Private Health Insurance (Health Insurance Business) Rules 2015

Administered by Department of Health, Disability and Ageing

Legislation au F2015L00664 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 (Health Insurance Business) Rules 2015  

 

Section 333-20 of the Private Health Insurance Act 2007 (the Act) provides that the Minister may make Private Health Insurance (Health Insurance Business) Rules providing for matters required or permitted by Part 4-2 of the Act, or necessary or convenient in order to carry out or give effect to Part 4-2 of the Act.

 

The Private Health Insurance (Health Insurance Business) Rules 2015 (the Rules) revoke and remake the Private Health Insurance (Health Insurance Business) Rules 2013 (the previous Rules).  The Rules update the kinds of statistical information to be provided by hospitals to private health insurers and by private hospitals to the Department of Health (the Department).

 

Section 121-5 of the Act enables the Minister to grant or revoke a declaration that a facility is a public or private hospital for the purposes of the Act.  The Act specifies a number of matters to which the Minister must have regard in granting or revoking a hospital declaration, including whether the facility has entered into or complied with undertakings to provide private health insurers with the kinds of information specified in the Rules relating to the treatment of insured persons (paragraph 121-5(7)(e)). 

 

The Rules specify that for paragraph 121-5(7)(e) of the Act, the kinds of information are those specified in the HCP Data from Hospitals to Insurers document (HCP document) approved on 25th April 2015 by the First Assistant Secretary of the Acute Care Division of the Department (see rule 4). 

 

Section 121-7 of the Act provides that hospital declarations are subject to conditions specified in the Rules.  Rule 7 of the Rules provides that private hospital declarations are subject to the condition that the hospital provide the Department with the kinds of information specified in the PHDB Data from Private Hospitals to the Department document (PHDB document) approved on 25th April 2015 by the First Assistant Secretary of the Acute Care Division of the Department.  This information must be provided within 6 weeks from the time the insured person is discharged from hospital.

 

The HCP and PHDB documents replace the documents that were referred to in the previous Rules, and can be found on the Department of Health website at:

http://www.health.gov.au/internet/main/publishing.nsf/Content/health-casemix-data-collections-about-HCP.

 

The changes consist of minor housekeeping type changes.  They are as follows:

 

1. Adding support for ICD-10-AM version 9

2. Adding support for AR-DRG version 8

3. Raising ICU Charge Threshold (a warning is currently generated when the charges exceed $5000; inflation has made this unrealistic and the threshold is being raised to $8000)

4. Change to Prosthesis charge check in edit rule EW204 (This  is  to correct an issue of this error flagging episodes with no Theatre or Bundled charge where the member is having chemo in Hospital in the Home and the prosthesis charge is for an infuser device)

5. Remove ICU hours from edit rule EE203 (ICU Hours is listed as an optional field and as an optional field it should not be included in an edit rule check)

6. Remove provider number check from edit rule EE065 when mode of separation is “discharge/transfer to other health care accommodation” (some health care accommodation facilities are not declared and do not have provider numbers, ie some aged care facilities).

 

There are no other changes from the previous Rules.

 

Consultation

The Department has consulted with the private health insurance and private hospital industry through existing Working Group arrangements regarding the amendments required to the HCP and PHDB specifications.  Private health insurance and private hospital stakeholder representatives interested in developing the amendments participated in the process.  Industry is of the view that it is appropriate for minor amendments to be managed by this Working Group.  Previous minor amendments have been managed in this way.  The amended data specifications are distributed to industry via Private Health Insurance Circulars.

 

The Act does not specify any conditions that need to be met before the power to make the Rules may be exercised. 

 

The Rules are a legislative instrument for the purposes of the Legislative Instruments Act 2003. 

 

The Rules commence on 1 July 2015.

 


Statement of Compatibility with Human Rights

Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011

 

Private Health Insurance (Health Insurance Business) Rules 2015

This Legislative Instrument is compatible with the human rights and freedoms recognised                 or declared in the international instruments listed in section 3 of the                                                       Human Rights (Parliamentary Scrutiny) Act 2011.

 

Overview of the Legislative Instrument

The Private Health Insurance (Health Insurance Business) Rules provide for matters required or permitted by Part 4-2 of the Private Health Insurance Act 2007 (the Act), or necessary or convenient in order to carry out or give effect to Part 4-2 of the Act.

