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Private Health Insurance (Complying Product) Rules 2015

made under item 3 of the table in subsection 333‑20(1) of the

Private Health Insurance Act 2007

Compilation No. 23

Compilation date: 1 November 2019

Includes amendments up to: F2019L01384

Registered: 13 November 2019

About this compilation

This compilation

This is a compilation of the Private Health Insurance (Complying Product) Rules 2015 that shows the text of the law as amended and in force on 1 November 2019 (the compilation date).

The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.

Uncommenced amendments

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.

Application, saving and transitional provisions for provisions and amendments

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.

Editorial changes

For more information about any editorial changes made in this compilation, see the endnotes.

Modifications

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.

Self‑repealing provisions

If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.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

Part 1 Preliminary 1

1.Name of Rules 1

3AAuthority 1

4.Definitions 1

Part 2 General 5

5.Insured groups 5

5A Psychiatric treatment—limitations 5

6.Maximum percentage of discount 6

7.Benefits authorised to be provided under a policy 6

8.Complying products―coverage requirements 7

8ABenefit requirement―nursing‑home type patients 8

9.Waiting periods―former gold card holders 9

9AATerminating products—portability requirements 9

9A Specialist psychiatric treatment—portability requirements 11

9B Specialist psychiatric treatment—choice to have upgrade treated
in accordance with rule 9A 12

10.Transfer certificates 13

11.Performance indicators 13

Part 2AAge‑based discounts 14

11A. Definitions 14

11B. Requirements for age‑based discount policy to be complying
health insurance policy 15

11C. Calculation of age‑based discount 15

11D. Circumstances in which a person is entitled to age‑based discount 16

Part 2B Requirements relating to product tiers for, and names of,
insurance policies 17

11E. Product tiers for insurance policies that cover hospital treatment 17

11F. Coverage of treatments for insurance policies that cover hospital
treatment 17

11G. Provision of restricted and unrestricted cover 18

11H. Naming of insurance policies that cover hospital treatment 19

11J. Naming of insurance policies that cover general treatment only 19

Part 3 Private health information statements and other information
that must be given 20

12.Private health information statements 20

13.Method of making private health information statements
available 20

14. Information relating to changes to premiums to be provided to Private Health Insurance Ombudsman 21

15. Information provided to insured persons 21

16. Information provided to persons about product subgroups 22

Part 4 Pilot Projects 23

17.Kinds of pilot projects 23

18.Requirements of pilot projects 23

Part 5 Transitional provisions 24

19. Transitional provisions relating to the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018 24

20. Transitional provisions relating to the Private Health Insurance (Reforms) Amendment Rules 2018—private health information statements 24

21. Transitional provisions relating to the Private Health Insurance (Reforms) Amendment Rules 2018—product tiers 25

Schedule 1―Information and form of words for private health information statement—all policies 27

Schedule 2―Additional information, and form of words, for private health information statement—hospital treatment 30

Schedule 3―Additional information, and form of words, for private health information statement—general treatment 34

Schedule 4—Product tiers and clinical categories 39

Schedule 5—Clinical categories 41

Schedule 6—Common treatments list 61

Schedule 7—Support treatments list 62

Endnotes 64

Endnote 1—About the endnotes 64

Endnote 2—Abbreviation key 65

Endnote 3—Legislation history 66

Endnote 4—Amendment history 68

Part 1 Preliminary

1.Name of Rules

These Rules are the Private Health Insurance (Complying Product) Rules 2015.

3A Authority

These Rules are made under the Private Health Insurance Act 2007.

4.Definitions

In these Rules:

Act means the Private Health Insurance Act 2007.

addiction medicine specialist means a specialist (within the meaning of the Health Insurance Act 1973) in relation to addiction medicine.

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.

certified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

certified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

clinical category, for hospital treatment, means a clinical category that is set out in Schedule 5.

consultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

consultant psychiatrist means a specialist (within the meaning of the Health Insurance Act 1973) in relation to psychiatry.

Department means the Private Health Insurance Branch of the Department of Health.

general medical services table has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

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.

implantable cardiac event recorder includes a component of an implantable cardiac event recorder.

insulin infusion pump includes a component of an insulin infusion pump.

insurer means a private health insurer.

MBS item means an item that is in, or which from time to time a determination under section 3C of the Health Insurance Act 1973 deems to be 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 that Act, as in force from time to time;

(c) the pathology services table, made under section 4A of that Act, as in force from time to time.

National Law means:

(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or

(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 that corresponds to the Health Practitioner Regulation National Law.

Note: The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions that was made on 26 March 2008 provides for the enactment of the State and Territory legislation mentioned in this definition.

period of pre‑upgrade hospital cover has the meaning given by subrule 9A(5).

policy means a complying health insurance policy.

private hospital means a hospital in respect of which there is in force a statement under subsection 121‑5 (8) of the Act that the hospital is a private hospital.

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”.

professional attendance has the same meaning as in clause 1.2.3 of the general medical services table.

professional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

psychiatric treatment means hospital treatment, or hospital‑substitute treatment, that is psychiatric care.

public hospital means a hospital in respect of which there is in force a statement under subsection 121‑5 (8) of the Act that the hospital is a public hospital.

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.

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.

specialist psychiatric treatment means psychiatric treatment provided to a person who is:

(a) an admitted patient of a hospital; and

(b) under the care of an addiction medicine specialist or consult psychiatrist.

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.

upgrade, in relation to psychiatric treatment, has the meaning given by subrules 9A(2) and (3).

Note: Unless the contrary intention appears, 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
applicable benefits arrangement
complying health insurance policy
complying health insurance product
cover
dependent child
dependent child non‑student
general treatment
hospital cover
hospital‑substitute treatment
hospital treatment
medical practitioner
medicare benefit
policy holder
private health information statement
private health insurer
product subgroup
risk equalisation jurisdiction
rules [of an insurer]
transfer
waiting period

Part 2 General

5. Insured groups

(1) For the purposes of paragraph 63‑5 (2A) (b) of the Act, the following insured groups are specified:

(a) for policies other than a non‑student policy or a policy referred to in paragraph (c), the insured groups are:

(i) only one person;

(ii) 2 adults (and no‑one else);

(iii) 2 or more people, none of whom is an adult;

(iv) 2 or more people, only one of whom is an adult;

(v) 3 or more people, only 2 of whom are adults;

(vi) 3 or more people, at least 3 of whom are adults;

(b) for policies that are a non‑student policy (unless the policy is a non‑student policy referred to in paragraph (c)), the insured groups are:

(i) 2 or more people, only one of whom is an adult;

(ii) 3 or more people, only 2 of whom are adults;

(c) for non‑student policies which have as conditions of the policy that the dependent child non‑student is not covered for general treatment, other than hospital‑substitute treatment, and must have his or her own policy with the same insurer covering general treatment (other than hospital‑substitute treatment), the insured groups are:

(i) 2 or more people, only one of whom is an adult;

(ii) 3 or more people, only 2 of whom are adults.

(2) In this rule a non‑student policy is a complying health insurance policy that covers one or more dependent child non‑students.

5A Psychiatric treatment—limitations

For the purposes of paragraph 63‑10(g) of the Act, an insurance policy must not reduce a benefit for psychiatric treatment provided to a person if the reduction is because of:

(a) the number of psychiatric treatments, for which there is or has been an entitlement to a benefit under any policy, provided to the person during a period; or

(b) the number of a particular kind of such psychiatric treatments provided to the person during a period.

6.Maximum percentage of discount

(1) For subparagraph 66‑5 (1) (c) (ii) of the Act, the maximum percentage discount allowed is 12% per annum.

(2) The discount for a policy is the difference between the full premium and the net premium.

(3) The full premium for a policy is the premium that would be received by the private health insurer for a policy in the same product subgroup without any reduction due to the circumstances set out in paragraphs 66‑5 (3) (a) to (ea) of the Act.

(4) The net premium is the full premium less the cost, or the cost foregone, of any of the following:

(a) incentive payment;

(b) promotional payment;

(c) rebate; and

(d) any other inducement whatsoever,

made available by the insurer to another person, including to an insured person, in respect of the payment of the premium for the policy, including to induce a person to purchase or maintain a policy.

(5) For the purposes of this rule, disregard:

(a) a brokerage fee or commission paid in respect of the policy; and

(b) the cost of any discount, product, service, waiver or other thing (promotion) offered to a person at the time the person first purchases a policy from the insurer if:

(i) the cost of the promotion does not exceed 12% of the full premium, for a year, for the policy purchased; and

(ii) the promotion is provided in the first year after the person purchases the policy; and

(c) any age‑based discount that might apply in relation to the policy (see Part 2A).

7.Benefits authorised to be provided under a policy

(1) In this rule, specified benefit means a benefit specified in subrule (3).

(2) If a person was entitled to a specified benefit under an applicable benefits arrangement or a table of ancillary health benefits in force at the commencement of the Act, the provision of the same specified benefit under the person's policy is authorised for the purposes of paragraph 69‑1 (1) (b) of the Act as long as the person's policy continues to cover the same specified treatments and provide the same specified benefits.

Note: Section 10 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of existing applicable benefits arrangements and tables of ancillary benefits at the commencement of the Act.

(3) The specified benefits for this rule are:

(a) benefits paid in connection with the birth of a baby;

(b) funeral benefits;

(c) disability benefits.

