EXPLANATORY STATEMENT

Issued by Authority of the Minister for Health and Ageing

National Health Act 1953

Determination under Schedule 1, paragraph (1)(bj)

(HIB 03/2007)

Schedule 1, paragraph (1)(bj) of the National Health Act 1953 (the Act) provides that the Minister may determine the minimum levels of benefits payable by a registered health benefits organization (RHBO) for hospital treatment provided to contributors, other than in emergencies, in a hospital or day hospital facility with which the RHBO does not have a hospital purchaser-provider agreement (HPPA) which covers such treatment. These benefits are known in the industry as “default benefits”. 

This determination is comprised of seven schedules setting out the minimum levels of benefit which are payable for a range of hospital treatment.  Namely, benefits for overnight accommodation (Schedules 1 and 2), same day accommodation (Schedule 3), nursing home type patients (Schedule 4), second tier default benefits (Schedule 5), care plans and case conferencing (Schedule 6) and outreach services (Schedule 7).

This determination revokes and remakes HIB 02/2007 to incorporate amendments to Schedules, 2, 3, 4, and 5.

Amendments to Schedule 2

Schedule 2 of this determination requires a RHBO to pay a default benefit for overnight accommodation for patients in shared ward accommodation in recognised hospitals in the Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia and Western Australia. 

This determination amends the overnight rate for recognised hospitals in the Northern Territory from $261 per night to $269 per night.

Amendments to Schedule 3

Schedule 3 of this determination requires a RHBO to pay a default benefit for same day accommodation in all hospital and day hospital facilities in all States and Territories. 

This determination amends the benefit amounts under the band levels for patients of a recognised hospital whose hospital stay does not include an overnight stay within the Northern Territory:

   From   To

Band 1  $189   $195

Band 2  $216   $222

Band 3  $238   $258

Band 4  $261   $269

Amendments to Schedule 4

Schedule 4 of this determination requires a RHBO to pay a default benefit for patients that are classified as nursing home type patients (NHTP) in particular State/Territories and private hospitals within Australia. 

This determination amends the rate for the private hospital default benefit in all states and territories from $73.80 to $72.90 from 20 March 2007.  

The determination also amends Schedule 4 of the Determination to include the increase to the Tasmanian NHTP daily accommodation default benefit from $89.50 to $91.68, the New South Wales NHTP daily accommodation default benefit from $92.80 to $95.30, the Victorian NHTP daily accommodation default benefit from $89.15 to $92.15 and the Northern Territory NTHP daily accommodation default benefit from $51.80 to $56.85.

Amendments to Schedule 5

Schedule 5 of this determination requires a RHBO to pay second tier default benefits for most episodes of hospital treatment provided in private hospitals and private day hospital facilities that are specified in Schedule 5 with which the RHBO does not have a HPPA.  Schedule 5 sets a higher minimum level of benefit (for overnight treatment and day only treatment provided in specified facilities) than the minimum benefit set for such treatment by Schedules 1, 2, 3 and 7 of Schedule 1, paragraph (1)(bj) of the Act.

Changes to Facilities Specified as Eligible for Second Tier Default Benefits

This determination specifies three new facilities to be entitled to second tier default benefits. The new facilities are:

1.  Sydney Haematology & Oncology Clinics  HORNSBY   NSW

2.  The Burnside War Memorial Hospital   TOORAK GARDENS  SA

3.  The Marian Centre      WEMBLEY   WA

Consultation

The Department of Health and Community Services, Northern Territory was consulted in regard to increasing the overnight rates and same day accommodation rates for recognised hospitals within the Northern Territory.

Each State and Territory Health Authority is consulted in regard to increasing the NHTP default benefits for their state/territory.  This is calculated in accordance with the biannual change to the pension increase which will occur on 20 March 2007.

The amendment to the NHTP rate for private hospitals is mechanical in nature.  The changes are linked to the biannual change to the pension, the next increase of which will occur on
20 March 2007. The amendment does not substantially alter existing arrangements for the private hospital sector.

Consultation for changes to Schedule 5 occurred with industry through the Second Tier Advisory Committee, which includes equal representation from both the private hospital and health insurance fund sectors.

This determination commences on the 20 March 2007.

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

MARCH 2007