40704 40705 40706 40707 40708 40709 40712 40800 40801 40803 40850 40851 40852 40854 40856 40858 40860 40862 40903 40905 43987 51011 51012 51013 51014 51015 52800 52803 52806 52809 52812 52815 52818 52821 52824 52826 52828 52830 52832
Hospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction and/or reduction following breast surgery or a preventative mastectomy.
For example: breast lesions, breast tumours, asymmetry due to breast cancer surgery, and gynecomastia.
This clinical category does not require benefits to be paid for cosmetic breast surgery that is not medically necessary.
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 30299 30300 30302 30303 31500 31503 31506 31509 31512 31515 31516 31519 31524 31525 31530 31533 31536 31539 31542 31545 31548 31551 31554 31557 31560 31563 31566 45060 45061 45062 45520 45522 45523 45524 45527 45528 45530 45533 45536 45539 45542 45545 45546 45548 45551 45553 45554 45556 45558
Hospital treatment for surgery to remove a cataract and replace with an artificial lens.
Treatments involving the provision of the following MBS items: 42698 42701 42702 42703 42704 42705 42707 42710 42713 42716
Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours.
Surgical treatment of cancer is listed separately under each body system.
Treatments involving the provision of the following MBS items: 13760 13915 13918 13921 13924 13927 13930 13933 13936 13939 13942 13945 13948 14221 14245 15000 15003 15006 15009 15012 15100 15103 15106 15109 15112 15115 15211 15214 15215 15218 15221 15224 15227 15230 15233 15236 15239 15242 15245 15248 15251 15254 15257 15260 15263 15266 15269 15272 15275 15303 15304 15307 15308 15311 15312 15315 15316 15319 15320 15323 15324 15327 15328 15331 15332 15335 15336 15338 15339 15342 15345 15348 15351 15354 15357 15500 15503 15506 15509 15512 15513 15515 15518 15521 15524 15527 15530 15533 15536 15539 15550 15553 15555 15556 15559 15562 15565 15600 15700 15705 15710 15715 15800 15850 15900 16003 16006 16009 16012 16015 16018 30400 34521 34524 34527 34528 34529 34530 34533 34534 34539 34540 35404 35406 35408 50950 50952
Hospital treatment for surgery to the teeth and gums.
For example: surgery to remove wisdom teeth, and dental implant surgery.
Treatments involving the provision of the following MBS items: 75006 75030 75033 75034 75036 75037 75039 75042 75045 75048 75049 75050 75051 75156 75200 75203 75206 75400 75403 75406 75409 75412 75415 75600 75603 75606 75609 75612 75615 75618 75621 75800 75803 75806 75809 75812 75815 75818 75821 75824 75827 75830 75833 75836 75839 75842 75845 75848 75851 75854
Hospital treatment for the investigation and management of diabetes.
For example: stabilisation of hypo‑ or hyper‑ glycaemia, contour problems due to insulin injections.
Treatment for diabetes‑related conditions is listed separately under each body system affected. For example, treatment for diabetes‑related eye conditions is listed separately under
Treatment for ulcers is listed separately under
Provision and replacement of insulin pumps is listed separately under
Treatments involving the provision of the following MBS items: 31346 81100 81105
Hospital treatment for dialysis treatment for chronic kidney failure.
For example: peritoneal dialysis and haemodialysis.
Treatments involving the provision of the following MBS items: 13100 13103 13104 13106 13109 13110
Hospital treatment for the investigation and treatment of the digestive system, including the oesophagus, stomach, gall bladder, pancreas, spleen, liver and bowel.
For example: oesophageal cancer, irritable bowel syndrome, gall stones and haemorrhoids.
