Private Health Insurance (Risk Equalisation Administration) Rules 2007 (Cth)

Private Health Insurance (Risk Equalisation Administration) Rules 2007

as amended

made under section 333‑25 of the

Private Health Insurance Act 2007

This compilation was prepared on 30 March 2011

taking into account amendments up to Private Health Insurance (Risk Equalisation Administration) Amendment Rules 2011 (No. 1)

Prepared by the Office of Legislative Drafting and Publishing,

Attorney‑General’s Department, Canberra

Contents

Part 1 Preliminary

Part 2 Requirement for records to be kept

Part 3 Quarterly returns

Part 1Preliminary

1Name of Rules [see Note 1]

These Rules are the Private Health Insurance (Risk Equalisation Administration) Rules 2007.

2Commencement [see Note 1]

These Rules commence:

1. (a)

   if the Rules are registered before the Act commences — at the same time as the Act commences; or

2. (b)

   if the Rules are registered on or after the day on which the Act commences — on the day after the Rules are registered,

whichever occurs first.

3Interpretation

Note Terms used in these Rules have the same meaning as in the Act — see section 13 of the Legislative Instruments Act 2003. These terms include:

Adult

complying health insurance policy

Council

Cover

general treatment

health benefits fund

hospital cover

hospital‑substitute treatment

hospital treatment

medicare benefit

officer

policy holder

private health insurer

risk equalisation jurisdiction

(1)

In these Rules:

Actmeans the Private Health Insurance Act 2007.

Business Rulesmeans the Private Health Insurance (Health Insurance Business) Rules 2007 made under the Act.

chronic disease management program or CDMP:

1. (a)

   has the same meaning as in the Business Rules; and

2. (b)

   for hospital treatment, includes a program similar to a chronic disease management program as referred to in the definition of ‘eligible benefit’ in the Risk Equalisation Policy Rules.

fund means a health benefits fund.

insured person, in relation to a policy,means a person covered by the policy.

insurer means a private health insurer.

policy means a complying health insurance policy.

quarter means a period of 3 months ending on 31 March, 30 June, 30 September or 31 December in a year.

Risk Equalisation Policy Rules means the Private Health Insurance (Risk Equalisation Policy) Rules 2007 made under the Act.

(2)

In these Rules, a category of policy is to be identified as follows:

1. (a)

   for a policy under which only one person is insured — as ‘single’;

2. (b)

   for a policy under which 2 adults are insured (and no‑one else) — as ‘couple’;

3. (c)

   for a policy under which 2 or more people are insured, none of whom is an adult — as ‘2 + persons, no adults’;

4. (d)

   a policy under which 2 or more people are insured, only one of whom is an adult — as ‘single parent’;

5. (e)

   a policy under which 3 or more people are insured, only 2 of whom are adults — as ‘family’;

6. (f)

   a policy under which 3 or more adults are insured — as ‘3 + adults’.

(4)

In these Rules, the following terms relevant to the high cost claimants pool have the same meaning as in the Risk Equalisation Policy Rules:

age based pool (ABP)

designated threshold

high cost claimants pool (HCCP)

gross benefit.

Part 2Requirement for records to be kept

4General records

For each fund conducted by an insurer, the insurer must keep records that contain the following details about each policy of the fund:

1. (a)

   the name, date of birth, age and principal place of residence of each person covered by the policy; and

2. (b)

   which of the following the policy covers:

   1. (i)

      hospital treatment;

   2. (ii)

      hospital-substitute treatment;

   3. (iii)

      chronic disease management programs;

   4. (iv)

      ambulance service;

   5. (v)

      other general treatment; and

3. (c)

   whether the policy includes any excesses or co‑payments payable; and

4. (d)

   the category of policy by reference to the number of adults and dependent children covered; and

Note Subrule 3 (2) deals with the identification of ‘categories of policies’.

1. (e)

   for each benefit that is paid to or on behalf of an insured person:

   1. (i)

      the name of the insured person to whom the benefit relates; and

   2. (ii)

      the medical or health speciality for which the benefit was paid; and

   3. (iii)

      whether the benefit was paid for:

      1. (A)

         hospital treatment; or

      2. (B)

         hospital-substitute treatment; or

      3. (C)

         chronic disease management program treatment; or

      4. (D)

         ambulance services; or

      5. (E)

         other general treatment; and

   4. (iv)

      if the treatment was provided in accordance with a chronic disease management program, the type of disease for which the program was provided and whether the treatment was provided as hospital treatment or general treatment; and

   5. (v)

      the gross benefits paid; and

   6. (vi)

      the date of treatment; and

   7. (vii)

      the date of payment.

5High cost claimants pool records

1. (1)

   This rule applies if the insurer includes in a quarterly return a gross benefit for the high cost claimants pool.

   Note Part 3 sets out the requirements for providing quarterly returns.

2. (2)

   In addition to the information to be kept in accordance with rule 4, the insurer must keep a record that contains the following information in respect of the insured person to whom the gross benefit relates:

   1. (a)

      the name and age of the person; and

   2. (b)

      the dates of the treatment; and

   3. (c)

      the gross benefits paid; and

   4. (d)

      the dates of payment; and

   5. (e)

      the amount of gross benefit included in the age based pool; and

   6. (f)

      the amount of gross benefit included in the high cost claimants pool; and

   7. (g)

      the amount of gross benefits paid for any of the preceding 3 quarters (after 1 April 2007).

