Private Health Insurance (Benefit Requirements) Rules 2011
As amended
Made under item 3A of the table in section 333-20 of the Private Health Insurance Act 2007.
This compilation was prepared on 7 January 2013 taking into account amendments up to the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 10).
Prepared by the Department of Health and Ageing, Canberra
Contents
Part 1 Preliminary 3
1. Name of Rules 3
2. Commencement and Revocation 3
3. Definitions 3
4. Psychiatric care, rehabilitation and palliative care 5
5. Other hospital treatments 5
6. Benefit not to exceed hospital fees or charges 5
Schedule 1―Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 6
Schedule 2―Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia 17
Schedule 3―Same-day accommodation: hospitals in all States/Territories 18
Schedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories 31
Schedule 5―Second-tier default benefits 34
Notes 50
Part 1 Preliminary
These Rules are the Private Health Insurance (Benefit Requirements) Rules 2011.
(1) These Rules commence on 1 November 2011, or if registered after 1 November 2011, the day after registration.
(2) These Rules revoke the Private Health Insurance (Benefit Requirements) Rules 2010.
3. Definitions
In these Rules:
Act means the Private Health Insurance Act 2007.
ACT means the Australian Capital Territory.
certified Type B procedure means a Type B procedure certified in accordance with clause 10 of Schedule 1.
certified overnight Type C procedure means a Type C procedure certified in accordance with clause 11 of Schedule 1.
certified Type C procedure means a Type C procedure certified in accordance with clause 7 of Schedule 3.
continuous period of hospitalisation, for the purpose of counting days of hospital treatment, includes any two periods during which a patient was, or is, receiving hospital treatment as a patient at a hospital, whether or not the same hospital, where the periods are separated from each other by a period of not more than 7 days during which the patient was not receiving hospital treatment as a patient at any hospital.
diagnostic imaging services table means the table prescribed under subsection 4AA (1) of the Health Insurance Act 1973.
fee in the MBS means the Schedule fee as defined in subsection 8 (1A) of the Health Insurance Act 1973.
general medical services table means the table prescribed under subsection 4 (1) of the Health Insurance Act 1973.
insurer means a private health insurer.
item has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.
MBS comprises the:
(a) general medical services table;
(b) diagnostic imaging services table; and
(c) pathology services table.
negotiated agreement means an agreement entered into between a hospital and an insurer, that includes provisions to the effect that, except to the extent (if any) provided in the agreement, the hospital agrees to accept payment by the insurer in satisfaction of any amount that would, apart from the agreement, be owed to the hospital, in relation to an episode of hospital treatment, by an insured person under a policy.
NSW means the State of New South Wales.
nursing-home type patient has the meaning given by Schedule 4
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.
outreach service means a service referred to in subsection 16 (1) of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007, unless subsection 16 (2) of that Act applies to the particular service.
participating midwife has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.
pathology services table means the table prescribed under subsection 4A (1) of the Health Insurance Act 1973.
policy means a complying health insurance policy.
private hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a private hospital.
Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.
professional service has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.
public hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a public hospital.
Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.
Type A procedure means:
(a) a procedure specified in clauses 3 to 9 of Schedule 1; or
(b) a certified Type B procedure; or
(c) a certified overnight Type C procedure.
Type B procedure means:
(a) a procedure specified in clauses 3 to 7 of Schedule 3 other than a certified Type B procedure; or
(b) a certified Type C procedure.
Type C procedure means a procedure specified in clause 8 of Schedule 3 other than a certified Type C procedure.
Part 2 Minimum benefit requirements
(1) For item 1 in the table in subsection 72-1 (2) of the Act, the minimum benefit for hospital treatment specified in that item is the amount set out, or worked out using the method for working out the minimum benefit for that treatment, in Schedules 1, 2, 3 or 5 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.
Note: Item 1 in the table in subsection 72-1 (2) of the Act requires that each policy that covers hospital treatment must cover any part of hospital treatment that is psychiatric care, rehabilitation or palliative care if the treatment is provided in a hospital and no medicare benefit is payable for that part of the treatment.
(2) Despite subrule (1), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person's policy in respect of that treatment.
(1) For item 5 in the table in subsection 72-1 (2) of the Act, for a policy that covers any type of hospital treatment provided in a hospital, other than treatment referred to in rule 4, the minimum benefit for that treatment is the amount set out, or worked out using the method for working out the minimum benefit, for that treatment in Schedules 1, 2, 3, 4 or 5 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.
(2) Despite subsection (1), if a policy covers a type of hospital treatment, other than treatment referred to in rule 4, and the insurer for that policy has a negotiated agreement with the hospital in which the treatment is provided, the minimum benefit for that treatment is the amount specified for the treatment in the negotiated agreement.
(3) Despite subrules (1) and (2), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person’s policy in respect of that treatment.
(1) In respect of treatment referred to in rule 4 and in rule 5 other than hospital treatment for a nursing-home type patient (as set out in Schedule 4), the amount of benefit payable by the insurer in respect of hospital treatment for a person will not exceed the fees or charges incurred in respect of that hospital treatment.
(2) In respect of treatment referred to in rule 5 of this Part, the amount of benefit payable by the insurer in respect of hospital treatment for a nursing-home type patient (as set out in Schedule 4) will not exceed an amount equal to the fees or charges incurred in respect of that hospital treatment less the amount of the patient contribution in relation to the patient for each day on which the patient was a patient in the hospital.
Schedule 1―Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania
Part 1―General
1. Circumstances
For rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is:
(a) provided to a patient who is not a nursing-home type patient; and
(b) provided to a patient:
(i) at a private hospital; or
(ii) as shared ward accommodation at a public hospital in Victoria or Tasmania; and
Note: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.
(c) provided for the purpose of permitting the provision to the patient of hospital treatment that is:
(i) a Type A procedure; and
(ii) for a period that includes part of an overnight stay.
Note: A Type A procedure is defined to include a certified Type B procedure and a certified overnight Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.
2. Minimum benefit
(1) The minimum benefit for hospital treatment provided in the circumstances specified in this Schedule is the amount set out in the tables in this Schedule for that hospital treatment.
(2) When counting the days referred to in the tables in this Schedule to determine the minimum benefit in respect of any particular patient, days forming part of a continuous period of hospitalisation are to be counted.