Endoscopy is listed separately under
Hernia and appendicectomy procedures are listed separately under
Bariatric surgery is listed separately under
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 11800 11801 11810 13506 14212 30373 30375 30376 30378 30379 30382 30384 30385 30387 30392 30393 30396 30397 30399 30402 30406 30408 30409 30411 30412 30414 30415 30416 30417 30418 30419 30421 30422 30425 30427 30428 30430 30431 30433 30434 30436 30437 30438 30439 30440 30441 30442 30443 30445 30446 30448 30449 30450 30451 30452 30454 30455 30457 30458 30460 30461 30463 30464 30466 30467 30469 30472 30481 30482 30483 30492 30495 30496 30497 30499 30500 30502 30503 30505 30506 30508 30509 30515 30517 30518 30520 30521 30523 30524 30526 30527 30529 30530 30532 30533 30535 30536 30538 30539 30541 30542 30544 30545 30547 30548 30550 30551 30553 30554 30556 30557 30559 30560 30562 30563 30564 30565 30566 30575 30577 30578 30580 30581 30583 30584 30586 30587 30589 30590 30593 30594 30596 30597 30599 30600 30601 30602 30603 30605 30606 30608 30619 30621 30622 30623 30626 30627 30636 30637 30639 31450 31452 31454 31456 31458 31460 31462 31464 31466 31468 31470 31472 32000 32003 32004 32005 32006 32009 32012 32015 32018 32021 32024 32025 32026 32028 32029 32030 32033 32039 32042 32045 32046 32047 32051 32054 32057 32060 32063 32066 32069 32096 32099 32102 32103 32104 32105 32106 32108 32111 32112 32114 32115 32117 32120 32123 32126 32129 32131 32132 32135 32138 32139 32142 32145 32147 32150 32153 32156 32159 32162 32165 32166 32168 32171 32174 32175 32177 32180 32183 32186 32200 32203 32206 32209 32210 32212 32213 32214 32215 32216 32217 32218 32220 32221 41816 41822 41825 41828 41831 41832 43801 43804 43807 43810 43813 43816 43819 43822 43825 43828 43831 43834 43840 43843 43846 43849 43852 43855 43858 43864 43867 43870 43873 43900 43903 43906 43930 43933 43936 43942 43945 43948 43951 43954 43957 43960 43963 43966 43969 43972 43975 43978 43990 43993 43996 43999 44101 44102 44104 44105
Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck.
For example: damaged ear drum, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer.
Tonsils, adenoids and grommets are listed separately under
The implantation of a hearing device is listed separately under
Orthopaedic neck conditions are listed separately under
Sleep studies are listed separately under
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 11300 18368 30104 30105 30246 30247 30250 30251 30253 30255 30256 30259 30262 30266 30269 30272 30275 30278 30281 30283 30286 30287 30289 30293 30294 30296 30297 30306 30310 30314 30315 30317 30318 30320 30326 30618 31400 31403 31406 31409 31412 31420 31423 31426 31429 31432 31435 31438 41500 41503 41506 41509 41512 41515 41518 41521 41524 41527 41530 41533 41536 41539 41542 41545 41548 41551 41554 41557 41560 41563 41564 41566 41569 41572 41575 41576 41578 41579 41581 41584 41587 41590 41593 41596 41599 41608 41611 41614 41615 41620 41623 41626 41629 41635 41638 41641 41644 41647 41650 41653 41656 41659 41662 41668 41671 41672 41674 41677 41683 41686 41689 41692 41698 41701 41704 41707 41710 41713 41716 41719 41722 41725 41728 41729 41731 41734 41737 41740 41743 41746 41749 41752 41755 41764 41767 41770 41773 41776 41779 41782 41785 41786 41787 41804 41807 41810 41813 41834 41837 41840 41843 41846 41855 41858 41861 41864 41867 41868 41870 41873 41876 41879 41880 41881 41884 41885 41886 41889 41892 41895 41898 41901 41904 41905 41907 41910 43832 45645 45646 47735 47738 47741 51900 51902 52021 52024 52025 52027 52030 52033 52034 52035 52055 52132 52133 52135 52138 52141 52147 52148 52158 53000 53003 53004 53006 53009 53012 53015 53016 53017 53019 53052 53054 53056 53058 53060 53062 53064 53068 53070 53458 53459 53460
Hospital treatment for the investigation and treatment of the eye and the contents of the eye socket.
