Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 4)

Administered by Department of Health, Disability and Ageing

Legislation au F2015L01451 Rules Not in force Legislative Instrument

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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. 4)

 

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. 4) (the Amendment Rules) amend 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 September 2015.

 

Schedule 5 of the Principal Rules requires a private health insurer to pay second-tier default benefits for most episodes of hospital treatment provided in private hospital facilities that are specified in Schedule 5 if the private health insurer does not have a negotiated agreement with the hospital.  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 27 August 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. Queensland, Victoria, The Northern Territory and Tasmania have advised that they will increase the NHTP accommodation rates in their public hospitals from 20 September 2014.  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 September 2015 or, if registered after 20 September 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

SEPTEMBER 2015

 


ATTACHMENT

 

DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2015 (No. 4)

 

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. 4) (the Amendment Rules).

 

Section 2 Commencement

 

Section 2 provides that the Amendment Rules are to commence on 20 September 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:

 

  •     Queensland $113.00 to $117.00;
  •     Northern Territory $86.10 to $90.15
  •     Tasmania $136.55 to $137.65
  •     Victoria $122.60 - $127.00

 

 

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 $54.20 to $53.75.

 

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. 4) were enacted to amend the Private Health Insurance (Benefit Requirements) Rules 2011 under the authority provided by Section 333-20 of the Private Health Insurance Act 2007. The rules aim to address the gap in the minimum benefits payable by private health insurers for nursing-home type patients in public and private hospitals, aligning them with the latest indexation of the Adult Pension Basic Rate and Maximum Daily Rate of Rental Assistance. The purpose of these amendments is to update the minimum benefits payable per night for nursing-home type patients in public hospitals in certain states and territories and to adjust the minimum benefit payable for such patients in private hospitals nationally. Additionally, the rules update the reference to the Second Tier Advisory Committee-approved list of facilities eligible for second-tier default benefits. The rules were developed following consultations with states and territories regarding the increase in nursing-home type patient rates and the industry through the Second Tier Advisory Committee for updates to the second-tier default benefits list. The amendments reflect the need for regular adjustments to ensure that benefits remain in line with current pension and rental assistance rates and to maintain an accurate list of facilities eligible for second-tier default benefits. The rules came into effect on 20 September 2015 or the day after registration if enacted later.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 4) amends the schedule of the Private Health Insurance (Benefit Requirements) Rules 2011 to alter the minimum benefits payable by private health insurers per night for nursing-home type patients (NHTP) at public hospitals in certain states and territories and at private hospitals nationally. The Amendment Rules apply to private health insurers, public and private hospitals, and consumers of private health insurance across Australia, providing consistency and predictability in the minimum benefits required under private health insurance policies. These rules are made under Section 333-20 of the Private Health Insurance Act 2007, empowering the Minister to establish rules for benefit requirements necessary for implementing the Act. The changes are scheduled to commence on 20 September 2015, with specific adjustments to the minimum benefits payable for NHTP in public hospitals in Queensland, the Northern Territory, Tasmania, and Victoria, and a reduction for private hospitals nationally. Additionally, the rules update the list of facilities eligible for second-tier default benefits, reflecting the most recent approval by the Second Tier Advisory Committee.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 4) (the Amendment Rules) make changes to the minimum benefits payable by private health insurers for nursing-home type patients (NHTP) and update the list of facilities eligible for second-tier default benefits. These amendments are made under section 333-20 of the Private Health Insurance Act 2007 (the Act), which allows the Minister to create rules that provide for matters required or permitted by Part 3-3 of the Act. The Amendment Rules alter the schedule of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules), which commenced on 1 November 2011. The Amendment Rules impose specific obligations on private health insurers regarding the minimum benefits payable for NHTP. For instance, Schedule A, Item 1 increases the minimum benefit payable per night for NHTP in public hospitals in Queensland, the Northern Territory, Tasmania, and Victoria, aligning these rates with the increases in the Pension and Rental Assistance Rates. Conversely, Schedule A, Item 2 reduces the minimum benefit payable per night for NHTP in private hospitals nationally from $54.20 to $53.75. These changes reflect the decisions of the relevant states and territories to adjust their NHTP contribution and accommodation rates. Additionally, Schedule B updates the list of facilities eligible for second-tier default benefits, ensuring that it corresponds to the most recent Second Tier Advisory Committee-approved list. Private health insurers are required to adhere to these updated minimum benefit rates for NHTP and the revised list of facilities eligible for second-tier default benefits. Failure to comply with these amendments could result in legal consequences. Although the Amendment Rules themselves do not specify particular offences or penalties for non-compliance, breaches of the Private Health Insurance Act 2007 or related regulations may incur penalties. For instance, under the Act, an authorised officer can issue infringement notices for civil penalties, and more severe breaches may lead to criminal charges, resulting in fines of up to $22,200 for individuals and $111,000 for corporations, as well as potential imprisonment terms. Additionally, insurers might face regulatory actions, including fines and sanctions, if they fail to meet the mandated benefit requirements.

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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.