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Private Health Insurance Act 2007
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Administered by
Department of Health, Disability and Ageing
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C2025C00097 (C38)
15 February 2025
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Chapter 1—Introduction
Part 1 1—Introduction
Division 1—Preliminary
1 1 Short title
1 5 Commencement
1 10 Identifying defined terms
1 15 Extension to Norfolk Island
Division 3—Overview of this Act
3 1 What this Act is about
3 5 Incentives (Chapter 2)
3 10 Complying health insurance products (Chapter 3)
3 15 Health insurance business, health benefits funds and miscellaneous obligations of private health insurers (Chapter 4)
3 20 Enforcement (Chapter 5)
3 25 Administration (Chapter 6)
3 30 Dictionary (Schedule 1)
Division 5—Constitutional matters
5 1 Meaning of insurance
5 5 Act not to apply to State insurance within that State
5 10 Compensation for acquisition of property
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Chapter 2—Incentives
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Part 2 1—Introduction
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Division 15—Introduction
15 1 What this Chapter is about
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Part 2 2—Premiums reduction scheme
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Division 20—Introduction
20 1 What this Part is about
20 5 Private Health Insurance (Incentives) Rules
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Division 22—PHIIB, PHII benefit and related concepts
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Subdivision 22 A—PHIIB, PHII benefit and related concepts
22 1 Application of Subdivision
22 5 Meaning of PHIIB
22 10 Meaning of PHII benefit
22 15 Meaning of share of the PHII benefit—single PHIIB
22 20 Meaning of share of the PHII benefit—multiple PHIIBs
22 25 Application of subsection 22 15(1) after a person 65 years or over ceases to be covered by policy
Subdivision 22 B—Private health insurance tiers
22 30 Private health insurance tiers
22 35 Private health insurance singles thresholds
22 40 Private health insurance family thresholds
22 45 Indexation
Division 23—Premiums reduction scheme
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Subdivision 23 A—Amount of reduction
23 1 Reduction in premiums
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Subdivision 23 B—Participation in the premiums reduction scheme
23 15 Registration as a participant in the premiums reduction scheme
23 20 Refusal to register
23 30 Participants who want to withdraw from scheme
23 35 Revocation of registration
23 40 Variation of registration
23 45 Retention of applications by private health insurers
Part 2 3—Lifetime health cover
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Division 31—Introduction
31 1 What this Part is about
31 5 Private Health Insurance (Lifetime Health Cover) Rules
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Division 34—General rules about lifetime health cover
34 1 Increased premiums for person who is late in taking out hospital cover
34 5 Increased premiums for person who ceases to have hospital cover after his or her lifetime health cover base day
34 10 Increased premiums stop after 10 years’ continuous cover
34 15 Meaning of hospital cover
34 20 Meaning of permitted days without hospital cover
34 25 Meaning of lifetime health cover base day
34 30 When a person is overseas or enters Australia
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Division 37—Exceptions to the general rules about lifetime health cover
37 1 People born on or before 1 July 1934
37 5 People over 31 and overseas on 1 July 2000
37 7 Person yet to turn 31
37 10 Hardship cases
37 15 Increases cannot exceed 70% of base rates
37 20 Joint hospital cover
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Division 40—Administrative matters relating to lifetime health cover
40 1 Notification to insured people etc.
40 5 Evidence of having had hospital cover, or of a person’s age
Part 2 4—Excess levels for medicare levy and medicare levy surcharge purposes
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Division 42—Introduction
42 1 What this Part is about
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Division 45—Excess levels for medicare levy and medicare levy surcharge purposes
45 1 Excess level amounts
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Chapter 3—Complying health insurance products
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Part 3 1—Introduction
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Division 50—Introduction
50 1 What this Chapter is about
50 5 Private Health Insurance Rules relevant to this Chapter
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Part 3 2—Community rating
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Division 55—Principle of community rating
55 1 What this Part is about
55 5 Principle of community rating
55 10 Closed products, and terminated products and product subgroups
55 15 Pilot projects
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Part 3 3—Requirements for complying health insurance products
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Division 60—Introduction
60 1 What this Part is about
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Division 63—Basic rules about complying health insurance products
63 1 Obligation to ensure products are complying products
63 5 Meaning of complying health insurance product
63 10 Meaning of complying health insurance policy
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Division 66—Community rating requirements
66 1 Community rating requirements
66 5 Premium requirement
66 10 Minister’s approval of premiums
66 15 Entitlement to benefits for general treatment
66 20 Different amount of benefits depending on where people live
66 25 Different amounts of benefits for travel or accommodation
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Division 69—Coverage requirements
69 1 Coverage requirements
69 5 Meaning of cover
69 10 Meaning of hospital substitute treatment
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Division 72—Benefit requirements for policies that cover hospital treatment
72 1 Benefit requirements
72 5 Rules requirement in relation to provision of benefits
72 10 Minimum benefits for medical devices and human tissue products
72 11 Meaning of medical device
72 12 Meaning of human tissue product
72 15 Fees for certain activities
72 20 Delisting because of unpaid fees or levy