For example: retinal detachment, tear duct conditions, eye infections and medically managed trauma to the eye.
Cataract procedures are listed separately under
Eyelid procedures are listed separately under
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 18366 18369 18370 18372 18374 42503 42505 42506 42509 42510 42512 42515 42518 42521 42524 42527 42530 42533 42536 42539 42542 42543 42545 42548 42551 42554 42557 42563 42569 42572 42573 42574 42575 42576 42581 42584 42587 42588 42590 42593 42596 42599 42602 42605 42608 42610 42611 42614 42615 42617 42620 42622 42623 42626 42629 42632 42635 42638 42641 42644 42647 42650 42651 42652 42653 42656 42662 42665 42667 42668 42672 42673 42676 42677 42680 42683 42686 42689 42692 42695 42719 42725 42731 42734 42738 42739 42740 42741 42743 42744 42746 42749 42752 42755 42758 42761 42764 42767 42770 42773 42776 42779 42782 42785 42788 42791 42794 42801 42802 42805 42806 42807 42808 42809 42810 42811 42812 42815 42818 42821 42824 42833 42836 42839 42842 42845 42848 42851 42854 42857 42869 43021 43022 43023
Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope.
For example: colonoscopy, gastroscopy, endoscopic retrograde cholangiopancreatography (ERCP).
Non‑endoscopic procedures for the digestive system are listed separately under
Treatments involving the provision of the following MBS items: 11820 11823 30473 30475 30478 30479 30484 30485 30488 30490 30491 30494 30568 30569 30680 30682 30684 30686 30687 30688 30690 30692 30694 32023 32072 32075 32084 32087 32088 32089 32090 32093 32094 32095
Hospital treatment for the investigation and treatment of the female reproductive system.
For example: endometriosis, polycystic ovaries, female sterilisation and cervical cancer.
Fertility treatments are listed separately under
Pregnancy and birth‑related conditions are listed separately under
Miscarriage or termination of pregnancy is listed separately under
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 30062 35410 35500 35502 35503 35506 35507 35508 35509 35513 35517 35518 35520 35523 35527 35530 35533 35534 35536 35539 35542 35545 35548 35551 35554 35557 35560 35561 35562 35564 35565 35566 35568 35569 35570 35571 35572 35573 35577 35578 35581 35582 35585 35595 35596 35597 35599 35602 35605 35608 35611 35612 35613 35614 35615 35616 35618 35620 35622 35623 35626 35627 35630 35633 35634 35635 35636 35637 35638 35641 35644 35645 35646 35647 35648 35649 35653 35657 35658 35661 35664 35667 35670 35673 35680 35684 35688 35691 35694 35697 35700 35703 35706 35709 35710 35713 35717 35720 35723 35726 35729 35730 35750 35753 35754 35756 35759
Hospital treatment for the investigation and treatment of the heart, heart‑related conditions and vascular system.
For example: heart failure and heart attack, monitoring of heart conditions, varicose veins and removal of plaque from arterial walls.