Table 1―Accommodation at private hospitals in all States/Territories
| Class of patient | Minimum benefit payable per night |
| Advanced surgical patient | |
| - first 14 days | $384 |
| - over 14 days | $266 |
| Surgical patient or obstetric patient | |
| - first 14 days | $356 |
| - over 14 days | $266 |
| Psychiatric patient | |
| - first 42 days | $356 |
| - 43 – 65 days | $309 |
| - over 65 days | $266 |
| Rehabilitation patient | |
| - first 49 days | $356 |
| - 50 - 65 days | $309 |
| - over 65 days | $266 |
| Other patients | |
| - first 14 days | $309 |
| - over 14 days | $266 |
Table 2― Victoria: shared ward accommodation at a public hospital
| Class of patient | Minimum benefit payable per night |
| Advanced surgical patient | |
| - first 14 days | $384 |
| - over 14 days | $266 |
| Surgical patient or obstetric patient | |
| - first 14 days | $356 |
| - over 14 days | $266 |
| Psychiatric patient | |
| - first 42 days | $356 |
| - 43 – 65 days | $309 |
| - over 65 days | $266 |
| Rehabilitation patient | |
| - first 49 days | $356 |
| - 50 - 65 days | $309 |
| - over 65 days | $266 |
| Other patients | |
| - first 14 days | $309 |
| - over 14 days | $266 |
Table 3― Tasmania: shared ward accommodation at a public hospital
| Class of patient | Minimum benefit payable per night |
| Advanced surgical patient | |
| - first 14 days | $384 |
| - over 14 days | $266 |
| Surgical patient or obstetric patient | |
| - first 14 days | $356 |
| - over 14 days | $266 |
| Psychiatric patient | |
| - first 42 days | $356 |
| - 43 – 65 days | $309 |
| - over 65 days | $266 |
| Rehabilitation patient | |
| - first 49 days | $356 |
| - 50 - 65 days | $309 |
| - over 65 days | $266 |
| Other patients | |
| - first 14 days | $309 |
| - over 14 days | $266 |
Part 2 Type A procedures
3. Interpretation
A Type A procedure is a procedure specified in this Part provided to a patient in one of the categories of patients in clauses 4 to 9.
4. Advanced surgical patient
(1) In this Schedule, advanced surgical patient has the meaning given by this clause.
(2) A patient is taken to be an advanced surgical patient upon admission to a hospital:
(a) from and including the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3) is rendered to the patient at that hospital, unless the particular advanced surgical procedure to be rendered is recognised as requiring a longer pre‑operative period; or
(b) if a longer pre-operative period than that referred to in paragraph (a) is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or
(c) if the advanced surgery is rendered to a patient during an admission, from the day the advanced surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before).
Note: The effect of the reference in subclause (2) (a) to a professional service, being a service for which a medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply.
(3) The item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS greater than $852.95:
15600 30177 30250 30251 30255 30275 30294 30296 30297 30309 30315 30317 30318 30320 30321 30323 30324 30335 30336 30379 30382 30384 30388 30396 30405 30415 30417 30418 30421 30425 30427 30428 30430 30438 30448 30449 30454 30455 30457 30458 30460 30461 30463 30464 30466 30467 30469 30472 30500 30502 30503 30506 30508 30509 30512 30514 30517 30518 30521 30523 30524 30526 30527 30529 30532 30533 30535 30536 30538 30539 30541 30542 30545 30547 30548 30550 30551 30553 30554 30556 30557 30560 30565 30566 30577 30578 30580 30583 30584 30589 30590 30593 30594 30596 30599 30601 30602 30603 30605 30606 30680 30682 30684 30686 31002 31409 31412 31429 31432 31435 31438 31464 31466 31468 31472 31524 32000 32003 32004 32005 32006 32009 32012 32015 32018 32024 32025 32026 32028 32030 32033 32036 32039 32042 32047 32051 32054 32060 32063 32069 32104 32106 32108 32117 32209 32220 32221 32514 32517 32700 32703 32708 32710 32711 32712 32715 32718 32721 32724 32730 32733 32739 32742 32745 32748 32751 32754 32763 33050 33055 33075 33080 33100 33103 33109 33112 33115 33116 33118 33119 33121 33124 33127 33130 33133 33136 33139 33142 33145 33148 33151 33154 33157 33160 33163 33166 33169 33172 33175 33178 33181 33500 33506 33509 33512 33515 33518 33521 33524 33527 33530 33533 33536 33539 33542 33800 33803 33811 33812 33815 33818 33821 33824 33827 33830 33833 33836 33839 33842 34112 34115 34118 34121 34124 34127 34136 34139 34142 34148 34151 34154 34157 34160 34163 34166 34169 34172 34175 34509 34512 34518 34533 34803 34806 34809 34812 34815 34818 34821 34833 35003 35006 35009 35307 35312 35315 35320 35412 35561 35562 35595 35597 35641 35661 35664 35667 35670 35697 35753 35754 36500 36503 36506 36516 36519 36522 36525 36526 36527 36528 36529 36531 36532 36533 36540 36543 36564 36567 36570 36573 36576 36588 36591 36594 36597 36600 36603 36606 36645 36648 36656 37014 37029 37042 37045 37047 37053 37200 37203 37207 37209 37210 37211 37220 37230 37309 37341 37343 37375 37384 37390 37405 37411 37423 37426 37432 37444 37607 37610 37824 37842 37848 37851 38212 38231 38237 38240 38246 38270 38272 38287 38290 38293 38309 38312 38315 38318 38358 38368 38384 38390 38418 38421 38424 38427 38438 38440 38441 38446 38447 38449 38450 