(4) In this rule, ancillary health benefit means ancillary health benefits within the meaning of section 67 the National Health Act 1953 as in force immediately before the commencement of the Act.

8.Complying products―coverage requirements

(1) For subsection 69‑1 (2) of the Act, a policy of a kind specified in the following table must also cover any treatment as specified in the table.

Coverage requirements
Item	Kind of policy	Treatments the policy must cover
1	A policy that includes cover for hospital‑substitute treatment.	Hospital treatment for the same types of treatment covered by the policy for hospital‑substitute treatment.
2	A policy under which a person is covered, wholly or partly, for hospital treatment where: (a) the treatment includes the provision of a prosthesis of a kind listed in the Private Health Insurance (Prostheses) Rules made under the Act; and (b) either: (i) a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis; or (ii) the provision of the prosthesis is associated with podiatric treatment by a registered podiatric surgeon; or (iii) for a prosthesis that is an insulin infusion pump: (A) the insulin infusion pump is provided during a professional service for which a medicare benefit is payable; and (B) the professional service is a professional attendance by a consultant physician in the practice of his or her specialty; and (C) the professional service is provided as a certified Type C procedure or certified overnight Type C procedure; and (D) the insulin infusion pump is provided for the purpose of administering insulin.	The provision of the prosthesis.
3	A policy under which a person is covered, wholly or partly, for hospital‑substitute treatment where: (a) the treatment includes the provision of a prosthesis of a kind listed in the Private Health Insurance (Prostheses) Rules made under the Act; and (b) a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis.	The provision of the prosthesis.

Note: The Private Health Insurance (Prostheses) Rules set out the benefit requirements for prostheses listed in those Rules.

(2) For the avoidance of doubt, a policy of a kind mentioned in the table may also be a policy that covers other types of treatment, unless excluded by rules made for the purpose of subsection 69‑1 (3).

8A Benefit requirement―nursing‑home type patients

(1) For paragraph 72‑1 (1) (b) of the Act, the requirement in subrule (2) is a benefit requirement for a policy that covers hospital treatment.

(2) The requirement is that the amount of benefit payable under the policy in respect of hospital treatment at a hospital for a nursing‑home type patient must not exceed an amount equal to the fees or charges incurred in respect of that hospital treatment less the amount of the patient contribution in relation to the patient for each day on which the patient is a nursing‑home type patient at the hospital.

(3) In this rule:

nursing‑home type patient has the same meaning as in the Private Health Insurance (Benefit Requirements) Rules, made under section 333‑20 of the Act, as in force from time to time.

patient contribution, for each day on which the patient is a nursing‑home type patient at the hospital, means:

(a) in relation to a nursing‑home type patient at a public hospital, the following amount for the State or Territory in which the hospital is located:

(i) Australian Capital Territory ‑ $61.30;

(ii) New South Wales ‑ $61.80;

(iii) Northern Territory ‑ $61.80;

(iv) Queensland ‑ $61.80;

(v) South Australia ‑ $61.80;

(vi) Tasmania ‑ $61.80;

(vii) Victoria ‑ $61.80; and

(viii) Western Australia ‑ $61.80.

(b) in relation to a nursing‑home type patient at a private hospital, $61.80.

9. Waiting periods―former gold card holders

(1) The waiting period requirements in subsection 75‑1 (1) of the Act are modified in relation to insured persons referred to in subrule (2) by specifying the conditions set out in that subrule.

(2) A policy that covers a person who:

(a) held a gold card, or was entitled to treatment under a gold card, before applying for the insurance; and

(b) applies for the insurance no longer than 2 months after the person ceased to hold, or be entitled under, the gold card,

must not apply to the person any waiting period or benefit limitation period for any hospital treatment or general treatment covered by the policy.

(3) In this rule:

gold card has the same meaning as in section 34‑15 of the Act.

benefit limitation period, in respect of the person's insurance policy, means a period:

(a) starting at the time the person becomes insured under the policy referred to in this rule; and

(b) ending at the time specified in the policy,

during which the amount of benefit in relation to any period is less than the amount for which the person would be eligible during any other period.

9AA Terminating products—portability requirements

(1) For paragraph 78‑1 (5A) (c) of the Act, the matters are:

(a) that the policy forms part of a product, or belongs to a product subgroup, that is being terminated and that will not be available to any person insured under a policy that forms part of the product or that belongs to the product subgroup, as appropriate (a terminating policy); and

(b) that, as a consequence, the persons insured under the policy are to be transferred to another insurance policy; and

(c) the date by which the transfer is to take place (the transfer date); and

(d) that:

(i) before the transfer date, the persons insured under the policy may transfer to any insurance policy of their choosing; but

(ii) if they do not do so before the transfer date, they will be transferred, on the transfer date, to a specified insurance policy (the default policy); and

(e) the matters set out in subrule(2) that relate to the default policy; and

(f) the other matters set out in subrule (3) that relate to the transfer.

Matters that relate to the default policy

(2) For paragraph (1) (e), the matters are:

(a) the private health information statement for the default policy; and

(b) details of the premium that would be payable for the default policy, including any increase in the premium under Part 2‑3 of the Act (lifetime health cover), and any discounts that might apply; and

(c) details of:

(i) any treatments that are covered under the terminating policy that will not be covered under the default policy; and

(ii) any differences between the excesses or co‑payments payable under the terminating policy and the default policy.

Other matters that relate to the transfer

(3) For paragraph (1) (f), the matters are:

(a) that if:

(i) a person transfers from the terminating policy to another policy, or is transferred to the default policy; and

(ii) there are particular hospital treatments or hospital‑substitute treatments that are covered by both the terminating policy and the policy to which the person transfers or is transferred;

for each such treatment, to the extent that the person has satisfied the waiting period (if any) under the terminating policy, the person will have satisfied the waiting period (if any) under the other policy; but

(b) that if:

(i) a person is transferred from the terminating policy to the default policy; and

(ii) the person subsequently transfers from the default policy to another insurance policy (the replacement policy);

then:

(iii) if there are any treatments that were not covered by the default policy but that are covered by the replacement policy—the person may be subject to a waiting period under the replacement policy in respect of those treatments, even if the treatments were originally covered by the terminating policy; and

(iv) if the default policy had higher excesses or co‑payments than the replacement policy—those higher excesses or co‑payments might, for a period of time, continue to apply under the replacement policy.

9A Specialist psychiatric treatment—portability requirements

(1) For the purposes of subsection 78‑1(6) of the Act, subrules (4) to (8) of this rule modify the requirements of section 78‑1 of the Act in relation to:

(a) an insurance policy (the new policy) to which a person transfers from another policy (the old policy), if:

(i) the transfer is an upgrade in relation to psychiatric treatment; and

(ii) the person chooses under rule 9B to have the upgrade treated in accordance with those subrules; and

(b) a benefit (the higher benefit) under the new policy for specialist psychiatric treatment provided to the person.

(2) The transfer is an upgrade, in relation to psychiatric treatment, if the benefit for psychiatric treatment under the new policy is higher than the benefit for psychiatric treatment under the old policy.

(3) For the purposes of subrule (2), disregard any co‑payment or excess that is required to be paid under the old policy or the new policy in respect of psychiatric treatment.

Waiting periods

(4) The new policy must not:

(a) if the length of the person’s period of pre‑upgrade hospital cover was 2 months or longer—apply to the person a waiting period for the higher benefit; or

(b) otherwise—apply to the person a waiting period for the higher benefit that is longer than 2 months reduced by the length of the person’s period of pre‑upgrade hospital cover.

(5) The person’s period of pre‑upgrade hospital cover is the longest period:

(a) that ended immediately before the upgrade; and

(b) at all times during which the person had hospital cover.

Retrospective cover

(6) Subrules (7) and (8) apply if the upgrade occurs:

(a) on or after the day (the admission day) the person became an admitted patient of a hospital in relation to the specialist psychiatric treatment mentioned in paragraph (1)(b); and

(b) on or before the fifth business day to occur on or after the admission day.

(7) The new policy’s coverage of specialist psychiatric treatment must start no later than the admission day.

Example: A person is admitted to hospital for specialist psychiatric treatment. The person’s insurance policy provides minimum benefits for psychiatric treatment. 3 business days later, the person upgrades to a new policy and chooses to have the upgrade treated in accordance with subrules (4) to (8). The higher benefits under the new policy for specialist psychiatric treatment must apply from the day of the admission.

(8) Subrule (7) does not prevent the new policy from applying a waiting period in accordance with subrule (4). The reference in paragraph (5)(a) to the upgrade is taken to be a reference to the start of the new policy’s coverage of specialist psychiatric treatment.

9B Specialist psychiatric treatment—choice to have upgrade treated in accordance with rule 9A

(1) A person may choose to have an upgrade in relation to psychiatric treatment treated in accordance with subrules 9A(4) to (8) if the person has not previously made such a choice in relation to any such upgrade.

(2) If:

(a) a person transfers to an insurance policy (the new policy), and the transfer is an upgrade in relation to psychiatric treatment; and

(b) a claim is made under the new policy for a benefit for specialist psychiatric treatment provided to the person; and

(c) a benefit of the amount claimed is only payable under the new policy for the treatment if the person chooses to have the upgrade treated in accordance with subrules 9A(4) to (8);

the making of the claim is sufficient evidence of the person choosing to have the upgrade treated in accordance with those subrules.