Chemotherapy and radiotherapy for cancer is listed separately under
Treatments involving the provision of the following MBS items: 13400 32500 32504 32507 32508 32511 32514 32517 32520 32522 32523 32526 32528 32529 32700 32703 32708 32710 32711 32712 32715 32718 32721 32724 32730 32733 32736 32739 32742 32745 32748 32751 32754 32757 32760 32763 32766 32769 33050 33055 33070 33075 33080 33100 33103 33109 33112 33115 33116 33118 33119 33121 33124 33127 33130 33133 33136 33139 33142 33145 33148 33151 33154 33157 33160 33163 33166 33169 33172 33175 33178 33181 33500 33506 33509 33512 33515 33518 33521 33524 33527 33530 33533 33536 33539 33542 33545 33548 33551 33554 33800 33803 33806 33810 33811 33812 33815 33818 33821 33824 33827 33830 33833 33836 33839 33842 33845 33848 34100 34103 34106 34109 34112 34115 34118 34121 34124 34127 34130 34142 34145 34148 34151 34154 34157 34160 34163 34166 34169 34172 34175 34500 34503 34506 34509 34512 34515 34518 34800 34803 34806 34809 34812 34815 34818 34821 34824 34827 34830 34833 35100 35103 35200 35202 35300 35303 35306 35307 35309 35312 35315 35317 35319 35320 35321 35324 35327 35330 35331 35360 35361 35362 35363 38200 38203 38206 38209 38212 38213 38215 38218 38220 38222 38225 38228 38231 38234 38237 38240 38241 38243 38246 38256 38270 38272 38273 38274 38275 38276 38285 38286 38287 38288 38290 38293 38300 38303 38306 38309 38312 38315 38318 38350 38353 38356 38358 38359 38362 38365 38368 38371 38384 38387 38390 38393 38447 38449 38450 38452 38470 38473 38475 38477 38478 38480 38481 38483 38485 38487 38488 38489 38490 38493 38495 38496 38497 38498 38500 38501 38503 38504 38505 38506 38507 38508 38509 38512 38515 38518 38550 38553 38556 38559 38562 38565 38568 38571 38572 38577 38588 38600 38603 38609 38612 38613 38615 38618 38621 38624 38627 38637 38650 38653 38654 38670 38673 38677 38680 38700 38703 38706 38709 38712 38715 38718 38721 38724 38727 38730 38733 38736 38739 38742 38745 38748 38751 38754 38757 38760 38763 38766 59903 59912 59925 59971 59972 59973
Hospital treatment for the investigation and treatment of a hernia or appendicitis.
Digestive conditions are listed separately under
Treatments involving the provision of the following MBS items: 30571 30572 30574 30609 30614 30615 30640 30645 30646 43805 43835 43837 43838 43841 43939 44108 44111 44114
Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device.
Stapedectomy is listed separately under
Treatments involving the provision of the following MBS items: 41603 41604 41617 41618
Hospital treatment for the provision and replacement of insulin pumps for treatment of diabetes.
Repeal the note.
Repeal the note.
Repeal the note.
Repeal the note.
Repeal the rule.
Repeal the clause, substitute:
(1) In this Schedule:
authorised officer means a departmental officer authorised by the Secretary of the Department to make a determination under subclause 1A (2), (3) or (4) or to review a determination under subclause 1B (3).
comparable has the meaning given by subclause 1A (6).
Hospital Casemix Protocol Data has the meaning given by rule 4 of thePrivate Health Insurance (Health Insurance Business) Rules 2018.
second‑tier eligible hospital means a hospital in the class set out in rule 7A of thePrivate Health Insurance (Health Insurance Business) Rules 2018 .
(2) In this Schedule, except in subclauses 1A (8) and (9), the Australian Capital Territory is taken to be part of New South Wales, and the Northern Territory is taken to be part of South Australia.
Insert:
(1) If, as at 1 January 2019, a departmental officer authorised by the Secretary of the Department for the purpose has, in anticipation of the commencement of this provision, caused to be published on the Department’s website a list of all the hospitals for which a declaration is in force under subsection 121‑5 (6) of the Act that places each hospital in a category set out in subclause (7), then each hospital is taken to be determined to be in that category.
(2) If such a list has not been published, then as soon as practicable an authorised officer must determine which category of hospital from the categories set out in subclause (7) each private hospital for which a declaration is in force under subsection 121‑5 (6) of the Act is to be placed in, and cause a list of the hospitals in each category to be published on the Department’s website.
Note: If a patient is admitted to a hospital between 1 January 2019 and 31 August 2019 insurers may continue to work out the average charge on the basis of the provisions of this Schedule as in force immediately before the commencement of Schedule 4 to the
Private Health Insurance (Reforms) Amendment Rules 2018 . However, insurers must use the Department’s published list of hospitals under subclause (1) or (2) to determine in which category a hospital claiming second‑tier default benefits is placed.(3) If a private hospital is declared under subsection 121‑5 (6) of the Act after 1 January 2019, an authorised officer must determine which category of hospital from the categories set out in subclause (7) that private hospital is to be placed in.
