National Health Act 1953 - Determination under Schedule 1, paragraph (1)(bj) (HIB 31/2006)

Administered by Department of Health, Disability and Ageing

Legislation au F2006L03539 Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Issued by Authority of the Minister for Health and Ageing

 

National Health Act 1953

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

(HIB 31/2006)

 

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”. 

 

The current Determination, dated 19 September 2006 (HIB20/2006) (as amended), is comprised of seven schedules setting out the minimum benefit levels payable for a range of hospital treatment.  

 

This Determination amends HIB20/2006 by omitting Schedule 1, 3, 4 and 6 and substituting with new Schedules 1, 3, 4 and 6.

 

Amendments to Schedule 1

 

Schedule 1 of this determination sets default benefits for overnight accommodation in certain situations by specifying the default benefits that are payable in relation to the Medicare Benefits Schedule (MBS) item numbers.   Schedule 1 categorises MBS item numbers into patient classifications (e.g. Advanced Surgical, Surgical/Obstetric or Other Patient).

 

Schedule 1 has been amended by adding and deleting MBS item numbers to reflect equivalent changes made to the MBS effective on and from 1 November 2006.

 

Schedule 1 has been amended to specify that advanced surgical patients are those undergoing a procedure with an MBS fee greater than $753.72 and surgical patients are those undergoing a procedure with an MBS fee within the range of $224.43 to $753.71.  These new amounts reflect a 2.1% fee increase which has been applied to MBS fees from 1 November 2006.  This amendment will ensure that MBS services that have been classified as surgical will not move up to the advanced surgical classification simply as a result of the MBS fee increase.

 

These changes were necessary because Schedule 1 links the default benefits that are payable to the types of professional services rendered to admitted hospital patients.  The types of professional services rendered are identified by reference to MBS item numbers and fees

 

Amendments to Schedule 3

 

Schedule 3 sets the default benefit payable for same day accommodation by specifying the default benefits that are payable in relation to MBS item numbers.

 

Schedule 3 has been amended by adding and deleting MBS item numbers to reflect changes made to the MBS effective on and from 1 November 2006.

 

These changes were necessary because Schedule 3 links the default benefits that are payable to the types of professional services rendered to admitted hospital patients.  The types of professional services rendered are identified by reference to MBS item numbers and fees.

 

 

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 (NHTP) in recognized hospitals in particular States and Territories and private hospitals in all States and Territories. 

 

This Determination adjusts the default benefit payable to NHTP in recognized hospitals within Queensland and Tasmania to take into account an increase to the bed day charge.  This determination also amends the private hospital default benefit in all States/Territories from $74.70 to $73.80. The default benefit amounts are effective the day after registration on the Federal Register of Legislative Instruments (FRLI).

 

This determination does not change the default benefit payable to NHTP in recognized hospitals in Western Australia, Australian Capital Territory, Victoria, South Australia, New South Wales or the Northern Territory.

 

Amendments to Schedule 6

 

Schedule 6 of this determination sets out the care plans and case conferencing.   The change to this schedule is the inclusion of two new MBS care plan item numbers effective from 1 November 2006.

 

Consultation
 

The changes to the MBS resulted from reviews by the Medicare Benefit Consultative Committee (MBCC). The MBCC is an informal consultative forum with representation drawn from the Department of Health and Ageing, Medicare Australia, the Australian Medical Association and relevant professional groups of the medical profession. The reviews conducted by the MBCC are designed to ensure that the MBS reflects current medical practice and encourages best practice.

The subsequent changes to Schedule 1, Schedule 3 and Schedule 6 were necessary to ensure that health funds, at a minimum, pay the ‘default benefit’ for their members where members receive hospital treatment corresponding to one of the new MBS item numbers, in a hospital where that health fund does not have a contractual arrangement with that hospital. Amendments to Schedule 1, 3 and 6 are machinery in nature and do not substantially alter existing arrangements.

 

The amendments made to Schedule 4 relating to default benefits for NHTPs in recognized hospitals within Queensland and Tasmania, were made with the agreement of Queensland Health and the Department of Human Services, Tasmania.  No consultation was undertaken for the private hospital default benefit within all States/Territories as the instrument is mechanical in nature.   The changes are linked to the biannual change to the pension increase, which occurred on the 20 September 2006 and do not substantially alter existing arrangements for the private hospital sector.