Part 3Quarterly returns

6Requirement to provide quarterly returns

1. (1)

   Within four weeks after the end of each quarter, an insurer must give to the Council, for each fund that it conducts, a quarterly return for each risk equalisation jurisdiction.

2. (2)

   The information to be provided in a quarterly return for a fund for a risk equalisation jurisdiction must:

   1. (a)

      relate only to insured persons of the fund whose principal place of residence is in that jurisdiction; or

   2. (b)

      if there are no such persons in the jurisdiction, state the amounts as nil.

3. (3)

   For subrule 6 (2), if a benefit is paid to or on behalf of an insured person during a quarter and the person changes his or her principal place of residence to another risk equalisation jurisdiction during the quarter, the person’s principal place of residence is the place at which the person resides at the end of the quarter.

4. (4)

   Amounts entered in the quarterly return as benefits paid may be entered:

   1. (a)

      as whole dollar amounts, rounded to the nearest dollar; or

   2. (b)

      as dollars and cents.

5. (4A)

   For the purpose of quarterly returns, a benefit is regarded as being paid during the quarter in which the benefit is recorded and liability for it is accepted.

6. (5)

   If the Council considers that any of the information provided in a quarterly return is inaccurate, the Council may seek a correction of the quarterly return by the insurer.

7Form of quarterly returns

1. (1)

   Quarterly returns must be:

   1. (a)

      given to the Council as electronic data in the form approved by the Council; and

   2. (b)

      accompanied by a signed copy of the certification mentioned in subrule (3) as a PDF file.

   Note for paragraph (a) The approved form for paragraph (a) is available at data mentioned in paragraph 1 (a) is to be provided as an unaccompanied workbook, and each worksheet within that workbook must not contain:

   1. (a)

      any links to any other worksheet within that workbook; or

   2. (b)

      any links to other workbooks.

2. (3)

   For paragraph 7 (1) (b), an officer of the insurer must certify that the information in the quarterly return is true and correct.

   Note Officer means a director, chief executive officer or person who makes, or participates in making, decisions that affect the whole, or a substantial part, of the business of the insurer — see the Dictionary in Schedule 1 of the Act.

3. (4)

   If an officer is unable to give the certification mentioned in subrule (3), the quarterly return must be accompanied by a statement by an officer of the insurer stating why the certification cannot be provided.

8Independent annual audit of quarterly returns

1. (1)

   By 30 September each year, the insurer must give to the Council an independent auditor’s report relating to:

   1. (a)

      each quarterly return provided by the insurer under rule 6 for the previous financial year; or

   2. (b)

      if the insurer provides an amended quarterly return to replace a return referred to in paragraph (a) — the amended quarterly return.

2. (2)

   The auditor providing the report to the insurer must not be an officer of, or employed by, the insurer.

3. (3)

   For subrule (1), the auditor’s report must be addressed to the Council and must set out the auditor’s opinion as to whether:

   1. (a)

      the records for the fund contain the information required to be kept by these Rules; and

   2. (b)

      the information contained in each of the quarterly returns, or amended quarterly returns, accurately reflects the information contained in the records of the fund; and

   3. (c)

      the records of the fund have been accurately compiled so as to permit the insurer to fairly state in the quarterly returns the information required to be provided.

4. (4)

   If the insurer received a qualified auditor’s report for a fund for the financial year previous to the year for which the report is provided, whether the auditor has examined the issues identified and is satisfied that the insurer has taken the appropriate steps to rectify the matters raised in the previous report.

5. (5)

   The auditor’s report must:

   1. (a)

      state details of the program adopted to carry out the audit; and

   2. (b)

      include the name of, and be signed by, the auditor who takes responsibility for the accuracy of the report.

Notes to the Private Health Insurance (Risk Equalisation Administration) Rules 2007

Note 1

The Private Health Insurance (Risk Equalisation Administration) Rules 2007 (in force under section 333‑25 of the Private Health Insurance Act 2007 ) as shown in this compilation is amended as indicated in the Tables below.

Table of Instruments

Title	Date of FRLI registration	Date of commencement	Application, saving or transitional provisions
Private Health Insurance (Risk Equalisation Administration) Rules 2007	31 Mar 2007 (see F2007L00876)	1 Apr 2007 (see r. 2 (a))
Private Health Insurance (Risk Equalisation Administration) Amendment Rules 2007 (No. 1)	18 Dec 2007 (se e F2007L04880)	19 Dec 2007	—
Private Health Insurance (Risk Equalisation Administration) Amendment Rules 2011 (No. 1)	29 Mar 2011 (see F2011L00518)	30 Mar 2011	—

Table of Amendments

ad. = added or inserted am. = amended rep. = repealed rs. = repealed and substituted
Provision affected	How affected
Part 1
R. 3.........................................	am. 2011 No. 1
Part 2
R. 4.........................................	am. 2011 No. 1
R. 5.........................................	am. 2011 No. 1
Part 3
R. 6.........................................	am. 2011 No. 1
R. 7.........................................	am. 2011 No. 1
R. 9.........................................	am. 2007 No. 1
rep. 2011 No. 1
Schedule...............................	rep. 2011 No. 1