(4) If a hospital has been placed in a category by a determination under this clause, an authorised officer may before 1 June of a particular year determine a different category of hospital from the categories set out in subclause (7) that the private hospital is to be placed in.
(5) A list of the hospitals in each category as of 1 August of each year must be published on the Department’s website.
(6) Private hospitals are
comparable if they are placed in the same category by a determination made under subclause (1), (2), (3) or (4).(7) For the purposes of this clause, the categories are the following:
(a) private hospitals that provide psychiatric care, including treatment of addictions, for at least 50% of the episodes of hospital treatment, and do not fall into category (g);
(b) private hospitals that provide rehabilitation care for at least 50% of the episodes of hospital treatment, and do not fall into categories (a) or (g);
(c) private hospitals that do not fall into categories (a), (b) or (g), with up to and including 50 licensed beds;
(d) private hospitals that do not fall into categories (a), (b) or (g), with more than 50 licensed beds and up to and including 100 licensed beds;
(e) private hospitals that do not fall into categories (a), (b) or (g), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit or an intensive care unit;
(f) private hospitals that do not fall into categories (a), (b) or (g), with more than 100 licensed beds, with either (or any combination of) an accident and emergency unit or a specialised cardiac care unit or an intensive care unit;
(g) private hospitals that provide episodes of hospital treatment only for periods of not more than 24 hours.
(8) If State or Territory legislation in the State or Territory where the private hospital is located regulates the number of beds or patients that a private hospital is permitted—in subclause (7), 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.(9) If State or Territory legislation in the State or Territory where the private hospital is located does not regulate the number of beds or patients that a private hospital is permitted—in subclause (7), a reference to
licensed beds is a reference to the beds and bed equivalents the private hospital operates.(10) An authorised officer must calculate proportions for the purposes of paragraphs (7) (a) and (b):
(a) if Hospital Casemix Protocol Data is available for the private hospital—using the most recent year of Hospital Casemix Protocol Data available to the Department for the private hospital; and
(b) otherwise—on the basis of any relevant information available to the Department about the episodes of hospital treatment at the private hospital.
(1) A private hospital subject to a determination made under subclause 1A (1), (2), (3) or (4) may request internal review of its categorisation by the determination.
(2) An application for internal review under subclause (1) must be made in writing within 28 days after the day the determination is notified to the hospital.
(3) If an application for internal review is made, an authorised officer (who must not be the authorised officer who made the original determination) must:
(a) review the determination; and
(b) either confirm the determination or make a fresh one within 28 days after the day on which the application was received by the Department.
Omit “facility”, insert “second‑tier eligible hospital”.
Repeal the subclause, substitute:
(3) If a hospital ceases to be a second‑tier eligible hospital for the purposes of this Schedule, the minimum benefit in relation to an episode of hospital treatment for an insured person who was an admitted patient at the hospital or booked for hospital treatment at the hospital (as opposed to merely being on the hospital’s waiting list) before the day that the hospital ceased to be a second‑tier eligible hospital is the minimum benefit that would have applied if the hospital continued to be a second‑tier eligible hospital at the time the treatment was provided.
Repeal the subclause, substitute:
(4) Subject to subclauses (2) and (8), the minimum benefit payable by an insurer for an episode of hospital treatment at a second‑tier eligible hospitalfor which the admission date wasbetween 1 September of a particular year (the
first year ) and 31 August of the next year is an amount no less than 85% of the average charge for the equivalent episode of hospital treatment, under that insurer’s negotiated agreements as in force on 1 August of the first year, with all private hospitals:
(a) that:
(i) if the second‑tier eligible hospital is on the list published on the Department’s website under subclause 1A (5)—were comparable on 1 August of the first year with the second‑tier eligible hospital; and
(ii) otherwise—are in the same category as the second‑tier eligible hospital in the list published on the Department’s website under subclause 1A (5) as at 1 August of the first year; and
(b) that are in the same State as the second‑tier eligible hospital.
Note: See clause 4 for a transitional arrangement for admissions to second‑tier eligible hospitals between 1 January 2019 and 31 August 2019.