38453 38455 38456 38457 38466 38468 38469 38470 38477 38478 38480 38481 38483 38487 38488 38489 38493 38497 38498 38500 38501 38503 38504 38506 38507 38508 38509 38512 38515 38518 38550 38553 38556 38559 38562 38565 38568 38571 38572 38600 38603 38615 38618 38624 38640 38643 38647 38650 38653 38654 38656 38670 38673 38677 38680 38700 38703 38706 38709 38712 38715 38718 38721 38724 38727 38730 38733 38736 38739 38742 38745 38748 38751 38754 38757 38760 38763 38766 39106 39112 39124 39139 39315 39500 39503 39603 39609 39612 39615 39640 39642 39646 39650 39653 39654 39656 39658 39660 39662 39706 39709 39712 39715 39718 39800 39803 39806 39815 39818 39821 39903 40000 40003 40012 40103 40106 40109 40112 40118 40300 40301 40303 40306 40309 40312 40315 40316 40318 40321 40330 40331 40332 40334 40335 40339 40342 40345 40348 40351 40600 40700 40703 40706 40712 40801 40803 40850 40851 40860 41518 41521 41530 41533 41536 41539 41542 41551 41554 41557 41560 41563 41564 41566 41569 41572 41575 41576 41578 41579 41581 41584 41587 41590 41593 41596 41599 41608 41614 41615 41617 41623 41635 41638 41728 41734 41782 41785 41834 41837 41840 41843 41879 42521 42539 42543 42545 42557 42569 42626 42653 42656 42659 42662 42672 42710 42716 42725 42731 42746 42749 42752 42767 42773 42776 42779 42801 42842 42851 42860 43801 43804 43807 43810 43813 43816 43819 43822 43825 43828 43831 43834 43837 43840 43843 43846 43852 43855 43861 43864 43870 43873 43876 43879 43882 43900 43903 43906 43909 43912 43915 43936 43945 43951 43954 43957 43963 43966 43969 43972 43975 43978 43984 43987 43990 43993 43996 44334 44373 45006 45036 45215 45415 45418 45460 45461 45464 45465 45466 45468 45469 45471 45472 45474 45475 45477 45478 45480 45481 45483 45484 45490 45491 45492 45494 45500 45501 45502 45503 45504 45505 45520 45528 45530 45533 45539 45558 45559 45561 45562 45563 45564 45565 45566 45570 45587 45588 45596 45597 45599 45624 45638 45639 45641 45644 45646 45647 45660 45661 45686 45720 45723 45726 45729 45731 45732 45735 45738 45741 45744 45747 45752 45753 45754 45767 45770 45773 45776 45779 45782 45785 45788 45791 45853 45861 45863 45869 45871 45873 45897 46315 46318 46321 46393 46477 46504 46507 47486 47489 47501 47504 47507 47510 47519 47525 47531 47534 47566 47588 47591 47687 47690 47693 47699 47702 48203 48427 48512 48606 48612 48613 48618 48621 48624 48627 48630 48632 48639 48640 48645 48648 48651 48654 48657 48660 48669 48672 48681 48684 48687 48690 48691 48692 48694 48918 48921 48924 48933 48939 48942 48951 48954 48957 48960 49106 49115 49116 49117 49210 49211 49306 49312 49318 49319 49321 49324 49327 49330 49333 49339 49342 49345 49512 49517 49518 49519 49521 49524 49527 49530 49533 49536 49539 49542 49548 49551 49554 49564 49715 49716 49717 49836 49838 49842 50212 50215 50218 50221 50224 50227 50230 50233 50236 50239 50300 50303 50306 50321 50324 50327 50336 50351 50354 50366 50372 50378 50384 50394 50399 50408 50411 50414 50417 50420 50423 50450 50451 50455 50456 50460 50461 50465 50466 50470 50471 50475 50476 50604 50608 50612 50620 50624 50628 50632 50636 50640 50644 52123 52126 52129 52158 52337 52342 52345 52348 52351 52354 52357 52360 52363 52366 52369 52372 52375 52379 52380 52382 52430 52446 52821 53209 53212 53221 53224 53227 53230 53233
5. Obstetric patient
(1) In this Schedule, obstetric patient has the meaning given by this clause.
(2) A patient shall be taken to be an obstetric patient during an admission to a hospital from and including:
(a) whichever is the earlier of:
(i) the day on which the patient commences labour leading to delivery in that hospital; or
(ii) the day on which a professional service with the item number 16406, 16515, 16518, 16519, 16522 (excluding caesarean), 16525, 16527 or 16528 is rendered to the patient in that hospital; or
(b) if the circumstances in paragraph (a) do not apply, the day before a professional service with the item number 16520 and 16522 (including caesarean) is rendered to the patient at that hospital, unless the particular obstetric procedure to be rendered is recognised as requiring a longer pre-operative period; or
(c) the day on which a professional service with the item number 82120 or 82125 is rendered to a patient by a participating midwife.
(3) In this clause, the item numbers specified are the item numbers in the general medical services table.
6. Surgical patient
(1) In this Schedule, surgical patient has the meaning given by this clause.
(2) A patient shall be taken to be a surgical patient upon admission to a hospital from and including:
(a) the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3), is rendered to the patient at that hospital, unless the particular surgical procedure to be rendered is recognised as requiring a longer pre-operative period; or
(b) if a longer pre-operative period is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or
(c) if the surgery is rendered to a patient during an admission, from the day the surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before).
Note: The effect of the reference in subclause (2) (a) to a professional service, being the service for which a medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply.
