EXPLANATORY STATEMENT

Issued by Authority of the Minister for Health and Ageing

National Health Act 1953

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

(HIB 17/2006)

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”. 

Rather than registering the principal determination and registering all subsequent amendments to the principal determination on the Federal Register of Legislative Instruments as required under the Legislative Instruments Act 2003, I have pursued the alternative option allowed under the Legislative Instruments Act 2003 of repealing and remaking the determination in a consolidated form.

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).

The determination HIB 16/2006 has been repealed and revoked by this determination to incorporate amendments made to Schedules 1, 2, 3, 4, 5 and 7.

Amendments to Schedules 1, 2, 3, and 7

Schedules 1, 2, 3 and 7 of this determination set out benefit levels in regard to overnight accommodation, overnight shared ward accommodation, same day accommodation and outreach services.  These schedules have been amended because the benefits are subject to annual review in accordance with the Consumer Price Index (CPI) from March quarter to March quarter each year with the agreement of the States and Territories. 

For the period between the March quarter 2005 to the March quarter 2006 there was an increase of 3.0% in the CPI. The amendments reflect this increase in the CPI and are to take effect for the financial year 2006-2007.

This determination sets out the level of benefits payable per night for hospital treatment provided to patients in private hospitals in all States and Territories and in shared ward accommodation in recognised hospitals in Victoria (VIC) and Tasmania (TAS) in Schedule 1.  All benefits in Schedule 1 have been adjusted.

This determination sets out the level of benefits payable per night for shard ward accommodation in recognised hospitals in the New South Wales (NSW), Queensland (QLD), South Australia (SA), Western Australia (WA), the Australian Capital Territory (ACT) and the Northern Territory (NT) in Schedule 2.  Benefits in Schedule 2 have been adjusted for NSW, SA and WA.

This determination sets out the level of benefits payable for same day accommodation for all hospitals or day hospital facilities in all States in Schedule 3.  Benefits in Schedule 3 have been adjusted for NSW, VIC, SA, WA, and TAS, private hospitals and private day hospital facilities.

This determination sets out the level of benefits payable for Outreach Services provided to a patient by or on behalf of, a hospital or day hospital facility in all States and Territories in Schedule 7.  Benefits in  Schedule 7 have been adjusted for NSW, VIC SA, WA, TAS, private hospitals and private day hospital facilities.

QLD, ACT and NT have not yet expressed their agreement to the increase in default benefits to the Commonwealth.

Amendments to Schedule 4

Schedule 4 of this determination sets out the default benefits that are payable per night for patients that are classified as Nursing Home Type Patients (NHTPs) in recognised hospitals in particular States and Territories and private hospitals in all States and Territories. 

This determination adjusts the default benefit that is payable to NHTPs in recognised hospitals in WA and SA to take into account changes to pension rates effective as of 20 March 2006.

This determination does not affect the default benefit payable to NHTPs in private hospitals in all States/Territories and in recognised hospitals in NSW, VIC, QLD, TAS, ACT and NT.

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 this determination.

Changes to Facilities Specified as Eligible for Second Tier Default Benefits

This determination includes 23 new facilities recommended to and approved by the delegate of the Minister for Health and Ageing by the Second Tier Advisory Committee to be entitled to second tier default benefits.  The new facilities are:

1. Calvary Health Care Tasmania - Launceston (St Vincent's Campus)
2. Eastern Suburbs Private Hospital
3. Figtree Private Hospital
4. Hopewell Hospice
5. Logan Surgery Centre
6. Manly Waters Private Hospital
7. Minchinbury Community Private Hospital
8. Mosman Private Hospital
9. Peninsula Private Hospital (Kippa-Ring)
10. Shellharbour Private Hospital
11. St John of God Health Care (Warrnambool)
12. St John of God Health Care Berwick
13. St John of God Healthcare Nepean Rehabilitation Hospital
14. St John of God Hospital Murdoch
15. St John of God Hospital Subiaco
16. St Kilda Day Hospital
17. Stirling District Hospital
18. Sydney Eastern Eye Centre
19. Sydney Eye Specialist Centre
20. The Double Bay Day Surgery
21. Wandene Private Hospital
22. Wesley Private Hospital
23. Western Private Hospital

This determination includes 78 renewed facilities recommended to and approved by the delegate of the Minister for Health and Ageing by the Second Tier Advisory Committee to have their entitlement to second tier default benefits continued.  The renewed facilities are:

1. (Alpha) Westmead Private Hospital
2. Aesthetic Day Surgery
3. Albury-Wodonga Private Hospital
4. Avenue Day Surgery
5. Bankstown Primary Health Care Day Surgery
6. Baringa Private Hospital
7. Bega Valley Day Surgery Centre and Private Hospital
8. Beleura Private Hospital
9. Berkeley Vale Private Hospital
10. Bondi Junction Private Hospital
11. Cairns  Private Hospital
12. Calvary Day Procedure Centre
13. Calvary Health Care Tasmania - Hobart (Lenah Valley Campus)
14. Calvary Health Care Tasmania - Hobart (St John's Campus)
15. Calvary Health Care Tasmania - Launceston (St Luke's Campus)
16. Calvary Hospital Adelaide
17. Calvary Private Hospital (Riverina)
18. Castle Hill Hospital
19. Central Districts  Private Hospital
20. Chesterville Day Hospital
21. Coffs Harbour Day Surgery Centre
22. Colin Street Day Surgery
23. College Grove Rehabilitation Hospital
24. Donvale Rehabilitation  Hospital
25. Epping Surgery Centre
26. Fullarton Private Hospital
27. Greenslopes  Private Hospital
28. Hollywood Private Hospital
29. Holy Spirit Northside
30. Hopetoun Rehabilitation Hospital
31. Hunters Hill Private Hospital
32. Kahlyn  Private Hospital
33. Lake Macquarie  Private Hospital
34. Lawrence Hargrave  Private Hospital
35. Liverpool Day Surgery
36. Maitland Private Hospital
37. Mater Hospital Yeppon
38. Mater Misericordiae Day Unit (Mackay)
39. Mater Misericordiae Hospital Bundaberg
40. Mater Misericordiae Hospital Gladstone
41. Mater Misericordiae Hospital Mackay
42. Mater Misericordiae Hospital Rockhampton
43. Mater Misericordiae Private Hospital (South Brisbane)
44. Mater Misericordiae Women's & Children's Private Health Service (Children's Campus)
45. Mater Misericordiae Women's & Children's Private Health Service (Women's Campus)
46. Mater Private Hospital Redland
47. Mitcham Private Hospital
48. Mount Olivet Hospital
49. Mt Wilga Private Hospital
50. New Farm Private Hospital
51. North Eastern Private Hospital
52. North Shore Private Hospital
53. Northside Clinic Private Hospital
54. Northside Cremorne Clinic
55. Northside West Clinic
56. Peninsula Private Hospital  (Frankston)
57. QFG Day Theatres
58. Rivercity Private Hospital
59. Rosebud SurgiCentre
60. South Coast Digestive Diseases Centre
61. Southern Highlands Private Hospital
62. Spendelove House Private Hospital
63. Sportsmed.SA Hospital
64. St Andrew's Toowoomba Hospital
65. St Vincents & Mercy Private Hospital, Mercy Campus
66. St Vincent's Hospital (Toowoomba)
67. St Vincent's Private Hospital (Fitzroy)
68. Sydney Adventist Private Hospital
69. Sydney Day Surgery
70. Tamara Private Hospital
71. The Adelaide Clinic
72. The Albert Road Clinic
73. The Bays Hospital - Mornington
74. The Valley Private Hospital
75. Toronto Private Hospital
76. Vista Laser Eye Clinics NSW
77. Wakefield Hospital
78. Western Plains Day Surgery

21 facilities have been deleted from Schedule 5 as they are no longer entitled to second tier default benefits.  The facilities that have been deleted from Schedule 5 are:

1. Cabrini Brighton
2. Calvary Health Care Sydney Hurstville Community
3. Calvary Private Hospital (ACT)
4. Caringbah Day Surgery
5. Healthwoods Specialist Centre
6. Illawarra Private Hospital
7. Inner West Endoscopy Centre
8. Mater Hospital North Sydney
9. Peninsula Private Hospital (Harbord)
10. Saint Francis Xavier Cabrini Hospital (Malvern)
11. Saint Francis Xavier Cabrini Hospital (Prahran)
12. South Eastern Private Hospital
13. South Western Day Surgery Centre
14. St. Vincent’s Private Hospital (Darlinghurst)
15. Sydney Retina Clinic & Day Surgery
16. Terrace West Endoscopy Centre
17. The Burnside War Memorial Hospital
18. The CAPS Clinic
19. The Eye Institute
20. Westside Private Hospital
21. Wolper Jewish Private Hospital

Second Tier Benefits for Rehabilitation
 

Sections relating to references to rehabilitation have been deleted from Schedule 5 of the determination.  These amendments correct an unintentional barrier to specified facilities accessing second tier default benefits for rehabilitation episodes of hospital treatment.

Consultation
 

The amendments made to Schedules 1, 2, 3 and 7 of this determination reflect the increase in default benefits due to the CPI change from the March 2005 to the March 2006.  Increases to the default benefits were made with the agreement of the relevant State or Territory.

The amendments made to Schedule 4 relate to default benefits for NHTPs in recognised hospitals and private hospitals in States and Territories.  Increases to the default benefits for recognised hospitals were made with the agreement of the relevant State or Territory.

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 fund sectors and the Consultative Committee on Private Rehabilitation, which includes representatives from the Australian Health Insurance Association, Australian Private Hospitals Association, Royal Australasian College of Physicians Australasian Faculty of Rehabilitation Medicine, Australian Government Departments of Health and Ageing, and Veterans’ Affairs, and the Private Health Insurance Ombudsman.

This determination commences on 1 July 2006.  This determination and this explanatory statement have been lodged for registration on the Federal Register of Legislative Instruments.

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

JULY 2006