Omit “facility”, substitute “second‑tier eligible hospital”.
Repeal the clause, substitute:
(1) If a patient is admitted to a second‑tier eligible hospital between 1 January 2019 and 31 August 2019:
(a) an insurer may instead work out the average charge on the basis of the repealed provisions; and
(b) if the insurer does so,
comparable has the same meaning as in the repealed provisions.(2) For subclause (1), the
repealed provisions are the provisions of this Schedule as in force immediately before the commencement of Schedule 4 to thePrivate Health Insurance (Reforms) Amendment Rules 2018 .Note: For the purpose of determining which category the second‑tier eligible hospital to which the patient was admitted is placed in, an insurer must use the Department’s determination in respect of that hospital under subclause 1A (1), (2), (3) or (4).
Insert:
accredited means assessed as being fully compliant with theNational Safety and Quality Health Service Standards by a body approved by the Australian Commission on Safety and Quality in Health Care to assess health service organisations against theNational Safety and Quality Health Service Standards .
Hospital Casemix Protocol Data means the data provided by hospitals to insurers that is the subject of rule 4.
makes provision for informed financial consent: a hospitalmakes provision for informed financial consent if it has procedures in place to inform a patient or nominee, in writing, of what hospital charges, insurer benefits and out‑of‑pocket costs (where applicable) are expected in respect of the hospital treatment. A patient or nominee must be informed:
(a) for scheduled admissions—at the earliest opportunity before admission for the hospital treatment; or
(b) for unplanned admissions—as soon after the admission as the circumstances reasonably permit.
minimum benefit means the minimum benefit calculated in accordance with clause 3 of Schedule 5 of thePrivate Health Insurance (Benefit Requirements) Rules 2011 .
National Safety and Quality Health Service Standards means the standards developed by the Australian Commission on Safety and Quality in Health Care.Note: Development of the
National Safety and Quality Health Service Standards is a function of the Australian Commission on Safety and Quality in Health Care under paragraph 9 (1) (e) ofNational Health Reform Act 2011 .
Insert:
For the purposes of subsection 121‑8 (1) of the Act, second‑tier eligible hospitals constitutes a class of hospital (the
second‑tier eligible hospitals class ).
For the purposes of paragraph 121‑8 (2) (b) of the Act, the application fee is $850 for each hospital that the application seeks to have included in the second‑tier eligible hospitals class.
For the purposes of subsection 121‑8A (1) of the Act, to be included in the second‑tier eligible hospitals class, a hospital must:
(a) be a private hospital; and
(b) be accredited; and
(c) not bill patients directly for the minimum benefit payable by the patient’s insurer; and
(d) make provision for informed financial consent; and
(e) submit Hospital Casemix Protocol Data to health insurers electronically with every claim for second‑tier default benefits.
Note: If a hospital is included in the second‑tier eligible hospitals class by the Minister under section 121‑8A of the Act, it will be a second‑tier eligible hospital for the purposes of Schedule 5 to the
Private Health Insurance (Benefit Requirements) Rules 2011 , and therefore eligible to claim second‑tier default benefits as specified in that Schedule.
A hospital that is included in the second‑tier eligible hospitals class must notify the Department in writing of any change in circumstances that may prevent that hospital from continuing to meet the assessment criteria set out in rule 7C as soon as practicable.
(1) A hospital that is a facility for the purposes of clause 4 of Schedule 5 to the
Private Health Insurance (Benefit Requirements) Rules 2011 immediately before the commencement of Schedule 4 to thePrivate Health Insurance (Reforms) Amendment Rules 2018 is taken to be included in the second‑tier eligible hospitals class.(2) A hospital referred to in subrule (1) is taken to be included in the second‑tier eligible hospitals class until the eligibility expiry date for that hospital.
(3) Despite subrule (2), if the date on which a hospital’s accreditation will expire falls within the 12 months following the hospital’s eligibility expiry date, then the hospital is taken to be included in the second‑tier eligible hospitals class until 60 calendar days after the day on which that hospital’s accreditation will expire.