(3) The item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS within the range of $254.00 to $852.95:
13212 13218 13251 13700 14230 14233 14236 14242 15303 15304 15307 15308 15311 15312 15315 15316 15319 15320 15323 15324 15327 15328 15331 15332 15335 15336 15345 16567 16570 16571 16573 30017 30020 30023 30024 30068 30110 30111 30114 30165 30168 30171 30174 30190 30197 30225 30229 30235 30241 30244 30246 30247 30253 30256 30272 30286 30289 30293 30299 30300 30302 30303 30306 30308 30310 30313 30314 30330 30332 30373 30375 30376 30378 30385 30387 30391 30392 30393 30394 30399 30400 30402 30403 30408 30414 30416 30419 30422 30431 30433 30434 30436 30437 30440 30443 30445 30446 30450 30451 30452 30475 30479 30481 30484 30485 30490 30491 30492 30493 30494 30495 30496 30497 30499 30505 30511 30515 30520 30530 30544 30559 30562 30563 30564 30568 30569 30571 30572 30575 30581 30586 30587 30597 30600 30609 30612 30614 30615 30616 30617 30620 30621 30635 30638 30641 30644 30672 30675 30676 30688 30690 30692 30694 30696 30710 31000 31001 31225 31245 31250 31260 31270 31275 31295 31300 31305 31310 31315 31320 31325 31330 31335 31340 31350 31355 31400 31403 31406 31423 31426 31450 31452 31454 31460 31462 31470 31500 31503 31506 31509 31512 31515 31518 31521 31527 31539 31545 31554 32021 32029 32045 32046 32057 32066 32090 32093 32094 32096 32099 32102 32103 32105 32111 32112 32120 32123 32126 32129 32131 32138 32139 32150 32159 32162 32165 32180 32183 32186 32200 32203 32206 32210 32213 32214 32216 32504 32507 32508 32511 32736 32757 32760 32766 32769 33070 33545 33548 33551 33554 33806 33810 33845 33848 34100 34103 34106 34109 34130 34133 34145 34500 34503 34515 34521 34524 34527 34528 34538 34800 34824 34827 34830 35000 35012 35100 35202 35300 35303 35306 35309 35317 35319 35321 35324 35327 35330 35331 35360 35361 35362 35363 35404 35406 35408 35410 35508 35530 35533 35536 35539 35542 35548 35551 35560 35564 35565 35566 35568 35570 35571 35573 35577 35578 35596 35599 35602 35605 35612 35613 35622 35623 35634 35635 35636 35637 35638 35645 35648 35649 35653 35657 35658 35673 35676 35677 35678 35680 35683 35684 35687 35688 35694 35700 35710 35712 35713 35716 35717 35720 35723 35726 35750 35756 35759 36502 36509 36537 36546 36549 36552 36558 36579 36585 36604 36605 36607 36608 36609 36612 36615 36618 36621 36624 36627 36630 36633 36636 36639 36642 36649 36652 36654 36658 36662 36663 36664 36666 36803 36806 36809 36811 36818 36821 36825 36833 36840 36842 36845 36854 36857 36863 37000 37004 37008 37020 37023 37026 37038 37043 37044 37050 37201 37202 37206 37208 37212 37215 37221 37224 37227 37233 37306 37318 37327 37330 37333 37336 37340 37342 37345 37348 37351 37354 37372 37381 37387 37396 37402 37408 37417 37418 37420 37429 37438 37601 37604 37605 37606 37613 37616 37619 37800 37803 37806 37809 37812 37818 37821 37827 37830 37833 37836 37839 37845 37854 38200 38203 38206 38209 38213 38215 38218 38222 38225 38228 38234 38241 38243 38256 38275 38300 38303 38306 38350 38353 38356 38362 38365 38371 38387 38393 38415 38430 38448 38452 38458 38460 38462 38464 38473 38475 38485 38490 38496 38505 38577 38588 38609 38612 38613 38621 38627 38637 39015 39018 39109 39118 39121 39125 39126 39127 39128 39130 39134 39137 39138 39140 39300 39303 39306 39309 39312 39318 39321 39323 39324 39327 39330 39331 39333 39600 39606 39700 39703 39721 39812 39900 39906 40006 40009 40015 40100 40115 40324 40327 40333 40336 40709 40800 40852 40854 40856 40858 40903 40905 41512 41515 41524 41527 41545 41548 41603 41611 41620 41629 41671 41672 41707 41710 41713 41716 41722 41725 41729 41731 41737 41743 41746 41749 41752 41767 41770 41773 41776 41779 41786 41787 41789 41792 41793 41813 41819 41820 41825 41831 41849 41852 41855 41858 41861 41864 41867 41868 41870 41873 41876 41880 41881 41885 41895 41898 41901 41905 41910 42506 42509 42510 42512 42515 42518 42527 42530 42533 42536 42542 42548 42551 42554 42563 42574 42584 42590 42596 42599 42602 42605 42608 42623 42629 42635 42638 42641 42665 42680 42686 42692 42695 42698 42701 42702 42703 42704 42707 42713 42719 42734 42737 42740 42743 42758 42761 42764 42770 42782 42783 42785 42786 42788 42789 42791 42792 42802 42805 42806 42807 42808 42809 42810 42815 42818 42833 42836 42839 42848 42854 42857 42863 42866 42869 43021 43022 43506 43509 43512 43515 43518 43521 43524 43849 43858 43867 43930 43933 43939 43960 43981 43999 44102 44108 44111 44114 44130 44133 44325 44328 44331 44350 44354 44359 44361 44364 44367 44370 45000 45003 45009 45012 45015 45018 45019 45020 45024 45026 45035 45042 45045 45048 45051 45200 45203 45206 45207 45209 45218 45221 45227 45233 45236 45239 45240 45403 45406 45409 45412 45439 45442 45445 45448 45451 45462 45485 45486 45487 45488 45489 45493 45496 45497 45498 45512 45519 45522 45524 45527 45536 45542 45545 45548 45551 45552 45553 45554 45555 45556 45557 45560 45568 45569 45572 45575 45578 45581 45584 45585 45586 45590 45593 45602 45605 45608 45611 45614 45620 45623 45626 45629 45632 45635 45652 45653 45656 45659 45662 45665 45668 45669 45671 45675 45676 45677 45680 45683 45689 45692 45695 45698 45701 45704 45707 45710 45713 45714 45716 45755 45758 45761 45794 45803 45809 45811 45813 45815 45817 45819 45821 45825 45827 45831 45833 45835 45837 45839 45841 45843 45845 45849 45855 45857 45859 45865 45867 45875 45877 45879 45885 45888 45891 45939 45984 45987 45990 45993 46300 46303 46306 46307 46309 46312 46324 46325 46330 46333 46336 46339 46342 46345 46351 46354 46357 46360 46372 46375 46378 46381 46384 46387 46390 46396 46399 46402 46405 46408 46411 46414 46417 46423 46426 46429 46432 46435 46441 46442 46444 46447 46453 46462 46468 46471 46474 46480 46483 46489 46492 46500 46501 46502 46503 46510 46522 47012 47021 47027 47033 47048 47051 47054 47063 47066 47333 47345 47357 47366 47372 47375 47381 47384 47385 47386 47387 47390 47393 47399 47402 47408 47417 47420 47426 47429 47432 47435 47438 47441 47447 47450 47451 47453 47456 47459 47468 47480 47483 47495 47498 47513 47516 47522 47528 47537 47546 47549 47552 47555 47558 47561 47564 47565 47567 47570 47573 47582 47585 47597 47600 47603 47609 47612 47615 47618 47621 47624 47630 47648 47654 47657 47684 47696 47705 47711 47717 47720 47723 47732 47741 47753 47756 47765 47768 47771 47774 47777 47780 47783 47786 47789 47920 47930 47936 47954 47957 47966 47969 47975 47982 48200 48206 48209 48212 48215 48218 48221 48224 48227 48230 48233 48236 48239 48242 48400 48403 48406 48409 48412 48415 48418 48421 48424 48500 48503 