 

The Private Health Insurance (Health Insurance Business) Rules 2015 (the Rules) revoke and remake the Private Health Insurance (Health Insurance Business) Rules 2013 (the previous Rules) to update the kinds of statistical information to be provided by hospitals to insurers and by private hospitals to the Department of Health (the Department).

 

Under paragraph 121-5(7)(e) of the Act, when making or revoking a hospital declaration the Minister must have regard to whether the facility has entered into or complied with undertakings to provide private health insurers with information specified in the Rules relating to the treatment of insured persons. 

 

The Rules specify that for paragraph 121-5(7)(e) of the Act, the kinds of information are those specified in the HCP Data from Hospitals to Insurers document (HCP document) approved on 25th April 2015 by the First Assistant Secretary of the Acute Care Division of the Department (see rule 4). 

 

Section 121-7 of the Act provides that hospital declarations are subject to any conditions specified in the Rules.  Rule 7 of the Rules provides that private hospital declarations are subject to the condition that the hospital provide the Department with the kinds of information specified in the PHDB Data from Private Hospitals to the Department document (PHDB document) approved on 25th April 2015 by the First Assistant Secretary of the Acute Care Division of the Department. 

 

The revised documents can be found on the Department of Health website at:

http://www.health.gov.au/internet/main/publishing.nsf/Content/health-casemix-data-collections-about-HCP.

 


The changes consist of minor housekeeping type changes.  They are as follows:

 

1. Adding support for ICD-10-AM version 9

2. Adding support for AR-DRG version 8

3. Raising ICU Charge Threshold (a warning is currently generated when the charges exceed $5000; inflation has made this unrealistic and the threshold is being raised to $8000)

4. Change to Prosthesis charge check in edit rule EW204 (This  is  to correct an issue of this error flagging episodes with no Theatre or Bundled charge where the member is having chemo in Hospital in the Home and the prosthesis charge is for an infuser device)

5. Remove ICU hours from edit rule EE203 (ICU Hours is listed as an optional field and as an optional field it should not be included in an edit rule check)

6. Remove provider number check from edit rule EE065 when mode of separation is “discharge/transfer to other health care accommodation” (some health care accommodation facilities are not declared and do not have provider numbers, ie some aged care facilities).

 

The Rules also:

  • provide for inclusions and exclusions to the definitions of ‘hospital treatment’ and ‘general treatment’ in the Act; and
  • specify certain treatment that is to be excluded from being ‘health insurance business’ ‑ only registered private health insurers may carry on health insurance business and an insurer may only offer insurance as part of its health insurance business in the form of a complying health insurance product. 

 

However, no changes to these provisions have been made from the previous Rules.

 

Human rights implications

The Rules will engage the human right to privacy but will not result in any limitation of that right.

 

Supply of the HCP Data from Hospitals to Insurers involves the disclosure of sensitive personal information, including health information, from hospitals to private health insurers.  However the information supplied is provided by hospitals with the patient’s consent as part of the patient’s contractual relationship with their hospital and private health insurer.  There are protections for the information provided to insurers under the Privacy Act 1988 and/or State or Territory privacy laws.  

 

Supply of the PHDB Data from Private Hospitals to the Department involves the disclosure of de-identified statistical information about the treatment of insured persons, from private hospitals to the Department.  The information supplied could not reasonably be used by the Department to identify a patient.  Further, Part 6-8 of the Act creates an offence for the unauthorised disclosure of information obtained by any person in the course of performing duties or powers, or exercising functions, under the Act. 

 

The revisions to the documents are essentially mechanical in nature, and do not substantively alter any legislative requirements.

 

Conclusion

This Legislative Instrument is compatible with human rights as although it engages the right of privacy in relation to personal information, it will not result in any limitation of that right.

 

 

Janet Anderson

First Assistant Secretary, Acute Care Division

Department of Health

 

Overview

The Private Health Insurance (Health Insurance Business) Rules 2015 were introduced to update the kinds of statistical information that hospitals must provide to private health insurers and the Department of Health, as required by Part 4-2 of the Private Health Insurance Act 2007. Enacted by the Minister for Health, these rules revoke and remake the previous rules from 2013. The primary objective of the rules is to ensure that the information provided is current and relevant, facilitating the administration of private health insurance and the regulation of the health insurance business. The rules specify the types of information that must be shared, including updates to support newer versions of the International Classification of Diseases and the Australian Refined Diagnosis Related Groups, as well as adjustments to thresholds and checks to reflect changes in healthcare practices and economic conditions. The rules also maintain the integrity of the information exchange process by ensuring that the data provided is accurate and useful for both insurers and regulatory purposes, while protecting patient privacy in accordance with existing privacy laws.