72 25 Minister may direct that activities not be carried out
72 27 Matters to have regard to before exercising certain powers
72 30 When cost recovery fee must be paid
72 35 Payment of cost recovery fee
72 40 Recovery of fee
72 45 Other matters
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Division 75—Waiting period requirements
75 1 Waiting period requirements
75 5 Meaning of waiting period
75 10 Meaning of transfers
75 15 Meaning of pre existing condition
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Division 78—Portability requirements
78 1 Portability requirements
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Division 81—Quality assurance requirements
81 1 Quality assurance requirements
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Division 84—Enforcement of this Part
84 1 Offence: advertising, offering or insuring under non complying policies
84 5 Offence: directors and chief executive officers liable if systems not in place to prevent breaches
84 10 Injunction in relation to non complying policies
84 15 Remedies for people affected by non complying policies
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Part 3 4—Obligations relating to complying health insurance products
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Division 90—Introduction
90 1 What this Part is about
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Division 93—Giving information to consumers
93 1 Maintaining up to date private health information statements
93 5 Meaning of private health information statement
93 10 Making private health information statements available
93 15 Giving information to newly insured people
93 20 Keeping insured people up to date
93 25 Giving advance notice of detrimental changes to rules
93 30 Failure to give information to consumers
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Division 96—Giving information to the Department and the Private Health Insurance Ombudsman
96 1 Giving private health information statements on request
96 5 Giving private health information statements for new products
96 10 Giving updated private health information statements
96 15 Giving additional information on request
96 20 Failure to give information to Department or Private Health Insurance Ombudsman
96 25 Giving information required by the Private Health Insurance (Complying Product) Rules
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Division 99—Transfer certificates
99 1 Transfer certificates
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Division 102—Private health insurers to offer cover for hospital treatment
102 1 Private health insurers to offer cover for hospital treatment
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Chapter 4—Health insurance business, health benefits funds and miscellaneous obligations of private health insurers
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Part 4 1—Introduction
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Division 110—Introduction
110 1 What this Chapter is about
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Part 4 2—Health insurance business
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Division 115—Introduction
115 1 What this Part is about
115 5 Private Health Insurance (Health Insurance Business) Rules
115 10 Whether a business etc. is health insurance business
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Division 121—What is health insurance business?
121 1 Meaning of health insurance business
121 5 Meaning of hospital treatment
121 7 Conditions on declarations of hospitals
121 8 Application for inclusion of hospital in a class
121 8A Minister to decide application
121 8B Period of inclusion of hospital in a class
121 8C Revocation of inclusion of hospital in a class
121 8D Private Health Insurance (Health Insurance Business) Rules
121 10 Meaning of general treatment
121 15 Extension to employee health benefits schemes
121 20 Exception: accident and sickness insurance business
121 25 Exception: liability insurance business
121 30 Exception: insurance business excluded by the Private Health Insurance (Health Insurance Business) Rules
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Part 4 4—Health benefits funds
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Division 131—Health benefits funds
131 1 What this Part is about
131 5 Private Health Insurance (Health Benefits Fund Policy) Rules
131 10 Meaning of health benefits fund
131 15 Meaning of health related business
131 20 Risk equalisation jurisdictions
131 25 Operation of health related businesses through health benefits funds
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Part 4 5—Miscellaneous obligations of private health insurers
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Division 157—Introduction
157 1 What this Part is about
157 5 Private Health Insurance (Data Provision) Rules
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Division 169—Notification obligations
169 10 Private health insurers to notify any changes to rules
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Division 172—Other obligations
172 5 Agreements with medical practitioners
172 10 Private health insurers to give information to Secretary
172 15 Restrictions on payment of pecuniary penalties etc.
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Chapter 5—Enforcement
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Part 5 1—Introduction
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Division 180—Introduction
180 1 What this Chapter is about
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Part 5 2—General enforcement methods
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Division 185—What this Part is about
185 1 Introduction
185 5 Meaning of enforceable obligation
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Division 188—Performance indicators
188 1 Performance indicators
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Division 191—Explanation of private health insurer’s operations
191 1 Minister may seek an explanation from a private health insurer
191 5 Minister must respond to insurer’s explanation
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Division 194—Investigation of private health insurer’s operations
194 1A Purposes for which powers may be exercised etc.
194 1 Minister may investigate a private health insurer
194 5 Notice to give information
194 10 Notice to produce documents
194 15 Notice to give evidence
194 20 Offences in relation to investigation notices
194 25 Authorisation to examine books and records etc.
