Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 1)

Administered by Department of Health, Disability and Ageing

Legislation au F2015L00324 Rules Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 1)

 

Authority

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 to be provided in order to carry out or give effect to Part 3-3 of the Act.

 

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 1) (the Amendment Rules) amends the schedule of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.

 

Purpose

Schedule A of the Amendment Rules

Schedule A of the Amendment Rules amends Schedule 4 of the Principal Rules.  The purpose of the amendments to Schedule 4 of the Principal Rules is to change the minimum benefits payable by private health insurers per night for nursing-home type patients (NHTP) at public hospitals in some states and territories and at private hospitals nationally.

 

Schedule B of the Amendment Rules

The purpose of the amendments to Schedule 5 of the Principal Rules is to update the reference to the new Second Tier Advisory Committee (the Committee) approved list of facilities that are eligible for second tier default benefits.

 

Background

The Principal Rules, which commenced on 1 November 2011, provide for the minimum benefit requirements for psychiatric, rehabilitation and palliative care and other hospital treatment.  Schedules 1 to 5 of the Principal Rules set out the minimum levels of benefits 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) and second tier default benefits (Schedule 5).

 

Schedule 1 categorises MBS item numbers into overnight patient classifications comprising ‘Advanced surgical patient’, ‘Obstetric patient’, ‘Surgical patient’, ‘Psychiatric patient’, ‘Rehabilitation patient’ and ‘Other patients’.  Schedule 3 sets out MBS items for the same day hospital accommodation benefits which are payable for privately insured patients in all states and territories.

 

The minimum benefits payable per night for hospital treatment provided to NHTP in Schedule 4 of the Principal Rules is subject to review and change twice annually, to reflect the indexation applied to the Adult Pension Basic Rate and Maximum Daily Rate of Rental Assistance (Pension and Rental Assistance Rates).  The latest indexation of these rates takes effect on 20 March 2015.

 

Schedule 5 of the Principal Rules requires a health insurer to pay second tier default benefits for episodes of hospital treatment provided in private hospital facilities that are specified in Schedule 5 if the health insurer does not have a negotiated agreement with the hospital for that service.  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 and 3 of the Principal Rules.

 

Details

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

 

Consultation

Schedule A of the Amendment Rules - Items 1 and 2

On 4 March 2015, states and territories were asked whether they would be increasing the NHTP contribution and accommodation rates in their jurisdiction in line with increases in the Pension and Rental Assistance Rates.  New South Wales, Tasmania and Northern Territory advised that they will increase the NHTP accommodation rates in their public hospitals from 20 March 2015.  The Australian Capital Territory advised that it is not increasing its NHTP contribution and accommodation rates at this time.

 

No specific consultation was undertaken in relation to Schedule A, item 2 of the Amendment Rules regarding private hospitals because the change was machinery in nature and linked to the twice annual Pension and Rental Assistance Rates increase.  The change does not substantially alter existing arrangements.

 

Schedule B of the Amendment Rules 

Consultation for changes to Schedule 5 occurred with industry through the Committee, which includes equal representation from both private hospital and private health insurance sectors.  Facilities wishing to be considered for inclusion in Schedule 5 were individually assessed and decided by the Committee. 

 

The Amendment Rules commence on 20 March 2015 or, if registered after 20 March 2015, the day after registration.

 

The Amendment Rules are a legislative instrument for the purposes of the

Legislative Instruments Act 2003.

Authority: Section 333-20 of the

Private Health Insurance Act 2007

 

MEDICAL BENEFITS DIVISION

DEPARTMENT OF HEALTH

MARCH 2015

 


ATTACHMENT

 

DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2015 (No. 1)

 

Section 1 Name of Rules

 

Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 1) (the Amendment Rules).

 

Section 2 Commencement

 

Section 2 provides that the Amendment Rules are to commence on 20 March 2015 or, if registered on a later date, the day after registration.

 

Section 3 Amendment of Private Health Insurance (Benefit Requirements) Rules 2011

 

Section 3 provides that Schedules A and B  to the Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.

 

Schedule A – Amendments

 

Item 1 – Schedule 4, Clause 6 Minimum benefit, Table 1

 

Item 1 of the schedule to the Amendment Rules increases the minimum benefit payable per night for nursing-home type patients in public hospitals in the following States in clause 6, Table 1:

 

  •     New South Wales $114.05 to $117.30;
  •     Northern Territory $83.10 to $86.10; and
  •     Tasmania $135.60 to $136.55.