48506 48615 48636 48642 48663 48666 48675 48678 48693 48900 48903 48906 48909 48912 48915 48927 48930 48936 48945 48948 49100 49103 49109 49112 49118 49121 49200 49203 49206 49209 49215 49218 49221 49224 49227 49300 49303 49309 49315 49336 49346 49360 49363 49366 49500 49503 49506 49509 49515 49534 49545 49557 49558 49559 49560 49561 49562 49563 49566 49569 49700 49703 49706 49709 49712 49718 49724 49727 49728 49812 49815 49818 49821 49824 49827 49830 49833 49837 49839 49845 49854 49857 49860 49863 49866 50102 50103 50104 50106 50109 50112 50118 50121 50127 50130 50201 50203 50206 50209 50309 50312 50315 50318 50333 50339 50342 50345 50353 50357 50360 50363 50369 50375 50381 50387 50393 50396 50402 50405 50426 50500 50504 50508 50512 50516 50520 50524 50528 50532 50536 50540 50544 50548 50552 50556 50560 50564 50568 50572 50576 50580 50584 50588 50600 50616 50650 50654 50950 50952 51900 51904 51906 52018 52035 52039 52048 52051 52054 52059 52063 52066 52078 52090 52092 52094 52095 52105 52108 52111 52114 52117 52120 52122 52130 52131 52138 52141 52144 52147 52148 52182 52184 52186 52300 52303 52306 52312 52315 52321 52324 52330 52333 52336 52339 52378 52424 52440 52442 52444 52450 52452 52456 52458 52460 52480 52482 52484 52600 52603 52609 52612 52615 52618 52621 52624 52626 52627 52633 52800 52803 52806 52809 52812 52815 52818 52824 52828 52830 52832 53006 53009 53015 53016 53017 53019 53215 53218 53220 53225 53226 53236 53239 53242 53406 53409 53412 53413 53414 53415 53416 53418 53419 53422 53423 53424 53425 53427 53429 53453 53455 53460 55135 57351 57356
7. Psychiatric patient
In this Schedule, a psychiatric patient is a patient in a hospital who is admitted for the purposes of undertaking a specific psychiatric treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient’s disease, injury or condition.
Note: If a patient is receiving psychiatric treatment that is not under a specific psychiatric treatment program, the patient is taken to be in the category of 'other patient'.
8. Rehabilitation patient
In this Schedule, a rehabilitation patient is a patient in a hospital who is admitted for the purposes of undertaking a specific rehabilitation treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient’s disease, injury or condition.
Note: If a patient is receiving rehabilitation treatment that is not under a specific rehabilitation treatment program, the patient is taken to be in the category of 'other patient'.
9. Other patient
(1) In this Schedule, other patient is deemed to be a patient at a hospital who is receiving any treatment that involves part of an overnight stay, but who is not:
(a) an advanced surgical patient;
(b) a surgical patient;
(c) an obstetric patient;
(d) a psychiatric patient; or
(e) a rehabilitation patient.
Note: A patient receiving hospital treatment that is palliative care as described in item 1 of the table in subsection 72-1 (2) of the Act is deemed to be in the category of 'other patient'.
Part 3 Certified Type B procedures and certified overnight Type C procedures
10. Certified Type B procedures
(1) Minimum benefits for overnight accommodation are payable for patients receiving a Type B procedure only if certification under subclause (2) is provided.
(2) Certification must be provided as follows:
(a) the practitioner providing the Type B procedure; or
(b) a professional employed by a hospital who is involved in the provision of the procedure provided by that hospital,
must certify in writing that:
(c) because of the medical condition of the patient specified in the certificate; or
(d) because of the special circumstances specified in the certificate,
it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay.
11. Certified overnight Type C procedures
(1) Minimum benefits for overnight accommodation are payable for patients receiving a certified Type C procedure only if:
(a) certification has first been provided for the Type C procedure in accordance with clause 7 of Schedule 3; and
(b) certification under subclause (2) is also provided.
(2) Certification must be provided as follows the practitioner providing the certified Type C procedure must certify in writing that:
(a) because of the medical condition of the patient specified in the certificate; or
(b) because of the special circumstances specified in the certificate,
it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay.
Schedule 2―Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia
1. Circumstances
For rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided:
(a) to a patient who is not a nursing-home type patient; and
(b) as shared ward accommodation at a public hospital in the ACT, NSW, Northern Territory, Queensland, South Australia or Western Australia; and
Note: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.
(c) for the purpose of permitting the provision to the patient of hospital treatment that is:
(i) a Type A procedure; and
(ii) for a period that includes part of an overnight stay.
Note: A Type A procedure is defined to include a certified Type B procedure and a certified overnight Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.
2. Minimum benefit
The minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in the table in this Schedule for that hospital treatment.
Table
| State/Territory | Minimum benefit payable per night |
| ACT | $318 |
| NSW | $318 |
| Northern Territory | $318 |
| Queensland | $324 |
| South Australia | $318 |
| Western Australia | $318 |
Schedule 3―Same-day accommodation: hospitals in all States/Territories
Part 1―General
1. Circumstances
For rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided for the purpose of permitting the provision to the patient of hospital treatment that:
(a) is a Type B procedure; and
(b) is provided to a patient at a hospital; and
(c) does not include part of an overnight stay at a hospital.
Note 1: A Type B procedure includes a certified Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.
Note 2: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.
2. Minimum benefit
(1) The minimum benefit for hospital treatment provided in the circumstances specified in this Schedule is the amount set out in Table 1 or 2 in this clause for that hospital treatment.
(2) The references to Bands in the tables are references as follows:
(a) Band 1 means Band 1 treatment;
(b) Band 2 means Band 2 treatment;
(c) Band 3 means Band 3 treatment;
(d) Band 4 means Band 4 treatment,
as those bands are described in Part 2 of this Schedule.