(4) In this rule:
eligibility expiry date means the date on which the hospital’s approval on the list of second‑tier eligible facilities existing on 1 January 2019 expires.Note: Hospitals that are specified in the Second Tier Advisory Committee approved list on 1 January 2019 will be second‑tier eligible hospitals for the purposes of Schedule 5 of the
Private Health Insurance (Benefit Requirements) Rules 2011 , and therefore eligible to claim second‑tier default benefits as specified in that Schedule. Unless subrule (3) applies,when the approval under the pre‑existing arrangements expires, the hospital will be required to apply under s 121‑8 of the Act to be included in the second‑tier eligible hospitals class.
Insert:
excluded natural therapy treatment means any of the following treatments:
(a) Alexander technique;
(b) aromatherapy;
(c) Bowen therapy;
(d) Buteyko;
(e) Feldenkrais;
(f) Western herbalism;
(g) homeopathy;
(h) iridology;
(i) kinesiology;
(j) naturopathy;
(k) Pilates;
(l) reflexology;
(m) Rolfing;
(n) shiatsu;
(o) tai chi;
(p) yoga.
Add:
; and (e) excluded natural therapy treatment.
Repeal the rule, substitute:
(1) For paragraph 121‑10 (3) (b) of the Act, the following treatments or classes of treatment are specified:
(a) treatment which primarily takes the form of sport, recreation or entertainment, other than treatment that is part of a chronic disease management program or a health management program if the programs have been approved by the private health insurer;
(b) excluded natural therapy treatment.
(2) In this rule:
health management program means a program that is intended to ameliorate a person’s specific health condition or conditions, but does not include treatment that is excluded natural therapy treatment.
Omit “standard information statement”, substitute “private health information statement”.
[2] Rule 4 (definition of Australian Government Rebate on private health insurance ) Repeal the definition, substitute:
Australian Government Rebate on private health insurance means:
(a) the premiums reduction scheme; or
(b) the private health insurance tax offset.
Repeal the rule.
Repeal paragraph 8(1)(a), substitute:
(a) if a participant in respect of a complying health insurance policy on issue from the insurer during any time in the previous financial year requests the following information from a participating insurer:
(i) the amount of the premium paid for the policy during the previous financial year;
(ii) the reduction, under the premiums reduction scheme, for the premium;
the participating insurer must issue to the participant a statement in accordance with rule 9;
Omit “annual”.
Repeal the rule, substitute:
(1) A statement under paragraph 8 (1) (a) must:
(a) be in writing; and
(b) set out, clearly and distinctly:
(i) if requested by the participant—the amount of the premium paid for the policy during a particular financial year; and
(ii) if requested by the participant—the amount of the reduction under the premiums reduction scheme for the premium; and
(c) be provided within 14 days of receipt of the request; and
(d) be provided:
(i) by post; or
(ii) if the participant has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the participant.
Example: If requested by the participant, the information may be provided in an electronic format, including via a web page.
(2) A statement under paragraph 8 (1) (a) may be accompanied by other information.
Repeal the subrule, substitute:
1) For the purposes of paragraph 40 (1) (a) of the Act, the following requirements are specified:
(a) the insurer must provide information about increases under Part 2‑3 in the amounts of premiums payable for the policy holder’s hospital cover in respect of the policy holder, if requested by the policy holder;
(b) the insurer must provide the following information to a policy holder affected by section 34‑1 or section 34‑5 of the Act, if requested by the policy holder:
(i) the amount by which the policy holder’s premiums payable for hospital cover are increased as a result of the operation of those sections;
(ii) the private health insurer’s record of the number of days the policy holder has not had hospital cover since his or her lifetime health cover base day, other than days to which paragraph 34‑20 (1) (a) of the Act applies.
Note: Paragraph 34‑20 (1) (a) of the Act deals with permitted days without hospital cover.
Repeal the subrule, substitute:
3) The information required to be provided by subrule 8 (1) must:
(a) be provided:
(i) by post; or
(ii) if the policy holder has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the policy holder; and
(b) in the case of joint policy holders, set out the details applying to the joint policy holder making the request; and
(c) be provided to the policy holder within 14 days of receipt of the request.
