Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4)

Administered by Department of Health, Disability and Ageing

Legislation au F2007L04454 Rules Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

 

Issued by Authority of the Minister for Health and Ageing

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No.4)

 

Section 333-20 of the Private Health Insurance Act 2007 (the Act) provides that the Minister may make Private Health Insurance (Benefit Requirements) Rules  providing for matters required or permitted by Part 3-3 of the Act, or necessary or convenient in order to carry out or give effect to Part 3-3 of the Act.

 

The Private Health Insurance (Benefit Requirements) Rules 2007 (No. 4) (the Rules) provide for the minimum benefit requirements for psychiatric, rehabilitation and palliative care and other hospital treatment.  Schedules 1 to 6 to the Rules set out the minimum levels of benefit which are payable for 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), and outreach services (Schedule 6).

 

The Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No.4) (the Amending Rules) amend the Rules by making amendments to Rule 3 and Schedule 4 with respect to nursing-home type patient accommodation in hospitals in all States/Territories.

 

The purpose of this amendment is to ensure that the definition of nursing-home type patient is substantially the same as applied prior to 1 April 2007, except for the removal of the requirement for statutory certification and the Acute Care Advisory Committee from the process. The removal of the requirement for statutory certification and the Acute Care Advisory Committee took place on 1 April 2007.

 

The definition of nursing-home type patient appearing in the Rules contains more detail, leaving less ambiguity for private health insurers, hospitals and patients regarding the correct interpretation of the definition of a nursing-home type patient, particularly regarding when a person becomes, and when a person ceases to be, a nursing-home type patient.

 

The definition of nursing-home type patient in the Rules (as amended) will apply for the purpose of private health insurance benefits. The definition of nursing-home type patient appearing in subsection 3(1) of the Health Insurance Act 1973 continues to apply in relation to public patients via the 2003-2008 Australian Health Care Agreements.

 

Details of the Amending Rules are set out in the Attachment.

 

Consultation

No specific consultation was undertaken in relation to the Amending Rules as the changes simply ensure the correct interpretation of the definition of a nursing-home type patient in line with current industry practice.

 

 

 

 

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

NOVEMBER 2007


ATTACHMENT

 

DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2007 (NO.4)

 

  1. Name of Rules

 

Rule 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No.4) (the Amending Rules).

 

2.             Commencement

 

Rule 2 provides that the Amending Rules are to commence the day after they are registered.

 

3.             Amendment of the Private Health Insurance (Benefit Requirements) Rules 2007 (No.4)

 

Rule 3 provides that the Schedule of the Amending Rules amends the Private Health Insurance (Benefit Requirements) Rules 2007( No.4) (the Rules).

 

Schedule Amendments

 

Item 1 – Rule 3 - Definitions

This clause amends the definition of a nursing-home type patient (NHTP) to refer to a definition of nursing-home type patient (NHTP) in Schedule 4 of the Rules.

 

Item 2 – Schedule 4, Clause 1

This clause inserts the following new clauses after Clause 1 in Schedule 4 of the Rules. 

 

2.   Interpretation

 

This Clause provides the definition of a NHTP for private health insurance purposes. A patient becomes a NHTP after they have received hospital treatment at a hospital for a continuous period of hospitalisation exceeding 35 days and are then receiving accommodation and nursing care as an end in itself.

 

3.   Application

 

Subclause 3(1) limits the new NHTP definition to a patient who has been admitted to hospital, or has returned to hospital with less than a seven day break from a previous hospital admission, after the commencement of the Amending Rules.

 

Subrule 3(2) provides that if subclause 3(1) does not apply to a patient, the definition of a NHTP in the Rules will apply.  The definition of a NHTP and the accompanying note, immediately before these Rules commenced was:

 

Nursing-home type patient has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

 

Note: Item 19 of Schedule 2 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 also deals with nursing-home type patients.


4.    Provision of acute care

 

Rule 4 allows a NHTP who requires acute care to cease being a NHTP for the period of acute care, and then become a NHTP again once they are again receiving accommodation and nursing care as an end in itself.

 

5.    Ceasing and resuming hospital treatment

 

Rule 5 provides that a NHTP who leaves hospital but returns to a hospital, whether or not the same hospital, not more than 7 days later will continue to be a NHTP unless they require acute care.