Table 1
| Public hospitals | Band 1 | Band 2 | Band 3 | Band 4 |
| | | | | |
| NSW | $230 | $257 | $283 | $318 |
| ACT | $230 | $257 | $283 | $318 |
| Northern Territory | $230 | $262 | $305 | $318 |
| Queensland | $236.50 | $264 | $291 | $324 |
| South Australia | $230 | $262 | $290 | $318 |
| Tasmania | $223 | $265 | $308 | $356 |
| Victoria | $225 | $266 | $310 | $356 |
| Western Australia | $260 | $260 | $260 | $260 |
Table 2
| Private hospitals | $199 | $251 | $305 | $356 |
Part 2―Type B procedures
3. Interpretation
A Type B procedure is a procedure specified as a Band 1, 2, 3 and 4 as described in this Part.
Note: These procedures normally require hospital treatment that does not include part of an overnight stay.
4. Band 1
(1) Hospital treatment that involves a professional service of the type identified by the MBS item number specified in this subclause is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule:
(a) category 3―therapeutic procedures, being the items below in the general medical services table:
T1: Miscellaneous Therapeutic Procedures:
13100 13103 13703 13706 13915 13918 13921 13924 13927 13930 13933 13936
T8: Surgical Operations:
30210 30473 30475 30476 30478 30679 32075 32078 32081 32084 32087 32090 32095 32215 35500 35539 35545 35703 36665 37011 39000 39100 41604 41647 41674 41680 42575 42741 45027 50658; and
(b) category 5―diagnostic imaging services, being the items below in the diagnostic imaging services table:
I1: Ultrasound:
55118 55600 55603; and
(2) Other hospital treatment requiring day admission to a hospital that is not Band 2, 3 or 4 treatment is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule.
5. Non-band specific Type B day procedures
(1) Hospital treatment that involves a professional service of the type identified by the MBS item number specified in this clause is a non-band specific Type B day procedure.
13110 13212 13215 13292 13318 13750 13755 13757 13815 13948 14218 15338 15513 15539 16512 16603 16618 18216 18230 18242 18274 18276 18280 18284 18286 18290 18294 18296 18298 30041 30042 30045 30055 30081 30084 30087 30094 30096 30099 30102 30103 30104 30106 30107 30187 30189 30190 30223 30225 30262 30269 30281 30282 30283 30390 30391 30409 30484 30493 30653 30656 30659 30660 30687 31225 31230 31235 31240 31255 31256 31257 31258 31260 31261 31262 31263 31265 31266 31267 31268 31270 31271 31272 31273 31275 31276 31277 31278 31280 31281 31282 31283 31285 31286 31287 31288 31290 31291 31292 31293 31295 31300 31305 31310 31315 31320 31325 31330 31335 31340 31345 31346 31350 31355 31441 31456 31458 31530 31551 31557 31560 31563 31566 32093 32094 32145 32147 32150 32153 32156 32168 32171 32177 32180 32217 32504 34109 34130 34500 34503 34506 34524 34539 35324 35507 35508 35509 35512 35513 35516 35517 35520 35523 35526 35527 35542 35557 35569 35572 35611 35615 35616 35617 35618 35622 35623 35626 35627 35630 35633 35637 35639 35640 35643 35644 35645 35646 35647 35648 35687 35688 36650 36660 36667 36668 36812 36815 36818 36821 36824 36827 36830 36833 36836 36860 37219 37315 37318 37321 37354 37369 37435 37622 37623 37803 37806 37809 37812 37815 37854 38285 38286 39013 39118 39133 39135 39140 39331 41503 41506 41509 41626 41629 41632 41644 41650 41653 41665 41668 41677 41695 41701 41716 41761 41764 41800 41801 41816 41819 41822 41825 41831 41849 41852 41855 41858 41861 41864 41886 41889 41892 41898 42503 42572 42573 42584 42593 42610 42611 42673 42680 42683 42686 42689 42692 42738 42739 42812 42818 42833 42845 42869 43942 43948 44102 44105 44136 44338 45019 45020 45030 45033 45039 45200 45224 45239 45506 45515 45626 45665 45668 45823 46327 46330 46336 46363 46366 46369 46396 46420 46423 46438 46441 46450 46486 46489 46494 46495 46501 46510 46525 47738 47906 47915 47918 47927 47972 48600 48603 48945 49218 49557 49700 49800 49803 49806 49809 50100 50115 51902 52015 52025 52042 52045 52057 52058 52061 52062 52064 52072 52073 52075 52081 52084 52087 52097 52099 52102 52180 52321 52826 53003 53006 53009 53054 53056 53058 53060 53062 53064 53070 53206 53215 53218 53225 53410 53459 58939 59903 59912 59925 59970 59971 59972 59973 59974 60000 60003 60006 60009 60012 60015 60018 60021 60024 60027 60030 60033 60036 60039 60042 60045 60048 60051 60054 60057 60060 60063 60066 60069 60072 60075 60078
(2) A non-band specific Type B day procedure is Band 2, 3 or 4 treatment depending on anaesthetic type and, where applicable, theatre time as specified in clause 6 of this Schedule.
(3) If a non-band specific Type B day procedure does not involve anaesthetic or theatre times, the minimum benefit is the benefit for Band 1 treatment.
6. Other bands
In this Schedule:
Band 2 treatment means procedures, other than those that are Band 1 treatment, carried out under local anaesthetic with no sedation.
Band 3 treatment means procedures, other than those that are Band 1 treatment, carried out under:
(a) general anaesthesia; or
(b) regional anaesthesia; or
(c) intravenous sedation,
where the theatre time, being the actual time in theatre, is less than one hour.
Band 4 treatment means procedures, other than those that are Band 1 treatment, carried out under:
(a) general anaesthesia; or
(b) regional anaesthesia; or
(c) intravenous sedation,
where the theatre time, being the actual time in theatre, is one hour or more.
7. Certified Type C procedure
Note: Type C procedures are procedures that do not normally require hospital treatment.
(1) Benefits for day-only accommodation are payable for patients receiving a Type C procedure only if certification under subclause (2) is provided.