 

Item 2 – Schedule 4, Clause 6 Minimum benefit, Table 2

 

Item 4 of the schedule to the Amendment Rules decreases the minimum benefit payable per night for nursing-home type patients in private hospitals in clause 6, Table 2:

 

  • Private hospitals from $54.60 to $54.20.

 

Schedule B – Amendments

 

Item 1 – Schedule 5, Clause 4 Facilities, subclause (1)  

 

Item 1 of Schedule C to the Amendment Rules updates the reference to the latest Second Tier Advisory Committee-approved list. The list of facilities eligible for second tier default benefits is the list existing at the time of this amendment and is published on the Department of Health’s website at http://www.health.gov.au/.


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 1) were enacted to modify the Private Health Insurance (Benefit Requirements) Rules 2011, which were originally established to set minimum benefit requirements for psychiatric, rehabilitation, and palliative care, as well as other hospital treatments under the Private Health Insurance Act 2007. This amendment was introduced by the Minister for Health under the authority granted by section 333-20 of the Private Health Insurance Act 2007, aiming to update the benefit requirements to reflect changes in relevant indexation rates. The primary objective of these amendments is to adjust the minimum benefits payable by private health insurers for nursing-home type patients at public hospitals in specific states and territories, as well as at private hospitals nationally, and to update the list of facilities eligible for second tier default benefits. The rules were implemented to ensure that the benefits provided align with current economic conditions and to maintain the integrity of the private health insurance system.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 1) amends the Private Health Insurance (Benefit Requirements) Rules 2011, which set out the minimum levels of benefits payable by private health insurers for hospital treatment. These Amendment Rules are applicable to private health insurers, hospitals, and consumers in Australia, with specific provisions for the minimum benefits payable for nursing-home type patients (NHTP) at public and private hospitals. The amendments in Schedule A of the Amendment Rules adjust the minimum benefits payable per night for NHTP in public hospitals in New South Wales, Northern Territory, and Tasmania, and in private hospitals nationally. These changes reflect the indexation applied to the Adult Pension Basic Rate and Maximum Daily Rate of Rental Assistance. Additionally, Schedule B updates the list of facilities eligible for second tier default benefits, which applies when health insurers do not have a negotiated agreement with a hospital for a particular service. These rules are made under the authority of Section 333-20 of the Private Health Insurance Act 2007, and they commenced on 20 March 2015 or the day after registration if enacted later.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 1) introduce changes to the minimum benefits payable by private health insurers for nursing-home type patients (NHTP) in public and private hospitals, as well as updating the list of facilities eligible for second tier default benefits. These changes are implemented through amendments to the Private Health Insurance (Benefit Requirements) Rules 2011. Specifically, Schedule A of the Amendment Rules adjusts the minimum benefits payable per night for NHTP in public hospitals in New South Wales, the Northern Territory, and Tasmania, while decreasing the minimum benefits for NHTP in private hospitals. Schedule B updates the list of facilities eligible for second tier default benefits, which is maintained by the Second Tier Advisory Committee. The Amendment Rules impose obligations on private health insurers to adhere to the updated minimum benefit requirements for NHTP in public and private hospitals as set out in Schedule 4, and to ensure compliance with the revised list of facilities eligible for second tier default benefits in Schedule 5. These changes necessitate that insurers review and potentially adjust their benefit payments to align with the new rates and the updated facility list. Insurers must also ensure that their policies and practices are updated to reflect these legislative changes. Failure to comply with the amended benefit requirements and facility list can result in regulatory scrutiny and potential enforcement actions by the relevant authorities. While the specific penalties for non-compliance are not detailed in the Amendment Rules, breaches of the Private Health Insurance Act 2007 can lead to significant consequences. These may include civil penalties, such as fines, and in more severe cases, criminal penalties. The exact penalties would depend on the nature and severity of the breach, as well as any relevant provisions within the overarching Act.

Legal classification tags

Area of Law
Health Law
Insurance Law
Instrument
Regulation
Concepts
Definitions & Interpretation
Regulatory Standards
Licensing & Registration
Reporting & Disclosure Obligations

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.