194 35 Minister must notify outcome of investigation
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Division 197—Enforceable undertakings
197 1 Minister may accept written undertakings given by a private health insurer
197 5 Enforcement of undertakings
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Division 200—Ministerial directions
200 1 Minister may give directions
200 5 Direction requirements
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Division 203—Remedies in the Federal Court
203 1 Minister may apply to the Federal Court
203 5 Declarations of contravention
203 10 Pecuniary penalty order
203 15 Compensation order
203 20 Adverse publicity order
203 25 Other order
203 30 Time limit for declarations and orders
203 35 Civil evidence and procedure rules for declarations and orders
203 40 Civil proceedings after criminal proceedings
203 45 Criminal proceedings during civil proceedings
203 50 Criminal proceedings after civil proceedings
203 55 Evidence given in proceedings for penalty not admissible in criminal proceedings
203 60 Minister may require person to assist
203 65 Relief from liability for contravening an enforceable obligation
203 70 Powers of Federal Court
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Division 206—Revoking entitlement to offer rebate as a premium reduction
206 1 Revocation of status of participating insurer
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Chapter 6—Administration
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Part 6 1—Introduction
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Division 230—Introduction
230 1 What this Chapter is about
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Part 6 4—Administration of premiums reduction scheme
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Division 276—Introduction
276 1 What this Part is about
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Division 279—Reimbursement of participating insurers and powers of Chief Executive Medicare
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Subdivision 279 A—Reimbursement of private health insurers for premiums reduced under scheme
279 1 Participating insurers may claim reimbursement
279 5 Participating insurers
279 10 Requirements for claims
279 15 Amounts payable to the private health insurer
279 20 Notifying private health insurers if amount is not payable
279 25 Additional payment if insurer claims less than entitlement
279 30 Additional payment if insurer makes a late claim
279 35 Content and timing of application
279 40 Decision on application
279 45 Reconsideration of decisions
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Subdivision 279 B—Powers of Chief Executive Medicare in relation to participating insurers
279 50 Audits by Chief Executive Medicare
279 55 Chief Executive Medicare may require production of applications
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Division 282—Recovery of amounts and other matters
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Subdivision 282 A—When and how payments can be recovered
282 1 Recovery of payments
282 5 Interest on amounts recoverable
282 10 Chief Executive Medicare may set off debts against amounts payable
282 15 Reconsideration of certain decisions under this Division
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Subdivision 282 AA—Recovery of certain amounts by Commissioner of Taxation
282 16 Administration of this Subdivision by Commissioner of Taxation
282 17 Subdivision operates in addition to Subdivision 282 A
282 18 Liability for excess private health insurance premium reduction or refund
282 19 When general interest charge payable
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Subdivision 282 B—Miscellaneous
282 20 Notification requirements—private health insurers
282 25 Use etc. of information relating to another person
282 30 Information to be provided to the Commissioner of Taxation
282 35 Delegation
282 40 Appropriation
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Part 6 6—Private health insurance levies
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Division 304—Introduction
304 1 What this Part is about
304 5 Private Health Insurance (Levy Administration) Rules
304 10 Meaning of private health insurance levy
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Division 307—Collection and recovery of private health insurance levies
307 1 When private health insurance levy must be paid
307 5 Late payment penalty
307 10 Payment of levy and late payment penalty
307 15 Recovery of levy and late payment penalty
307 20 Waiver of late payment penalty
307 30 Other matters
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Division 310—Returns, requesting information and keeping records: private health insurers
310 1 Returns relating to complaints levy
310 5 Insurer must keep records
310 10 Power to request information from insurer
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Division 313—Power to enter premises and search for documents related to complaints levy
313 1 Authorised officer may enter premises with consent
313 5 Authorised officer may enter premises under warrant
313 10 Announcement before entry
313 15 Executing a warrant to enter premises
313 20 Identity cards
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Part 6 7—Private Health Insurance Risk Equalisation Special Account
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Division 318—Private Health Insurance Risk Equalisation Special Account
318 1 Private Health Insurance Risk Equalisation Special Account
318 5 Credits to the Risk Equalisation Special Account
318 10 Purpose of the Risk Equalisation Special Account
318 15 Record keeping
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Part 6 8—Disclosure of information
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Division 323—Disclosure of information
323 1 Prohibition on disclosure of information
323 5 Authorised disclosure: official duties
323 10 Authorised disclosure: sharing information about insurers among agencies
323 15 Authorised disclosure: sharing information about insurers other than among agencies
323 20 Authorised disclosure: public interest
323 25 Authorised disclosure: by the Secretary if authorised by affected person
323 30 Authorised disclosure: court proceedings
323 40 Offence: disclosure of information obtained by certain authorised disclosures
323 45 Offence: soliciting disclosure of information
323 50 Offence: use etc. of unauthorised information
323 55 Offence: offering to supply protected information
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Part 6 9—Review of decisions
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Division 328—Review of decisions
328 1 What this Part is about
328 5 ART review of decisions
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Part 6 10—Miscellaneous
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Division 333—Miscellaneous
333 1 Delegation by Minister
333 5 Delegation by Secretary
333 10 Approved forms
333 15 Signing approved forms
333 20 Private Health Insurance Rules made by the Minister
333 25 Private Health Insurance Rules made by APRA
333 30 Regulations
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Schedule 1—Dictionary
1 Dictionary
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Endnotes
Endnote 1—About the endnotes
Endnote 2—Abbreviation key
Endnote 3—Legislation history
Endnote 4—Amendment history