Scope and Application

The Private Health Insurance (Health Insurance Business) Rules 2015, made under the Private Health Insurance Act 2007, apply to private health insurers and hospitals, including private hospitals, across Australia. These rules are designed to facilitate the provision of specific statistical information from hospitals to private health insurers and from private hospitals to the Department of Health. The information requirements are set out in the HCP Data from Hospitals to Insurers document and the PHDB Data from Private Hospitals to the Department document, both approved by the First Assistant Secretary of the Acute Care Division of the Department of Health. The rules mandate that private hospitals provide the Department with de-identified statistical information on the treatment of insured persons within six weeks of the patient's discharge. The changes introduced by these rules, which include updates such as support for newer versions of ICD-10-AM and AR-DRG, and adjustments to charge thresholds and data validation rules, are largely administrative in nature. These rules are applicable nationally and do not specify any exclusions beyond those outlined in the documents themselves. The rules commence on 1 July 2015 and are compatible with human rights, particularly the right to privacy, as they involve the disclosure of sensitive information under controlled conditions that safeguard patient privacy.

Key Provisions

The Private Health Insurance (Health Insurance Business) Rules 2015 (the Rules) serve to update the kinds of statistical information hospitals must provide to private health insurers and private hospitals to the Department of Health, as required or permitted by Part 4-2 of the Private Health Insurance Act 2007 (the Act). The Rules, which revoke and remake the Private Health Insurance (Health Insurance Business) Rules 2013, specify that the information must adhere to the HCP Data from Hospitals to Insurers document (HCP document) and the PHDB Data from Private Hospitals to the Department document (PHDB document) approved on 25 April 2015 by the First Assistant Secretary of the Acute Care Division of the Department. The HCP document governs the information hospitals must provide to insurers, while the PHDB document specifies the information private hospitals must supply to the Department. These documents can be found on the Department of Health website. The Act and the Rules impose specific obligations on the parties they govern. For instance, under Section 121-5 of the Act, the Minister must consider whether a facility has entered into or complied with undertakings to provide private health insurers with information specified in the Rules when making or revoking a hospital declaration. Moreover, Section 121-7 of the Act mandates that hospital declarations are subject to any conditions specified in the Rules. Rule 7 of the Rules stipulates that private hospital declarations must include the condition that the hospital provides the Department with the kinds of information specified in the PHDB document. These obligations ensure that hospitals and private hospitals comply with the specified data requirements to facilitate the proper functioning of the private health insurance system. The Rules and the Act do not specify any particular offences or penalties for breaches of the legislative requirements. However, Part 6-8 of the Act creates an offence for the unauthorised disclosure of information obtained by any person in the course of performing duties or powers, or exercising functions, under the Act. The unauthorised disclosure of sensitive personal information, including health information, could result in criminal and civil penalties under the Privacy Act 1988 and/or State or Territory privacy laws. Additionally, the Rules engage the human right to privacy, but they will not result in any limitation of that right, as the information supplied is provided by hospitals with the patient’s consent and there are protections for the information provided to insurers under the Privacy Act 1988 and/or State or Territory privacy laws. The Private Health Insurance (Health Insurance Business) Rules 2015 aim to update the kinds of statistical information to be provided by hospitals to private health insurers and by private hospitals to the Department of Health. These Rules specify the information to be provided in accordance with the HCP and PHDB documents and impose obligations on hospitals and private hospitals to comply with the specified data requirements. While the Rules and the Act do not specify particular offences or penalties for breaches of the legislative requirements, the unauthorised disclosure of sensitive personal information could result in criminal and civil penalties under the Privacy Act 1988 and/or State or Territory privacy laws. The Rules engage the human right to privacy, but they will not result in any limitation of that right, as the information supplied is provided by hospitals with the patient’s consent and there are protections for the information provided to insurers under the Privacy Act 1988 and/or State or Territory privacy laws.

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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.