(2) Certification must be provided as follows, the medical practitioner providing the professional service must certify in writing that:
(a) because of the medical condition of the patient specified in the certificate; or
(b) because of the special circumstances specified in the certificate,
it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that does not include part of an overnight stay.
Part 3―Type C procedures
8. Interpretation
A Type C procedure is a procedure specified in this clause by reference to MBS items.
Note: These procedures normally do not require hospital treatment.
Items in the general medical services table
The following items are items in the general medical services table.
Category 1 – Attendances
A1:
3 4 20 23 24 35 36 37 43 44 47 51
A2:
52 53 54 57 58 59 60 65 92 93 95 96
A3:
104 105 106 107 108 109
A4:
110 116 119 122 128 131 132 133
A28:
141 143 145 147
A5:
160 161 162 163 164
A6:
170 171 172
A7:
173 193 195 197 199
A8:
289 291 293 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 322 324 326 328 330 332 334 336 338 342 344 346 348 350 352 353 355 356 357 358 359 361 364 366 367 369 370
A9:
10801 10802 10803 10804 10805 10806 10807 10808 10809 10816
A12:
385 386 387 388
A13:
410 411 412 413 414 415 416 417
A15:
721 723 729 731 732 820 822 823 825 826 828 855 857 858
A17:
900 903
A18:
2497 2501 2503 2504 2506 2507 2509 2517 2518 2521 2522 2525 2526 2546 2547 2552 2553 2558 2559
A19:
2598 2600 2603 2606 2610 2613 2616 2620 2622 2624 2630 2631 2633 2635 2664 2666 2668 2673 2675 2677
A20:
2713 2721 2723 2725 2727
A21:
501 503 507 511 515 519 520 530 532 534 536
A22:
5000 5003 5010 5020 5023 5028 5040 5043 5049 5060 5063 5067
A23:
5200 5203 5207 5208 5220 5223 5227 5228 5260 5263 5265 5267
A24:
2801 2806 2814 2824 2832 2840 2946 2949 2954 2958 2972 2974 3005 3010 3014 3018 3023 3028 3032 3040 3044 3051 3055 3062
A25:
5906 5908 5910 5912
A26:
6007 6009 6011 6013 6015
A27:
4001
M3:
10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970
M5:
10988 10989
Category 2 – Diagnostic procedures & investigations
D1:
11000 11003 11006 11009 11012 11015 11018 11024 11027 11200 11204 11205 11210 11211 11215 11218 11221 11222 11224 11225 11235 11237 11240 11241 11242 11243 11300 11306 11309 11312 11315 11318 11321 11324 11327 11332 11333 11336 11339 11500 11503 11506 11509 11512 11602 11604 11605 11610 11611 11612 11614 11615 11700 11701 11702 11708 11709 11710 11711 11712 11713 11715 11718 11721 11722 11724 11727 11800 11810 11820 11823 11830 11833 11900 11903 11906 11909 11912 11915 11917 11919 11921 12000 12003 12012 12015 12018 12021 12200 12201 12306 12309 12312 12315 12318 12321 12323
D2:
12500 12503 12506 12509 12512 12515 12518 12521 12524 12527 12530 12533
Category 3 – Therapeutic procedures
T1:
13104 13200 13203 13206 13209 13221 13290 13312 13709 13760 13839 13842 13939 13942 13945 14050 14053 14100 14106 14109 14112 14115 14118 14124 14200 14201 14202 14203 14206 14209 14215 14221 14227 14245
T2:
15000 15003 15006 15009 15012 15100 15103 15106 15109 15112 15115 15211 15214 15215 15218 15221 15224 15227 15230 15233 15236 15239 15242 15245 15248 15251 15254 15257 15260 15263 15266 15269 15272 15500 15503 15506 15509 15512 15515 15518 15521 15524 15527 15530 15533 15550 15553 15556 15559 15562
15700 15705 15710 15800 15850
T3:
16003 16006 16009 16012 16015 16018
T4:
16400 16500 16501 16502 16504 16505 16508 16509 16511 16514 16600
T6:
17610 17615 17620 17625 17640 17645 17650 17655 17680 17690
T7:
18213
T8:
30003 30006 30026 30032 30038 30061 30062 30064 30071 30097 30185 30186 30192 30195 30196 30202 30203 30205 30207 30213 30214 30216 30219 30628 31200 31205 31210 31215 31220 32072 32115 32132 32135 32142 32500 32501 32520 32522 35502 35503 35554 35608 35614 35620 36800 37041 37217 37218 37300 37303 37415 38800 39115 40862 41500 41659 41662 41698 41704 41755 41828 41846 42587 42614 42615 42617 42620 42644 42650 42667 42668 42676 42677 42744 42782 42783 42785 42786 42788 42789 42791 42792 42794 42797 42806 42807 42808 42809 42811 45021 45025 45026 45546 45799 45801 45805 45807 45829 45847 45851 45882 47471 47735 47904 47912 47916 47924
T11:
18350 18351 18352 18354 18356 18358 18360 18361 18362 18364 18366 18368 18370 18371 18372 18373
Category 4 – Oral and maxillofacial
O1:
51700 51703
O3:
52034 52036 52039 52055 52056 52133
O7:
53000 53004 53052
O9:
53458
O10:
53600
Items in the diagnostic imaging services table
The following items are items in the diagnostic imaging services table.