 

Schedules 1, 3 & 6 of this Determinations commence on 1 November 2006, however Schedule 4 commences the day after registration on the FRLI.

 

 

 

 

 

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

OCTOBER 2006

 

 

Overview

The National Health Act 1953, enacted by the Australian Parliament, governs the provision of health services and the regulation of health insurance within Australia. One of its key provisions allows the Minister for Health to determine minimum levels of benefits payable by registered health benefits organisations (RHBs) for hospital treatment provided to contributors in hospitals or day hospitals without a hospital purchaser-provider agreement, known as "default benefits." The legislation aims to ensure that RHBs provide a baseline level of coverage for hospital treatment outside of contracted agreements. The 2006 determination under the Act, HIB 31/2006, updates the minimum benefit levels for certain hospital treatments, reflecting changes in the Medicare Benefits Schedule (MBS) and bed day charges in specific jurisdictions. The policy objective of these amendments is to maintain alignment between the MBS and the default benefits payable by RHBs, ensuring that RHBs continue to provide appropriate coverage for hospital treatments corresponding to MBS item numbers. This alignment supports equitable access to hospital services for all contributors, regardless of the specific hospital arrangements of their RHBs.

Scope and Application

The Determination under Schedule 1, paragraph (1)(bj) of the National Health Act 1953 applies to registered health benefits organisations (RHBO) operating in Australia, specifically governing the minimum levels of benefits, known as "default benefits," that these entities must pay for hospital treatment provided to their contributors in hospitals or day hospitals where no hospital purchaser-provider agreement (HPPA) exists. This determination is pivotal in ensuring that contributors receive a baseline level of hospital care benefits irrespective of the absence of a specific agreement between the RHBO and the hospital provider. The scope of this legislation extends across all states and territories of Australia, thereby maintaining a consistent standard of care benefits nationwide. The amendments to the determination, as outlined, include adjustments to the default benefits for overnight and same-day hospital accommodation, as well as for nursing home type patients (NHTP) in recognised hospitals, reflecting changes in the Medicare Benefits Schedule (MBS) and adjustments to bed day charges. Notably, the amendments to Schedule 4 were made in consultation with relevant state health authorities, while the changes to the private hospital default benefit were mechanical adjustments tied to the pension increase. These amendments ensure that health funds continue to meet minimum benefit requirements for hospital services as per the MBS, thereby maintaining the integrity and consistency of the health benefits system across Australia.

Key Provisions

The key provisions of this Determination under the National Health Act 1953 (the Act) focus on amending the minimum levels of benefits, referred to as “default benefits,” payable by registered health benefits organizations (RHBOs) for hospital treatment. These amendments are made in accordance with the Act’s provisions which allow the Minister to determine these benefits for certain hospital treatments not covered by a hospital purchaser-provider agreement (HPPA) (s 1(bj)). This Determination updates the minimum benefits payable for overnight and same-day hospital accommodation, and care plans for certain patients. This Determination imposes several obligations on RHBOs to ensure that they adhere to the newly set minimum benefits for hospital treatment. Specifically, Schedule 1 now requires that advanced surgical patients, identified by procedures with an MBS fee greater than $753.72, and surgical patients, identified by procedures with an MBS fee between $224.43 and $753.71, receive the newly specified default benefits. Schedule 3 adjusts the same-day accommodation benefits based on updated MBS item numbers. Schedule 4 modifies the default benefits for Nursing Home Type Patients (NHTP) in recognized hospitals in Queensland and Tasmania, as well as the default benefits for private hospitals across all states and territories. Schedule 6 includes new MBS care plan item numbers effective from 1 November 2006. Failure to comply with the minimum benefits outlined in this Determination could lead to non-adherence to the statutory requirements set forth by the Act. However, the Determination does not explicitly state any specific offences, penalties, or civil/criminal consequences for breaches. Nonetheless, non-compliance with the mandated minimum benefits may result in legal action being taken against the RHBOs for not fulfilling their obligations under the Act. The consequences of such breaches would likely be determined based on the specific circumstances and the extent of the non-compliance, potentially including financial penalties, corrective actions, or other remedial measures.

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Sourced from the Federal Register of Legislation at 26 August 2026. For the latest information on Australian Government law please go to https://www.legislation.gov.au.