 

Item 3 - Schedule 4, Clause 2

This clause was previously clause 2, Schedule 4 in the Rules and has been renumbered due to the insertion of new clauses into Schedule 4 by the Amending Rules.

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4), enacted by the Minister for Health and Ageing, serve to refine and clarify the definition of a "nursing-home type patient" (NHTP) for the purposes of private health insurance benefits. This legislative action was introduced to address ambiguity and ensure consistency in interpreting when a patient qualifies as a NHTP, particularly in relation to their eligibility for specific benefits under private health insurance policies. The rules were necessitated by the removal of statutory certification and the Acute Care Advisory Committee from the process on 1 April 2007, which required updating the regulatory framework to align with current practices. The policy objective is to provide clear guidelines to private health insurers, hospitals, and patients, ensuring that the interpretation of NHTP status is consistent and unambiguous. The rules specifically amend Rule 3 and Schedule 4 of the Private Health Insurance (Benefit Requirements) Rules 2007, providing detailed definitions and conditions for when a patient becomes and ceases to be classified as a NHTP. These amendments ensure that the definition of NHTP for private health insurance purposes is distinct from the definition used in public hospital settings, thereby maintaining clarity and avoiding overlap. The Amending Rules were implemented without specific consultation, as the changes were deemed necessary to align with industry practices post-April 2007.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) amends the Private Health Insurance (Benefit Requirements) Rules 2007 by clarifying the definition of a nursing-home type patient (NHTP) for private health insurance purposes. These rules apply to private health insurers, hospitals, and patients within Australia. The purpose of this amendment is to ensure that the definition of NHTP remains consistent with previous interpretations, with the notable exclusion of statutory certification and the Acute Care Advisory Committee, which were removed on 1 April 2007. The amendment ensures that the definition of NHTP for private health insurance benefits is clear and unambiguous, which is particularly important for determining when a patient becomes, and ceases to be, classified as an NHTP. This definition applies to patients admitted to hospital after the commencement of the Amending Rules or those returning to hospital within seven days of a previous admission. The rules also allow for NHTPs who require acute care to temporarily cease being classified as such during the period of acute care and resume the NHTP classification once they are again receiving accommodation and nursing care as an end in itself.

Key Provisions

The main operative sections of the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) (the Amending Rules) primarily concern the amendment of Rule 3 and Schedule 4 to ensure the correct interpretation of the definition of a nursing-home type patient (NHTP). Rule 3 specifies that the Schedule of the Amending Rules amends the Private Health Insurance (Benefit Requirements) Rules 2007 (No. 4) (the Rules). Schedule 4 has been amended to provide a detailed definition of a NHTP for the purposes of private health insurance benefits, which applies to patients admitted to hospital or who have returned to hospital with less than a seven-day break from a previous hospital admission after the commencement of the Amending Rules. The obligations and requirements imposed by the Amending Rules on the parties involved are mainly to ensure clarity in the definition of a NHTP. This definition applies to patients who have received hospital treatment for a continuous period exceeding 35 days and are receiving accommodation and nursing care as an end in itself. The Rules clarify that if a patient has been admitted to hospital or has returned within seven days of a previous admission after the commencement of the Amending Rules, they will be considered a NHTP. For those not meeting this criterion, the definition of a NHTP in the Rules will apply. The Amending Rules also allow NHTPs who require acute care to cease being a NHTP temporarily and become one again once they are receiving accommodation and nursing care as an end in itself. The Amending Rules impose specific consequences for breaches, though the explanatory statement does not detail specific offences or penalties. However, under the Private Health Insurance Act 2007, breaches of the Act or its rules can lead to various civil and criminal penalties, including fines and imprisonment. For instance, penalties for misleading or deceptive conduct can be significant, with fines up to $1.1 million for corporations and $220,000 for individuals, as well as potential imprisonment. Non-compliance with the rules concerning benefit requirements could similarly attract penalties under the Act. Given the importance of accurate definitions for benefit determination, any misinterpretation or misapplication of the NHTP definition could lead to disputes and potential enforcement actions under the Act.

Legal classification tags

Area of Law
Health Law
Insurance Law
Instrument
Regulation
Concepts
Definitions & Interpretation
Transitional Provisions
Compliance Obligations
Regulatory Standards
Catchwords
Nursing-home type patient

Interactions

Authorises

All Versions

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.