(3) For the purposes of paragraph (2)(c) of this rule, disregard any co‑payment or excess that is required to be paid under the new policy in respect of psychiatric treatment.

10.Transfer certificates

For section 99‑1 of the Act, the following periods are set out:

(a) for subsection 99‑1 (1), certificate for the insured person―14 days;

(b) for subsection 99‑1 (2), certificate for the new insurer―14 days;

(c) for subsection 99‑1 (3), old insurer to provide a certificate to the new insurer on request―14 days.

11.Performance indicators

For subsection 188‑1 (1) of the Act, the following performance indicators are set out:

(a) the number and kind of complaints made to the Private Health Insurance Ombudsman about private health insurers;

(b) changes in the number of insured persons in particular age groups;

(c) changes in the number of episodes of hospital treatment and hospital‑substitute treatment, and the average number of episodes of each, for particular age groups;

(d) changes in the nature of the episodes of hospital treatment and hospital‑substitute treatment, for which benefits are paid in particular age groups;

(e) changes in the average amount of benefits paid for an insured person, or an episode of hospital treatment or hospital substitute treatment, in particular age groups.

Part 2A Age‑based discounts

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).

11A. Definitions

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 (the old 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.

11B. Requirements for age‑based discount policy to be complying health insurance 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).

11C. Calculation of age‑based discount

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 in subrule (2), the table is:

If, for that period, the person is aged:	the person’s percentage for the period 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.

Person’s age at discount assessment date	Percentage
18 or older, but under 26	10%
26	8%
27	6%
28	4%
29	2%

11D. Circumstances in which a person is entitled to age‑based discount

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.

Part 2B Requirements relating to product tiers for, and names of, insurance policies

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.

11E. Product tiers for insurance policies that cover hospital treatment

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.

11F. Coverage of treatments for insurance policies that cover hospital treatment

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.

11G. Provision of restricted and unrestricted cover

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.

11H. Naming of insurance policies that cover hospital treatment

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 “+”.

11J. Naming of insurance policies that cover general treatment only

(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 “+”.

Part 3 Private health information statements and other information that must be given

Note: This Part deals with:

· the information and form for private health information statements, for the purposes of subsection 93‑5 (1) of the Act, and methods by which private health 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.

12. Private health information statements

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 private health 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.

13. Method of making private health information statements available

(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 private health information statement is accompanied by information additional to the information and form of words that are required by subrule 12 (1); and

(b) the private health 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 private health 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.

14. Information relating to changes to premiums to be provided to Private Health Insurance Ombudsman

(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 10 business 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.

15. Information provided to insured persons

(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.

16. Information provided to persons about product subgroups

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.

Part 4 Pilot Projects

17.Kinds of pilot projects

The kinds of pilot projects specified for subsection 55‑15(2) of the Act are projects that enable an insurer to trial and develop, with a limited group of policy holders, new models of service delivery or health care. The objectives of the pilot project must be for any or all of the following:

(a) to increase the value to consumers of their health insurance products by better meeting their needs;

(b) to prolong health, improve quality of life and reduce expenditure on hospital benefits by preventing and reducing disease and prevent the need for hospitalisation;

(c) to produce products that better reflect advances in medical knowledge and service delivery models.

18.Requirements of pilot projects

For the purposes of sub‑section 55‑15(2) of the Act, a pilot project of a kind specified in rule 17 is to be conducted in accordance with all the following requirements:

(a) an insurer must not charge a person to participate in the project;

(b) participation in a pilot project must be voluntary;

(c) a pilot project may be conducted for a maximum of four years;

(d) an insurer may only limit participation in a pilot project on the basis of where a person lives;

(e) an insurer must develop a written plan for a pilot project, including a timeline and evaluation process;

(f) written notice of the details of the project, including a copy of the written plan referred to in (e), must be provided to the Department at least 28 days before the pilot project commences.

Part 5 Transitional provisions

19.Transitional provisions relating to the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018

Definitions

(1) In this rule:

amending rules means the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018.

Application of subrule 9A(4)

(2) Subrule 9A(4), as inserted by the amending rules, applies to a waiting period that ends on or after 1 April 2018, whether the upgrade occurred before, on or after 1 April 2018.

Application of subrules 9A(6) to (8)

(3) Subrules 9A(6) to (8), as inserted by the amending rules, apply to an upgrade that occurs on or after 1 April 2018.

(4) If a person:

(a) became an admitted patient of a hospital in relation to specialist psychiatric treatment before 1 April 2018; and

(b) is still an admitted patient in relation to the treatment on 1 April 2018;

the reference in paragraph 9A(6)(a), as inserted by the amending rules, to the day the person became an admitted patient of a hospital in relation to the treatment is taken to be a reference to 1 April 2018.

(5) If subrule 9A(7), as inserted by the amending rules, would, apart from this subrule, require an insurance policy’s coverage of specialist psychiatric treatment to start before 1 April 2018, subrule 9A(7) is taken to require the coverage to start no later than 1 April 2018.

20. Transitional provision relating to the Private Health Insurance (Reforms) Amendment Rules 2018—private health information statements

(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.

Application of rule

(1) This rule applies until 31 March 2020.

Transitional provision

(2) A private health 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 private health information statement is 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 the Private 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.

21. Transitional provisions relating to the Private Health Insurance (Reforms) Amendment Rules 2018—product tiers

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.

Schedule 1―Information and form of words for private health information statement—all policies

1. Interpretation

In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.

2. Information and form of words for private health information statement—all policies

For paragraph 12 (1) (a) of these Rules, the information and form of words are set out in the following table:

Information and form of words for private health information statement—all policies
Item	Information and form of words
1	Policy name The name of the policy. Note 1: See rules 11H and 11J for rules governing the naming of policies that cover hospital treatment and the naming of policies that cover general treatment. Note 2: See rule 21 for a transitional provision relating to this item.
2	Name of private health insurer 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	Disclaimer for restricted access insurers If the policy is offered by a restricted access insurer—the following statement: “Membership of this insurer is restricted to” followed by the details.
4	Contact details A contact phone number and website address of the private health insurer.
5	State/s available in The States in which the product is available, expressed as either: (a) if: (i) the product is offered in all States; and (ii) every feature of the product (including the monthly premium referred to in item 6) is the same in each State; “All States”; or (b) otherwise—the State or States in which the product is available, expressed as whichever of the following is applicable: (i) “NSW & ACT”; (ii) “Northern Territory”; (iii) “Queensland”; (iv) “South Australia”; (v) “Tasmania”; (vi) “Victoria”; (vii) “Western Australia”.
6	Monthly premium 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”. Note: This item does not limit the information that a private health insurer may give to an insured person with regard to the premium payable after any rebate, loading and/or discount is applied.
7	Corporate products 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: (a) “Employees/members of [Company/Organisation]”; (b) “Employees/members of organisations with arrangements with this health insurer”.
8	Closed products 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: “This policy is closed to new members.”.
9	Who is covered The insured groups that may be covered, expressed as whichever of the following is applicable: (a) “only one person”; (b) “2 adults (and no‑one else)”; (c) “2 or more people, none of whom is an adult”; (d) “2 or more people, only one of whom is an adult”; (e) “3 or more people, only 2 of whom are adults”; (f) “3 or more people, at least 3 of whom are adults”. Note 1: The insured groups are set out in rule 5 of these Rules. Note 2: This item does not limit the information that a private health insurer may give to an insured person with regard to the name/s of person/s covered by the policy.
10	Ambulance cover The following information: (a) whether ambulance cover is included; (b) if so: (i) the waiting period (if any); and (ii) whether the cover is: (A) emergency only; or (B) emergency and non‑emergency; and (iii) any limits on cover (dollar amount or service); and (iv) any call‑out fees (if applicable); (c) for each State in which: (i) the product is available; and (ii) ambulance cover is not included; the following information: (iii) whether free ambulance services are available in that State; (iv) if so—whether they are limited to services in that State; (d) if ambulance cover were to be provided by a person other than the private health insurer who prepared the statement—whether the policy would provide a benefit for that cover.
11	Date available If, and only if, the policy is not yet available—the date from which the policy will be available.
12	Date statement issued or updated 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: “Date statement [issued/updated]: [dd]/[month in words]/[yyyy]”
13	Unique identifier The unique identifier for the private health information statement that is generated by the privatehealth.gov.au system.

Schedule 2—Additional information, and form of words, for private health information statement—hospital treatment

1. Interpretation

In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.