Example: For subparagraph (a) (ii), if requested by the policy holder, the information may be provided in an electronic format, including via a web page.
Repeal the definition (including the note).
Insert:
registered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.Note: The registration requirements for a registered podiatric surgeon for the purpose of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rulesas made from time to time.
[3] Subrule 8(1) (table item 2, column headed “Kind of policy”, subparagraph (b)(ii)) Omit “an accredited podiatrist”, substitute “a registered podiatric surgeon”.
Repeal the definition (including the note).
Insert:
registered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.
Note: The registration requirements for a registered podiatric surgeon for the purpose of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules as made from time to time.
Omit “an accredited podiatrist”, substitute “a registered podiatric surgeon”.
The endnotes provide information about this compilation and the compiled law.
The following endnotes are included in every compilation:
Endnote 1—About the endnotes
Endnote 2—Abbreviation key
Endnote 3—Legislation history
Endnote 4—Amendment history
The abbreviation key sets out abbreviations that may be used in the endnotes.
Amending laws are annotated in the legislation history and amendment history.
The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.
The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.
The
If the compilation includes editorial changes, the endnotes include a brief outline of the changes in general terms. Full details of any changes can be obtained from the Office of Parliamentary Counsel.
A misdescribed amendment is an amendment that does not accurately describe the amendment to be made. If, despite the misdescription, the amendment can be given effect as intended, the amendment is incorporated into the compiled law and the abbreviation “(md)” added to the details of the amendment included in the amendment history.
If a misdescribed amendment cannot be given effect as intended, the abbreviation “(md not incorp)” is added to the details of the amendment included in the amendment history.
ad = added or inserted | o = order(s) |
am = amended | Ord = Ordinance |
amdt = amendment | orig = original |
c = clause(s) | par = paragraph(s)/subparagraph(s) |
C[x] = Compilation No. x | /sub‑subparagraph(s) |
Ch = Chapter(s) | pres = present |
def = definition(s) | prev = previous |
Dict = Dictionary | (prev…) = previously |
disallowed = disallowed by Parliament | Pt = Part(s) |
Div = Division(s) | r = regulation(s)/rule(s) |
ed = editorial change | reloc = relocated |
exp = expires/expired or ceases/ceased to have | renum = renumbered |
effect | rep = repealed |
F = Federal Register of Legislation | rs = repealed and substituted |
gaz = gazette | s = section(s)/subsection(s) |
LA = | Sch = Schedule(s) |
LIA = | Sdiv = Subdivision(s) |
(md) = misdescribed amendment can be given | SLI = Select Legislative Instrument |
effect | SR = Statutory Rules |
(md not incorp) = misdescribed amendment | Sub‑Ch = Sub‑Chapter(s) |
cannot be given effect | SubPt = Subpart(s) |
mod = modified/modification | |
No. = Number(s) | commenced or to be commenced |
Private Health Insurance (Reforms) Amendment Rules 2018 | 11 Oct 2018 (F2018L01414) | Sch 1, Sch 2 (items 6–15), Sch 3 (items 1–4), Sch 5 and 6: Sch 2 (items 1–5) and Sch 4: 1 Jan 2019 (s 2(1) items 3, 8) Sch 2 (items 16–20) and Sch 3 (items 5–9): Remainder: 12 Oct 2018 (s 2(1) items 1, 11) | |
Private Health Insurance (Reforms) Amendment Rules (No. 2) 2018 | 30 Oct 2018 (F2018L01504) | 1 Nov 2018 (s 2(1) item 1) | — |
Private Health Insurance (Reforms) Amendment Rules (No. 3) 2018 | 19 Dec 2018 (F2018L01795) | Sch 1: 1 Jan 2019 (s 2(1) item 2) Sch 2: 31 Dec 2018 (s 2(1) item 3) | — |
item 6........................................ | am F2018L01795 |
item 4........................................ | am F2018L01504; F2018L01795 |
item 9........................................ | am F2018L01795 |
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