2. Additional information and form of words—hospital treatment

For paragraph 12 (1) (b) of these Rules, the additional information and form of words are set out in the following table:

Additional information and form of words—hospital treatment
Item	Additional information and form of words
1	Information relating to policies that are available only with a general treatment policy If the policy is available only with a policy that covers general treatment—whichever of the following is applicable: (a) if the policy may be purchased with any policy that covers general treatment offered by the insurer—the statement “must be purchased with a general treatment policy”; (b) if there is a set range of policies that cover general treatment with which the policy may be combined—the statement “must be purchased with certain general treatment policies”.
2	Whether the policy exempts holders from the Medicare Levy Surcharge Whichever of the following is applicable: (a) “This policy exempts you from the Medicare Levy Surcharge”; (b) “This policy does not exempt you from the Medicare Levy Surcharge”.
3	What’s included and what’s not included in the policy An indication of: (a) treatments that are covered by the policy, consisting of the words: “This policy includes cover for”; and (b) treatments that are not covered by the policy, consisting of the words: “This policy does not include cover for”; followed, in each case, by: (c) the relevant clinical categories; and (d) whichever of the following (if any) is appropriate: (i) accident cover; (ii) benefits for travel or accommodation. Note: See rule 21 for a transitional provision relating to this item.
4	Restrictions A list of all clinical categories (if any) that have restricted cover. Note: See rule 21 for a transitional provision relating to this item.
5	Waiting periods for new and upgrading members The waiting periods that apply under the policy before a policy holder can claim, expressed either: (a) in the following format, with the bracketed text replaced with the appropriate figures: (i) “[the number of months (up to 2)] months for palliative care, rehabilitation and psychiatric treatments”; (ii) “[the number of months (up to 12)] months for pre‑existing conditions”; (iii) if, and only if, the policy covers pregnancy and birth (obstetrics)—“[the number of months (up to 12)] months for pregnancy and birth (obstetrics)”; (iv) “[the number of months (up to 2)] months for all other treatments”; or (b) if shown in a table—for all clinical categories covered by the policy, the appropriate figure for the relevant waiting period. Note 1: This item does not limit the information that a private health insurer may provide with regard to an individual’s policy. Note 2: The obstetrics waiting period of up to 12 months does not apply to treatment for neonatal care. Note 3: See rule 21 for a transitional provision relating to this item.
6	Excess Whichever of the following is appropriate: (a) if there is no excess—the words “No excess”; (b) if there is an excess: (i) whichever of the following is appropriate, with the bracketed text replaced with the appropriate figure, and where the dollar amount for excess per admission is the excess for an overnight admission, if this is different from the excess for day surgery: (A) “You will have to pay an excess of $[number] per admission.”; (B) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per year.”; (C) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per year.”; (D) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per person per year.”; (E) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per person and $[number] per policy per year.”; (F) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per person and $[number] per policy per year.”; (G) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per policy per year.”; and (ii) if applicable—“Excess payments do not apply to hospital admissions for accidents, of child dependants, or for day surgery”, with any of “accidents”, “child dependants” and “day surgery” that do not apply deleted, but with the order of those terms otherwise unchanged.
7	Extra cost per day (co‑payments) If there are no co‑payments—the statement “No co‑payments”. If there are co‑payments: (a) the statement “Every time you go to hospital you will have to pay”, followed by (with the bracketed text replaced with the appropriate figures): (i) either: (A) the statement “$[number] per day for overnight admissions”; or (B) the statements: · “$[number] per day for a shared room for overnight admissions”; and · if the policy covers accommodation in a private room—“$[number] per day for a private room for overnight admissions”; and (ii) as applicable, either: (A) the statement “$[number] for day surgery (no overnight stay)”; or (B) the statement “No co‑payment for day surgery (no overnight stay)”; and (iii) the statement “– up to $[number] per hospital stay”, placed, if applicable, and if the insurer so chooses, directly after the statements referred to in subparagraph (i); and (b) if applicable—the statement “The maximum co‑payment is $[number] per year” (with the bracketed text replaced with the appropriate figures).
8	Note on out of pocket costs/doctors’ fees The following statement: “Under this policy, you may have to pay out‑of‑pocket costs above what you get from Medicare or your private health insurer. Before you go to hospital, you should ask your doctors, hospital and health insurer about any out‑of‑pocket costs that may apply to you.”.
9	Note on information relating to contracts between hospitals and insurers The following statement: “The benefits paid for hospital treatment will depend on the type of cover you purchase and whether your fund has an agreement in place with the hospital in which you are treated. See ‘Agreement Hospitals’ on privatehealth.gov.au for which hospitals have arrangements with your insurer.”.
10	Other features 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. Example: Benefits for travel or accommodation, or aged‑based or other discounts. Note: This statement (if included) is in addition to the statement (if included) that is referred to in item 9 of Schedule 3.

Schedule 3—Additional information, and form of words, for private health information statement—general treatment

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.

1. Interpretation

In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.

2. Additional information and form of words—general treatment

For paragraph 12 (1) (c) of these Rules, the additional information and form of words are set out in the following table:

Additional information and form of words—general treatment
Item	Additional information and form of words
1	Information relating to policies that are available only with a hospital policy If the policy is available only with a policy that covers hospital treatment—whichever of the following is applicable: (a) if the policy may be purchased with any policy that covers hospital treatment offered by the insurer—the statement “must be purchased with a hospital policy”; (b) if there is a set range of policies that cover hospital treatment with which the policy may be combined—the statement “must be purchased with certain hospital policies”.
2	Preferred service provider arrangements Whichever of the following is appropriate: (a) if the private health insurer has preferred service provider arrangements—either: (i) a brief outline of the appropriate arrangements; or (ii) the following statement, with the bracketed text replaced with the appropriate text: “By using [insert name of insurer]’s ‘preferred providers’ you may have lower out of pocket costs on [insert services or use “many allied health”] treatments and have access to more ‘no gap’ treatments. A list of ‘preferred providers’ is available from [insert name of insurer].”; (b) otherwise—the following statement, with the bracketed text replaced with the appropriate text: “[Insert name of insurer] does not operate a preferred provider scheme.”.
3	Treatments covered by the policy A complete list of treatments that are covered by the policy, expressed in terms of the following: (a) general dental; (b) major dental; (c) endodontic; (d) orthodontic; (e) optical; (f) non PBS pharmaceuticals; (g) physiotherapy; (h) chiropractic; (i) podiatry; (j) psychology; (k) acupuncture; (l) remedial massage; (m) hearing aids; (n) blood glucose monitors; (o) for any treatment that cannot be classified as any of the above—the name of the treatment. Note: Insurers may cover additional treatments, for example, exercise physiology and occupational therapy.
4	Treatments not covered by the policy A list of treatments that are not covered by the policy, expressed in terms of the treatments listed in item 3.
5	Waiting period (months) For each treatment that is covered by the policy—whichever of the following is applicable, with the bracketed text replaced with the appropriate text: (a) if there is a waiting period—“[Number] months”; (b) if there is no waiting period for the treatment—“None”. Note: If an insured person has already served all applicable waiting periods, this item does not limit the information that a private health insurer may provide with regard to the individual’s policy.
6	Benefit limits (per 12 months) 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: (a) either: (i) any of the following statements: (A) “$[number] per person”; (B) “$[number] per treatment”; (C) “$[number] per policy”; or (ii) any combination of the statements set out in subparagraph (a) (i), linked by the words “up to”; (b) if there is a limit on claims per specified number of years—whichever of the following is applicable: (i) “[number] appliance(s) every [specified number] years”; (ii) “[number] service(s) every [specified number] years”; (c) in the case of combined limits: (i) for the treatment against which the combined limit is listed— “(combined limit for [list treatments listed in item 3 in relation to which limit is combined])”; and (ii) for the other treatments in relation to which the limit is combined—“(combined limit – see [treatment against which the combined limit is listed])”; (d) in the case of limits for individually grouped treatments—whichever of the following statements is applicable: (i) “$[number] per person (combined limit for [whichever of general dental, major dental, endodontic & orthodontic is applicable])”; (ii) “$[number] lifetime limit for [whichever of general dental, major dental, endodontic & orthodontic is applicable]”; (e) if a sub‑limit applies on any treatment—the statement “Sub‑limits apply” (in bold font); (f) if: (i) there is a limit on general dental; but (ii) there is no limit on preventative dental; the statement “(no limit on preventative dental)”; (g) if none of paragraphs (a) to (f) apply—a brief outline of the applicable limits. Note 1: If an insured person has used a portion of lifetime limits, this item does not limit the information that a private health insurer may provide with regard to the individual’s usage of lifetime limit amounts. Note 2: This item does not limit the information that a private health insurer may give to an insured person. For example, if limits apply to the policy other than those listed in this item, private health insurers may provide information about those other benefit limits to insured persons.
7	Examples of maximum benefits—general dental, major dental, endodontic and orthodontic For each treatment listed in paragraphs (a) to (d) of item 3 (whether or not covered by the policy): (a) the following treatments, broken down into the following dental item numbers: (i) for general dental: (A) “Periodic oral examination”—012; and (B) “Scale & clean”—114; and (C) “Fluoride treatment”—121; and (D) if covered under general dental—“Surgical tooth extraction”—322; (ii) for major dental treatment: (A) if covered under major dental—“Surgical tooth extraction”—322; and (B) “Full crown veneered”—615; (iii) for endodontic treatment—“Filling of one root canal”—417; (iv) for orthodontic treatment—“Braces for upper and lower teeth, including removal plus fitting of retainer”—881; and (b) if the dental item number is covered by the policy—an example of the maximum benefit that is payable when an insured person visits a practitioner who is not a preferred service provider, expressed using whichever of the following is applicable: (i) “$[number]”, with the bracketed text replaced by the appropriate figure, if: (A) the benefit is a dollar figure; or (B) the insurer pays a benefit that is a percentage of the charge up to a dollar limit that is specified for the item separately from an annual limit; (ii) if the only benefit limit for the item is an annual limit— “[number]% of charge”, with the bracketed text replaced by the appropriate figure; and (c) if the dental item number is not covered by the policy—the statement “n/a”. For paragraph (b) of this item: (d) if: (i) the dental item number is provided by orthodontists and general dentists; and (ii) different benefits are offered for orthodontists and general dentists; the lower of: (iii) the benefit for the orthodontist; and (iv) the benefit for the general dentist; must be used; and (e) if examples are given for initial and subsequent visits, examples must be for individual sessions.
8	Examples of maximum benefits—other 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: (a) if examples are given for initial and subsequent visits, examples must be for individual sessions; and (b) if: (i) optical treatment is covered; and (ii) benefits for frames and lenses are paid separately; the example must be expressed as the sum of the benefit for each component. Note 1: If treatments are listed for the purposes of paragraph (o) of item 3, examples of maximum benefits for those treatments must be given. Note 2: This item does not limit the information that a private health insurer may give to an insured person. Note 3: The insurer may provide information about the benefits that apply if treatment is through a preferred provider.
9	Other features 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. Example: Benefits for travel or accommodation, or discounts. Note: This statement (if included) is in addition to the statement (if included) that is referred to in item 10 of Schedule 2.

Schedule 4—Product tiers and clinical categories

Note: See rule 4 and Part 2B.

1. Product tiers and clinical categories

For the definition of gold policy, silver policy, bronze policy and basic 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.

Clinical category	Basic	Bronze	Silver	Gold
Rehabilitation	üR	üR	üR	ü
Hospital psychiatric services	üR	üR	üR	ü
Palliative care	üR	üR	üR	ü
Brain and nervous system	RCP	ü	ü	ü
Eye (not cataracts)	RCP	ü	ü	ü
Ear, nose and throat	RCP	ü	ü	ü
Tonsils, adenoids and grommets	RCP	ü	ü	ü
Bone, joint and muscle	RCP	ü	ü	ü
Joint reconstructions	RCP	ü	ü	ü
Kidney and bladder	RCP	ü	ü	ü
Male reproductive system	RCP	ü	ü	ü
Digestive system	RCP	ü	ü	ü
Hernia and appendix	RCP	ü	ü	ü
Gastrointestinal endoscopy	RCP	ü	ü	ü
Gynaecology	RCP	ü	ü	ü
Miscarriage and termination of pregnancy	RCP	ü	ü	ü
Chemotherapy, radiotherapy and immunotherapy for cancer	RCP	ü	ü	ü
Pain management	RCP	ü	ü	ü
Skin	RCP	ü	ü	ü
Breast surgery (medically necessary)	RCP	ü	ü	ü
Diabetes management (excluding insulin pumps)	RCP	ü	ü	ü
Heart and vascular system	RCP	ü	ü
Lung and chest	RCP	ü	ü
Blood	RCP	ü	ü
Back, neck and spine	RCP	ü	ü
Plastic and reconstructive surgery (medically necessary)	RCP	ü	ü
Dental surgery	RCP	ü	ü
Podiatric surgery (provided by a registered podiatric surgeon)	RCP	ü	ü
Implantation of hearing devices	RCP	ü	ü
Cataracts	RCP	ü
Joint replacements	RCP	ü
Dialysis for chronic kidney failure	RCP	ü
Pregnancy and birth	RCP	ü
Assisted reproductive services	RCP	ü
Weight loss surgery	RCP	ü
Insulin pumps	RCP	ü
Pain management with device	RCP	ü
Sleep studies	RCP	ü

ü	Indicates the clinical category is a minimum requirement of the product tier. The clinical category must be covered on an unrestricted basis.
üR	Indicates the clinical category is a minimum requirement of the product tier. The clinical category may be offered on a restricted cover basis in Basic, Bronze and Silver product tiers only.
RCP	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.

Lung and chest	Hospital treatment for the investigation and treatment of the lungs, lung‑related conditions, mediastinum and chest. For example: lung cancer, respiratory disorders such as asthma, pneumonia, and treatment of trauma to the chest. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.	Treatments involving the provision of the following MBS items: 30090 30696 30710 34133 34136 34139 38415 38418 38421 38424 38427 38430 38436 38438 38440 38441 38446 38448 38453 38455 38460 38462 38464 38466 38468 38469 38640 38643 38647 38656 38800 38803 38806 38809 38812 43861 43909 43912
Male reproductive system	Hospital treatment for the investigation and treatment of the male reproductive system including the prostate. For example: male sterilisation, circumcision and prostate cancer. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.	Treatments involving the provision of the following MBS items: 30628 30631 30635 30641 30642 30643 30644 30649 30654 30658 30663 30666 37200 37201 37202 37203 37206 37207 37208 37209 37210 37211 37212 37215 37217 37218 37219 37220 37221 37223 37224 37227 37230 37233 37245 37393 37396 37402 37405 37408 37411 37415 37417 37418 37420 37423 37426 37429 37432 37435 37438 37601 37604 37613 37616 37619 37623 37803 37804 37806 37807 37809 37810 37812 37813 37815 37816 37818 37819 37821 37822 37824 37825 37827 37828 37830 37831 37833 37834 37836 37839
Miscarriage and termination of pregnancy	Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.	Treatments involving the provision of the following MBS items: 16530 16531 35640 35643 35674 35677 35678
Pain management	Hospital treatment for pain management that does not require the insertion or surgical management of a device. For example: treatment of nerve pain and chest pain due to cancer by injection of a nerve block. Pain management using a device (for example an infusion pump or neurostimulator) is listed separately under Pain management with device.	Treatments involving the provision of the following MBS items: 39100 39106 39109 39112 39115 39118 39121 39124 39140 39323 45939
Pain management with device	Hospital treatment for the implantation, replacement or other surgical management of a device required for the treatment of pain. For example: treatment of nerve pain, back pain, and pain caused by coronary heart disease with a device (for example an infusion pump or neurostimulator). Treatment of pain that does not require a device is listed separately under Pain management.	Treatments involving the provision of the following MBS items: 14218 39125 39126 39127 39128 39130 39131 39133 39134 39135 39136 39137 39138 39139
Plastic and reconstructive surgery (medically necessary)	Hospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether acquired as a result of illness or accident, or congenital. For example: burns requiring a graft, cleft palate, club foot and angioma. Plastic surgery that is medically necessary relating to the treatment of a skin‑related condition is listed separately under Skin. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.	Treatments involving the provision of the following MBS items: 30003 30006 30010 30014 30017 30020 30176 38457 38458 42860 42863 42866 42872 43882 45000 45003 45006 45009 45012 45015 45018 45019 45021 45024 45025 45026 45027 45030 45033 45035 45036 45039 45042 45045 45048 45051 45054 45200 45201 45202 45203 45206 45207 45209 45212 45215 45218 45221 45224 45227 45230 45233 45236 45239 45240 45400 45403 45406 45409 45412 45415 45418 45439 45442 45445 45448 45451 45460 45461 45462 45464 45465 45466 45468 45469 45471 45472 45474 45475 45477 45478 45480 45481 45483 45484 45485 45486 45487 45488 45489 45490 45491 45492 45493 45494 45496 45497 45498 45499 45500 45501 45502 45503 45504 45505 45506 45512 45515 45518 45519 45560 45561 45562 45563 45564 45565 45566 45568 45569 45570 45572 45575 45578 45581 45584 45585 45587 45588 45590 45593 45596 45597 45599 45602 45608 45611 45614 45617 45620 45623 45624 45625 45626 45627 45629 45632 45635 45641 45644 45647 45650 45652 45653 45656 45659 45660 45661 45662 45665 45668 45669 45671 45674 45675 45676 45677 45680 45683 45686 45689 45692 45695 45698 45701 45704 45707 45710 45713 45714 45716 45720 45723 45726 45729 45731 45732 45735 45738 45741 45744 45747 45752 45753 45754 45755 45758 45761 45767 45770 45773 45776 45779 45782 45785 45791 45794 45797 45799 45801 45803 45805 45807 45809 45811 45813 45815 45817 45819 45821 45823 45825 45827 45829 45831 45833 45835 45837 45839 45841 45843 45845 45847 45849 45853 45865 45877 45879 45882 45885 45888 45891 45894 45897 45900 45975 45984 45990 50411 50414 50417 50420 50423 51904 51906 52010 52036 52045 52048 52106 52108 52111 52117 52120 52122 52123 52300 52303 52306 52309 52312 52315 52318 52319 52321 52324 52327 52330 52333 52336 52337 52339 52342 52345 52348 52351 52354 52357 52360 52363 52366 52369 52372 52375 52378 52379 52380 52382 52420 52424 52430 52440 52442 52444 52446 52450 52452 52456 52458 52460 52480 52482 52484 52600 52603 52606 52609 52612 52615 52618 52621 52624 52626 52627 52630 52633 52636 53242 53453 53455 75024 75027
Podiatric surgery (provided by a registered podiatric surgeon)	Hospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon, but limited to cover for: · accommodation; and · the cost of a prosthesis as listed in the prostheses list set out in the Private Health Insurance (Prostheses) Rules, as in force from time to time. Note: Insurers are not required to pay for any other benefits for hospital treatment for this clinical category but may choose to do so.
Pregnancy and birth	Hospital treatment for investigation and treatment of conditions associated with pregnancy and child birth. Treatment for the baby is covered under the clinical category relevant to their condition. For example, respiratory conditions are covered under Lung and chest. Female reproductive conditions are listed separately under Gynaecology. Fertility treatments are listed separately under Assisted reproductive services. Miscarriage and termination of pregnancy is listed separately under Miscarriage and termination of pregnancy.	Treatments involving the provision of the following MBS items: 16400 16401 16404 16406 16407 16408 16500 16501 16502 16505 16508 16509 16511 16512 16514 16515 16518 16519 16520 16522 16527 16528 16533 16534 16564 16567 16570 16571 16573 16590 16591 16600 16603 16606 16609 16612 16615 16618 16621 16624 16627 82100 82105 82110 82115 82120 82125
Skin	Hospital treatment for the investigation and treatment of skin, skin‑related conditions and nails. The removal of foreign bodies is also included. Plastic surgery that is medically necessary and relating to the treatment of a skin‑related condition is also included. For example: melanoma, minor wound repair and abscesses. Removal of excess skin due to weight loss is listed separately under Weight loss surgery. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.	Treatments involving the provision of the following MBS items: 12012 12017 12021 12022 12024 14050 14100 14106 14115 14118 14124 18362 30023 30024 30026 30029 30032 30035 30038 30042 30045 30049 30052 30055 30064 30071 30099 30180 30183 30187 30189 30190 30191 30192 30196 30202 30207 30210 30216 30219 30223 30676 30679 31000 31001 31002 31003 31004 31005 31206 31211 31216 31220 31221 31225 31245 31250 31340 31345 31356 31357 31358 31359 31360 31361 31362 31363 31364 31365 31366 31367 31368 31369 31370 31371 31372 31373 31374 31375 31376 44136 46486 46489 46513 46516 46528 46531 46534 47904 47906 47912 47915 47916 47918 52000 52003 52006 52009 52039 52042 52051 52054
Sleep studies	Hospital treatment for the investigation of sleep patterns and anomalies. For example: sleep apnoea and snoring.	Treatments involving the provision of the following MBS items: 12203 12204 12205 12207 12208 12210 12213 12215 12217 12250 12254 12258 12261 12265 12268 12272
Tonsils, adenoids and grommets	Hospital treatment of the tonsils, adenoids and insertion or removal of grommets.	Treatments involving the provision of the following MBS items: 41632 41789 41793 41797 41801
Weight loss surgery	Hospital treatment for surgery that is designed to reduce a person’s weight, remove excess skin due to weight loss and reversal of a bariatric procedure. For example: gastric banding, gastric bypass, sleeve gastrectomy.	Treatments involving the provision of the following MBS items: 30165 30168 30171 30172 30177 30179 31569 31572 31575 31578 31581 31584 31587 31590

Schedule 6—Common treatments list

Note: Rule 11F is the principal provision that deals with what hospital treatments must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 5 and Schedule 7.

1 Common treatments list

For sub‑subparagraph 11F (5) (b) (ii) (A), the common treatments list is set out in the following table:

Common treatments list
3 4 23 24 36 37 44 47 52 53 54 57 58 59 60 65 104 105 106 107 108 109 110 111 115 116 117 119 120 122 128 131 132 133 135 137 141 143 145 147 160 161 162 163 164 173 188 193 195 197 199 214 215 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 235 236 237 238 239 240 243 244 253 255 257 260 262 264 266 269 271 272 276 277 279 281 282 285 287 291 293 296 299 300 302 304 306 308 310 312 314 316 318 319 330 332 334 336 338 353 355 356 357 358 359 361 385 386 387 388 410 411 412 413 414 415 416 417 501 503 507 511 515 519 520 530 532 534 536 585 588 591 594 599 600 701 703 705 707 715 721 723 729 731 732 733 735 737 739 743 747 750 758 820 822 823 825 826 828 830 832 834 835 837 838 871 872 880 900 903 2100 2497 2501 2503 2504 2506 2507 2509 2517 2518 2521 2522 2525 2526 2546 2547 2552 2553 2558 2559 2598 2600 2603 2606 2610 2613 2616 2620 2622 2624 2631 2633 2635 2664 2666 2668 2673 2675 2677 2801 2806 2814 2824 2832 2840 2946 2949 2954 2958 2972 2974 2978 2984 2988 2992 2996 3000 4001 5000 5003 5010 5020 5023 5028 5040 5043 5049 5060 5063 5067 5200 5203 5207 5208 5220 5223 5227 5228 5260 5263 5265 5267 6051 6052 6057 6058 6059 6060 6062 6063 6064 6065 6067 6068 6071 6072 6074 6075 10905 10907 10910 10911 10912 10913 10914 10915 10916 10918 10921 10922 10923 10924 10925 10926 10927 10928 10929 10930 10945 10946 10947 10948 11830 11833 12000 12001 12002 12003 12004 12005 13015 13020 13025 13030 13757 13870 13873 14200 14201 14202 14209 17615 17620 17625 17640 17645 17650 17655 18216 18219 18282 18284 18286 18288 18290 18292 18294 18296 18298 30058 30061 30068 30072 30075 30078 30081 30084 30087 30093 30094 30096 30097 30224 30225 30323 30329 30330 30332 30335 30336 30388 30390 30391 30394 30403 30405 30611 31350 31355 34538 36502 37607 37610 38456 39000 43915 44130 46324 46325 46519 46525 50127 51700 51703 52012 52015 52018 52144 75001 75004 75150 75153 82130 82135 82140 82205 82210 82215

Common treatments list

3 4 23 24 36 37 44 47 52 53 54 57 58 59 60 65 104 105 106 107 108 109 110 111 115 116 117 119 120 122 128 131 132 133 135 137 141 143 145 147 160 161 162 163 164 173 188 193 195 197 199 214 215 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 235 236 237 238 239 240 243 244 253 255 257 260 262 264 266 269 271 272 276 277 279 281 282 285 287 291 293 296 299 300 302 304 306 308 310 312 314 316 318 319 330 332 334 336 338 353 355 356 357 358 359 361 385 386 387 388 410 411 412 413 414 415 416 417 501 503 507 511 515 519 520 530 532 534 536 585 588 591 594 599 600 701 703 705 707 715 721 723 729 731 732 733 735 737 739 743 747 750 758 820 822 823 825 826 828 830 832 834 835 837 838 871 872 880 900 903 2100 2497 2501 2503 2504 2506 2507 2509 2517 2518 2521 2522 2525 2526 2546 2547 2552 2553 2558 2559 2598 2600 2603 2606 2610 2613 2616 2620 2622 2624 2631 2633 2635 2664 2666 2668 2673 2675 2677 2801 2806 2814 2824 2832 2840 2946 2949 2954 2958 2972 2974 2978 2984 2988 2992 2996 3000 4001 5000 5003 5010 5020 5023 5028 5040 5043 5049 5060 5063 5067 5200 5203 5207 5208 5220 5223 5227 5228 5260 5263 5265 5267 6051 6052 6057 6058 6059 6060 6062 6063 6064 6065 6067 6068 6071 6072 6074 6075 10905 10907 10910 10911 10912 10913 10914 10915 10916 10918 10921 10922 10923 10924 10925 10926 10927 10928 10929 10930 10945 10946 10947 10948 11830 11833 12000 12001 12002 12003 12004 12005 13015 13020 13025 13030 13757 13870 13873 14200 14201 14202 14209 17615 17620 17625 17640 17645 17650 17655 18216 18219 18282 18284 18286 18288 18290 18292 18294 18296 18298 30058 30061 30068 30072 30075 30078 30081 30084 30087 30093 30094 30096 30097 30224 30225 30323 30329 30330 30332 30335 30336 30388 30390 30391 30394 30403 30405 30611 31350 31355 34538 36502 37607 37610 38456 39000 43915 44130 46324 46325 46519 46525 50127 51700 51703 52012 52015 52018 52144 75001 75004 75150 75153 82130 82135 82140 82205 82210 82215

Schedule 7—Support treatments list

Note: Rule 11F is the principal provision that deals with what hospital treatments must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 5 and Schedule 6.

1 Support treatments list

For sub‑subparagraph 11F (5) (b) (ii) (B), the support treatments list is:

(a) the MBS items set out in the following table; and

(b) any MBS item that is not listed in the table or in Schedule 5 or 6 but is, at the time of the relevant treatment, listed in the diagnostic imaging services table or the pathology services table made under section 4AA or 4A of the Health Insurance Act 1973, including by reason of a determination under section 3C of that Act.

Table of MBS items
6080 6081 10801 10802 10803 10804 10805 10806 10807 10808 10809 10816 10931 10932 10933 10940 10941 10942 10943 10944 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 11000 11003 11004 11005 11006 11009 11012 11015 11018 11021 11024 11027 11200 11204 11205 11210 11211 11215 11218 11219 11220 11221 11224 11235 11237 11240 11241 11242 11243 11244 11303 11304 11306 11309 11312 11315 11318 11324 11327 11330 11332 11333 11336 11339 11503 11505 11506 11507 11508 11512 11600 11602 11604 11605 11610 11611 11612 11614 11615 11627 11700 11701 11702 11708 11709 11710 11711 11712 11713 11715 11718 11719 11720 11721 11722 11724 11725 11726 11727 11728 12200 12201 12306 12312 12315 12320 12321 12322 12325 12326 12500 12503 12506 12509 12512 12515 12518 12521 12530 12533 13300 13303 13306 13309 13312 13318 13319 13703 13706 13709 13750 13755 13815 13818 13830 13839 13842 13847 13848 13851 13854 13857 13876 13881 13882 13885 13888 17610 17680 17690 18213 18222 18225 18226 18227 18228 18230 18232 18233 18234 18236 18238 18240 18242 18244 18248 18250 18252 18254 18256 18258 18260 18262 18264 18266 18268 18270 18272 18274 18276 18278 18280 18297 20100 20102 20104 20120 20124 20140 20142 20143 20144 20145 20146 20147 20148 20160 20162 20164 20170 20172 20174 20176 20190 20192 20210 20212 20214 20216 20220 20222 20225 20230 20300 20305 20320 20321 20330 20350 20352 20355 20400 20401 20402 20403 20404 20405 20406 20410 20420 20440 20450 20452 20470 20472 20474 20475 20500 20520 20522 20524 20526 20528 20540 20542 20546 20548 20560 20600 20604 20620 20622 20630 20632 20634 20670 20680 20690 20700 20702 20703 20704 20706 20730 20740 20745 20750 20752 20754 20756 20770 20790 20791 20792 20793 20794 20798 20799 20800 20802 20803 20804 20806 20810 20815 20820 20830 20832 20840 20841 20842 20844 20845 20846 20847 20848 20850 20855 20860 20862 20863 20864 20866 20867 20868 20880 20882 20884 20886 20900 20902 20904 20905 20906 20910 20911 20912 20914 20916 20920 20924 20926 20928 20930 20932 20934 20936 20938 20940 20942 20943 20944 20946 20948 20950 20952 20954 20956 20958 20960 21100 21110 21112 21114 21116 21120 21130 21140 21150 21155 21160 21170 21195 21199 21200 21202 21210 21212 21214 21216 21220 21230 21232 21234 21260 21270 21272 21274 21275 21280 21300 21321 21340 21360 21380 21382 21390 21392 21400 21402 21403 21404 21420 21430 21432 21440 21445 21460 21461 21462 21464 21472 21474 21480 21482 21484 21486 21490 21500 21502 21520 21522 21530 21532 21535 21600 21610 21620 21622 21630 21632 21634 21636 21638 21650 21652 21654 21656 21670 21680 21682 21685 21700 21710 21712 21714 21716 21730 21732 21740 21756 21760 21770 21772 21780 21785 21790 21800 21810 21820 21830 21832 21834 21840 21842 21850 21860 21865 21870 21872 21878 21879 21880 21881 21882 21883 21884 21885 21886 21887 21900 21906 21908 21910 21912 21914 21915 21916 21918 21922 21925 21926 21930 21935 21936 21939 21941 21942 21943 21945 21949 21952 21955 21959 21962 21965 21969 21970 21973 21976 21980 21990 21992 21997 22002 22007 22008 22012 22014 22015 22020 22025 22031 22036 22041 22042 22051 22055 22060 22065 22075 22900 22905 23010 23025 23035 23045 23055 23065 23075 23085 23091 23101 23111 23112 23113 23114 23115 23116 23117 23118 23119 23121 23170 23180 23190 23200 23210 23220 23230 23240 23250 23260 23270 23280 23290 23300 23310 23320 23330 23340 23350 23360 23370 23380 23390 23400 23410 23420 23430 23440 23450 23460 23470 23480 23490 23500 23510 23520 23530 23540 23550 23560 23570 23580 23590 23600 23610 23620 23630 23640 23650 23660 23670 23680 23690 23700 23710 23720 23730 23740 23750 23760 23770 23780 23790 23800 23810 23820 23830 23840 23850 23860 23870 23880 23890 23900 23910 23920 23930 23940 23950 23960 23970 23980 23990 24100 24101 24102 24103 24104 24105 24106 24107 24108 24109 24110 24111 24112 24113 24114 24115 24116 24117 24118 24119 24120 24121 24122 24123 24124 24125 24126 24127 24128 24129 24130 24131 24132 24133 24134 24135 24136 25000 25005 25010 25015 25020 25025 25030 25050 25200 25205 30001 51300 51303 51306 51309 51312 51315 51318 51800 51803 53700 53702 53704 53706 75009 75012 75015 75018 75021 75023 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 10984 10987 10988 10989 10990 10991 10992 10997 81000 81005 81010

Table of MBS items

6080 6081 10801 10802 10803 10804 10805 10806 10807 10808 10809 10816 10931 10932 10933 10940 10941 10942 10943 10944 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 11000 11003 11004 11005 11006 11009 11012 11015 11018 11021 11024 11027 11200 11204 11205 11210 11211 11215 11218 11219 11220 11221 11224 11235 11237 11240 11241 11242 11243 11244 11303 11304 11306 11309 11312 11315 11318 11324 11327 11330 11332 11333 11336 11339 11503 11505 11506 11507 11508 11512 11600 11602 11604 11605 11610 11611 11612 11614 11615 11627 11700 11701 11702 11708 11709 11710 11711 11712 11713 11715 11718 11719 11720 11721 11722 11724 11725 11726 11727 11728 12200 12201 12306 12312 12315 12320 12321 12322 12325 12326 12500 12503 12506 12509 12512 12515 12518 12521 12530 12533 13300 13303 13306 13309 13312 13318 13319 13703 13706 13709 13750 13755 13815 13818 13830 13839 13842 13847 13848 13851 13854 13857 13876 13881 13882 13885 13888 17610 17680 17690 18213 18222 18225 18226 18227 18228 18230 18232 18233 18234 18236 18238 18240 18242 18244 18248 18250 18252 18254 18256 18258 18260 18262 18264 18266 18268 18270 18272 18274 18276 18278 18280 18297 20100 20102 20104 20120 20124 20140 20142 20143 20144 20145 20146 20147 20148 20160 20162 20164 20170 20172 20174 20176 20190 20192 20210 20212 20214 20216 20220 20222 20225 20230 20300 20305 20320 20321 20330 20350 20352 20355 20400 20401 20402 20403 20404 20405 20406 20410 20420 20440 20450 20452 20470 20472 20474 20475 20500 20520 20522 20524 20526 20528 20540 20542 20546 20548 20560 20600 20604 20620 20622 20630 20632 20634 20670 20680 20690 20700 20702 20703 20704 20706 20730 20740 20745 20750 20752 20754 20756 20770 20790 20791 20792 20793 20794 20798 20799 20800 20802 20803 20804 20806 20810 20815 20820 20830 20832 20840 20841 20842 20844 20845 20846 20847 20848 20850 20855 20860 20862 20863 20864 20866 20867 20868 20880 20882 20884 20886 20900 20902 20904 20905 20906 20910 20911 20912 20914 20916 20920 20924 20926 20928 20930 20932 20934 20936 20938 20940 20942 20943 20944 20946 20948 20950 20952 20954 20956 20958 20960 21100 21110 21112 21114 21116 21120 21130 21140 21150 21155 21160 21170 21195 21199 21200 21202 21210 21212 21214 21216 21220 21230 21232 21234 21260 21270 21272 21274 21275 21280 21300 21321 21340 21360 21380 21382 21390 21392 21400 21402 21403 21404 21420 21430 21432 21440 21445 21460 21461 21462 21464 21472 21474 21480 21482 21484 21486 21490 21500 21502 21520 21522 21530 21532 21535 21600 21610 21620 21622 21630 21632 21634 21636 21638 21650 21652 21654 21656 21670 21680 21682 21685 21700 21710 21712 21714 21716 21730 21732 21740 21756 21760 21770 21772 21780 21785 21790 21800 21810 21820 21830 21832 21834 21840 21842 21850 21860 21865 21870 21872 21878 21879 21880 21881 21882 21883 21884 21885 21886 21887 21900 21906 21908 21910 21912 21914 21915 21916 21918 21922 21925 21926 21930 21935 21936 21939 21941 21942 21943 21945 21949 21952 21955 21959 21962 21965 21969 21970 21973 21976 21980 21990 21992 21997 22002 22007 22008 22012 22014 22015 22020 22025 22031 22036 22041 22042 22051 22055 22060 22065 22075 22900 22905 23010 23025 23035 23045 23055 23065 23075 23085 23091 23101 23111 23112 23113 23114 23115 23116 23117 23118 23119 23121 23170 23180 23190 23200 23210 23220 23230 23240 23250 23260 23270 23280 23290 23300 23310 23320 23330 23340 23350 23360 23370 23380 23390 23400 23410 23420 23430 23440 23450 23460 23470 23480 23490 23500 23510 23520 23530 23540 23550 23560 23570 23580 23590 23600 23610 23620 23630 23640 23650 23660 23670 23680 23690 23700 23710 23720 23730 23740 23750 23760 23770 23780 23790 23800 23810 23820 23830 23840 23850 23860 23870 23880 23890 23900 23910 23920 23930 23940 23950 23960 23970 23980 23990 24100 24101 24102 24103 24104 24105 24106 24107 24108 24109 24110 24111 24112 24113 24114 24115 24116 24117 24118 24119 24120 24121 24122 24123 24124 24125 24126 24127 24128 24129 24130 24131 24132 24133 24134 24135 24136 25000 25005 25010 25015 25020 25025 25030 25050 25200 25205 30001 51300 51303 51306 51309 51312 51315 51318 51800 51803 53700 53702 53704 53706 75009 75012 75015 75018 75021 75023 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 10984 10987 10988 10989 10990 10991 10992 10997 81000 81005 81010

Endnotes

Endnote 1—About the endnotes

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

Abbreviation key—Endnote 2

The abbreviation key sets out abbreviations that may be used in the endnotes.

Legislation history and amendment history—Endnotes 3 and 4

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.

Editorial changes

The Legislation Act 2003 authorises First Parliamentary Counsel to make editorial and presentational changes to a compiled law in preparing a compilation of the law for registration. The changes must not change the effect of the law. Editorial changes take effect from the compilation registration date.

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.

Misdescribed amendments

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.

Endnote 2—Abbreviation key

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 = Legislation Act 2003	Sch = Schedule(s)
LIA = Legislative Instruments Act 2003	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	underlining = whole or part not
No. = Number(s)	commenced or to be commenced

Endnote 3—Legislation history

Name	Registration	Commencement	Application, saving and transitional provisions
Private Health Insurance (Complying Product) Rules 2015	30 June 2015 (F2015L01021)	1 July 2015 (r 2)
Private Health Insurance (Complying Product) Amendment Rules 2015 (No.3)	17 September 2015 (F2015L01449)	20 September 2015	—
Private Health Insurance (Complying Product) Amendment Rules 2016 (No.1)	18 March 2016 (F2016L00353)	20 March 2016	—
Private Health Insurance (Complying Product) Amendment Rules 2016 (No.2)	2 June 2016 (F2016L00985)	2 June 2016	—
Private Health Insurance (Complying Product) Amendment Rules 2016 (No.3)	29 June 2016 (F2016L01102)	1 July 2016	—
Private Health Insurance (Complying Product) Amendment Rules 2016 (No.4)	16 September 2016 (F2016L01447)	20 September 2016	—
Private Health Insurance (Complying Product) Amendment Rules 2016 (No.5)	20 September 2016 (F2016L01464)	20 September 2016	—
Private Health Insurance (Complying Product) Amendment Rules 2016 (No.6)	22 November 2016 (F2016L01790)	23 November 2016	—
Private Health Insurance (Complying Product) Amendment Rules 2017 (No.1)	17 March 2017 (F2017L00243)	20 March 2017	—
Private Health Insurance (Complying Product) Amendment Rules 2017 (No.2)	28 June 2017 (F2017L00776)	1 July 2017	—
Private Health Insurance (Complying Product) Amendment Rules 2017 (No.3)	28 June 2017 (F2017L01219)	20 September 2017	—
Private Health Insurance (Complying Product) Amendment Rules 2018 (No.1)	19 March 2018 (F2018L00314)	20 March 2018	—
Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018	26 March 2018 (F2018L00393)	1 April 2018	—
Private Health Insurance (Complying Product) (ACT Nursing Home Type Patient) Amendment Rules 2018	28 June 2018 (F2018L00918)	1 July 2018 (s 2)	—
Private Health Insurance (Complying Product) Amendment (Terminating Products) Rules 2018	17 Sept 2018 (F2018L01304)	Sch 1: 22 Sept 2018 (s 2(1) item 2)	—
Private Health Insurance (Complying Product) Amendment Rules 2018 (No. 5)	19 Sept 2018 (F2018L01316)	20 Sept 2018 (s 2)	—
Private Health Insurance (Reforms) Amendment Rules 2018	11 Oct 2018 (F2018L01414)	Sch 1, Sch 2 (items 6–15) and Sch 3 (items 1–4): 1 Apr 2019 (s 2(1) items 2, 4, 6) Sch 2 (items 1–5): 1 Jan 2019 (s 2(1) item 3) Sch 2 (items 16–20) and Sch 3 (items 5–9): 1 Apr 2020 (s 2(1) items 5, 7) Sch 7 (items 1–3): 12 Oct 2018 (s 2(1) item 11)	—
as amended by
Private Health Insurance (Reforms) Amendment Rules (No. 2) 2018	30 Oct 2018 (F2018L01504)	1 Nov 2018 (s 2(1))	—
Private Health Insurance (Reforms) Amendment Rules (No. 3) 2018	19 Dec 2018 (F2018L01795)	Sch 1: 1 Jan 2019 (s 2(1) item 2)	—
Private Health Insurance (Complying Product) Amendment Rules (No. 2) 2019	20 Mar 2019 (F2019L00328)	Sch 2: 1 July 2019 (s 2(1) item 3) Remainder: 20 Mar 2019 (s 2(1) items 1, 2)	—
as amended by
Private Health Insurance Legislation Amendment Rules (No. 1) 2019	29 Apr 2019 (F2019L00639)	Sch 4: 30 Apr 2019 (s 2(1) item 5)	—
Private Health Insurance (Complying Product) Amendment Rules (No. 1 ) 2019	29 Mar 2019 (F2019L00464)	30 Mar 2019 (s 2(1) item 1)	—
Private Health Insurance (Complying Product) Amendment Rules (No. 3) 2019	29 Mar 2019 (F2019L00481)	1 Apr 2019 (s 2(1) item 2)	—
Private Health Insurance Legislation Amendment Rules (No. 1) 2019	29 Apr 2019 (F2019L00639)	Sch 3: 1 May 2019 (s 2(1) item 4)	—
Private Health Insurance Legislation Amendment (No. 2) Rules 2019	28 June 2019 (F2019L00925)	Sch 2: 1 July 2019 (s 2(1) item 1)	—
Private Health Insurance Legislation Amendment (No. 3) Rules 2019	19 Sept 2019 (F2019L01221)	Sch 2: 20 Sept 2019 (s 2(1) item 1)	—
Private Health Insurance Legislation Amendment Rules (No. 4) 2019	30 Oct 2019 (F2019L01384)	Sch 2: 1 Nov 2019 (s 2(1) item 1)	—

Endnote 4—Amendment history

Provision affected	How affected
Part 1
r 2.............................................	rep LA s 48D
r 3.............................................	rep LA s 48C
r 4.............................................	am F2018L00393; F2018L01414; F2019L00481
Part 2
r 5A..........................................	am F2018L00393
r 6.............................................	am F2018L01414
r 8.............................................	am F2018L01414
r 8A..........................................	am F2015L01449; F2016L00353; F2016L00985; F2016L01447; F2016L01464; F2017L00243; F2017L00776; F2017L01219; F2018L00314; F2018L00918; F2018L01316
ed C13
am F2019L00328
ed C17
am F2019L00328; F2019L00925
ed C21
am F2019L01221
ed C22
r 9AA........................................	ad F2018L01304
am F2018L01414
r 9A..........................................	ad F2018L00393
r 9B...........................................	ad F2018L00393
Part 2A
Part 2A......................................	ad F2018L01414
r 11A........................................	ad F2018L01414
r 11B.........................................	ad F2018L01414
r 11C.........................................	ad F2018L01414
r 11D........................................	ad F2018L01414
Part 2B
Part 2B......................................	ad F2018L01414
r 11E.........................................	ad F2018L01414
am F2018L01414
r 11F.........................................	ad F2018L01414
am F2018L01414
r 11G........................................	ad F2018L01414
am F2018L01414
r 11H........................................	ad F2018L01414
am F2018L01414
r 11J..........................................	ad F2018L01414
Part 3
Part 3 heading...........................	am F2018L01414
Part 3........................................	rs F2018L01414
am F2018L01414
ed C19
r 12...........................................	rs F2018L01414
am F2018L01414
r 13...........................................	rs F2018L01414
am F2018L01414
r 14...........................................	rs F2018L01414
am F2019L01384
r 15...........................................	rep F2018L01414
ad F2018L01414 (as am by F2018L01795)
r 16...........................................	rep F2018L01414
ad F2018L01414
Part 4
r 18...........................................	am F2019L00464
Part 5
r 19...........................................	ad F2018L00393
r 20...........................................	ad F2018L01414
am F2018L01414
rep F2018L01414
r 21...........................................	ad F2018L01414
rep F2018L01414
Schedule 1
Schedule 1 heading...................	am F2018L01414
Schedule 1................................	rs F2018L01414
c 1.............................................	ad F2018L01414
c 2.............................................	ad F2018L01414
am F2018L01414 (Sch 2 item 17)
Schedule 2
Schedule 2 heading...................	am F2018L01414
Schedule 2................................	rs F2018L01414
c 1.............................................	ad F2018L01414
c 2.............................................	ad F2018L01414
am F2018L01414 (Sch 2 items 18–20)
Schedule 3
Schedule 3 heading...................	am F2018L01414
Schedule 3................................	rs F2018L01414
c 1.............................................	ad F2018L01414
c 2.............................................	ad F2018L01414
Schedule 4
Schedule 4................................	rep F2018L01414
ad F2018L01414
c 1.............................................	ad F2018L01414
Schedule 5
Schedule 5................................	ad F2018L01414
c 1.............................................	ad F2018L01414
c 2.............................................	ad F2018L01414 (as am by F2018L01504)
am F2019L00639; F2019L00925; F2019L01384
Schedule 6
Schedule 6................................	ad F2018L01414
c 1.............................................	ad F2018L01414 (as am by F2018L01504)
am F2019L00481; F2019L00925; F2019L01384
Schedule 7
Schedule 7................................	ad F2018L01414
rs F2019L00481
c 1.............................................	ad F2018L01414 (as am by F2018L01504; F2018L01795)
rs F2019L00481
am F2019L00925; F2019L01384