Category 5 – Diagnostic Imaging Services
I1:
55028 55029 55030 55031 55032 55033 55036 55037 55038 55039 55044 55045 55048 55049 55054 55070 55073 55076 55079, 55113 55114 55115 55116 55117 55238 55244 55246 55248 55252 55274 55276 55278 55280 55282 55284 55292 55294 55296 55700 55703 55704 55705 55706 55707 55708 55709 55712 55715 55718 55721 55723 55725 55729 55731 55733 55736 55739 55812 55814 55816 55818 55820 55822 55824 55826 55828 55830 55832 55834 55836 55838 55840 55842 55844 55846 55852 55854
I2:
56001 56007 56010 56013 56016 56022 56028 56030 56036 56041 56047 56050 56053 56056 56062 56068 56070 56076 56101 56107 56141 56147 56220 56221 56223 56224 56225 56226 56227 56228 56229 56230 56231 56232 56233 56234 56235 56236 56237 56238 56239 56240 56259 56301 56307 56341 56347 56401 56407 56409 56412 56441 56447 56449 56501 56507 56541 56547 56552 56554 56619 56625 56659 56665 56801 56807 56841 56847 57001 57007 57041 57047 57201 57247 57341 57345 57350 57355
I3:
57506 57509 57512 57515 57518 57521 57524 57527 57700 57703 57706 57709 57712 57715 57721 57901 57902 57903 57906 57909 57912 57915 57918 57921 57924 57927 57930 57933 57939 57942 57945 57960, 57963 57966 57969 58100 58103 58106 58108 58109 58112 58115 58300 58306 58500 58503 58506 58509 58521 58524 58527 58700 58706 58715 58718 58721 58900 58903 58909 58912 58915 58916 58921 58924 58927 58933 58936 59103 59300 59303 59306 59309 59312 59314 59318 59503 59700 59703 59712 59715 59718 59724 59733 59736 59739 59751 59754 59760 59763 60100 60500 60503 60918 60927
I4:
61302 61303 61306 61307 61310 61313 61314 61316 61317 61320 61328 61340 61348 61352 61353 61356 61360 61361 61364 61368 61372 61373 61376 61381 61383 61384 61386 61387 61389 61390 61393 61397 61401 61402 61405 61409 61413 61417 61421 61425 61426 61429 61430 61433 61434 61437 61438 61441 61442 61445 61446 61449 61450 61453 61454 61457 61458 61462 61465 61469 61473 61480 61484 61485 61495 61499 61505 61541 61544 61553 61556 61565 61568
I5:
63001 63004 63007 63010 63040 63043 63046 63049 63052 63055 63058 63061 63064 63067 63070 63073 63101 63111 63114 63125 63128 63131 63151 63154 63161 63164 63167 63170 63173 63176 63179 63182 63185 63201 63204 63219 63222 63225 63228 63231 63234 63237 63240 63243 63271 63274 63277 63280 63301 63304 63307 63322 63325 63328 63331 63334 63337 63340 63361 63385 63388 63391 63401 63404 63416 63425 63428 63440 63443 63446 63461 63464 63467 63470 63473 63476 63482 63491 63494 63497 63507 63510 63513 63516 63519 63522 63525 63526 63527 63528 63529 63530
Category 6 – Pathology services
The following items are items in the pathology services table.
P1:
65060 65066 65070 65072 65075 65078 65079 65081 65082 65084 65087 65090 65093 65096 65099 65102 65105 65108 65109 65110 65111 65114 65117 65120 65123 65126 65129 65137 65142 65144 65147 65150 65153 65156 65157 65158 65159 65162 65165 65166 65171 65175 65176 65177 65178 65179 65180 65181
P2:
66500 66503 66506 66509 66512 66517 66518 66519 66536 66539 66542 66545 66548 66551 66554 66557 66560 66563 66566 66569 66572 66575 66578 66581 66584 66587 66590 66593 66596 66599 66602 66605 66606 66607 66608 66609 66623 66626 66629 66632 66635 66638 66639 66641 66642 66644 66647 66650 66651 66652 66653 66655 66656 66659 66660 66662 66663 66665 66666 66667 66671 66674 66677 66680 66683 66686 66695 66696 66697 66698 66701 66704 66707 66711 66712 66714 66715 66716 66719 66722 66723 66724 66725 66728 66731 66734 66743 66749 66750 66751 66752 66755 66756 66757 66758 66761 66764 66767 66770 66773 66776 66779 66780 66782 66783 66785 66788 66789 66790 66791 66792 66800 66803 66804 66805 66806 66812 66815 66816 66817 66819 66820 66821 66822 66825 66826 66827 66828 66830 66831 66832 66900
P3:
69300 69303 69306 69309 69312 69316 69317 69318 69319 69321 69324 69325 69327 69328 69330 69331 69333 69336 69339 69345 69354 69357 69360 69363 69379 69383 69384 69387 69390 69393 69396 69400 69401 69405 69408 69411 69413 69415 69418 69419 69445 69451 69471 69472 69474 69475 69478 69481 69482 69483 69484 69488 69489 69491 69492 69494 69495 69496 69497 69498 69499 69500
P4:
71057 71058 71059 71060 71062 71064 71066 71068 71069 71071 71072 71073 71074 71075 71076 71077 71079 71081 71083 71085 71087 71089 71090 71091 71092 71093 71095 71096 71097 71099 71101 71103 71106 71119 71121 71123 71125 71127 71129 71131 71133 71134 71135 71137 71139 71141 71143 71145 71146 71147 71148 71149 71151 71153 71154 71155 71156 71157 71159 71163 71164 71165 71166 71167 71168 71169 71170 71180 71183 71186 71189 71192 71195 71198 71200 71203
P5:
72813 72816 72817 72818 72823 72824 72825 72826 72827 72828 72830 72836 72838 72844 72846 72847 72848 72849 72850 72851 72852 72855 72856 72857
P6:
73043 73045 73047 73049 73051 73053 73055 73057 73059 73060 73061 73062 73063 73064 73065
P7:
73287 73290 73291 73292 73293 73294 73289 73300 73305 73308 73309 73311 73312 73314 73315 73317 73318 73320 73321 73323 73324 73328 73330 73332 73333 73334 73335
P8:
73521 73523 73525 73527 73529
P9:
73801 73802 73803 73804 73805 73806 73807 73808 73809 73810 73811
P10:
73920 73922 73923 73924 73925 73926 73927 73928 73929 73930 73931 73932 73933 73934 73935 73936 73937 73938 73939
P11:
73940
P13:
74992 74993 74994 74995 74996 74997 74998 74999
Category 8 – Miscellaneous Services
The following items are items in the miscellaneous services table.
M13:
82100 82105 82110 82115 82130 82135 82140
Schedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories
1. Circumstances
(1) For rule 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided:
(a) to a nursing-home type patient; and
(b) at a hospital.
Note: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.
2. Interpretation
Nursing-home type patient, in relation to a hospital, means a patient who has been provided with hospital treatment whether:
(a) acute care; or
(b) accommodation and nursing care, as an end in itself; or
(c) a mixture of both,
for a continuous period of hospitalisation exceeding 35 days (35-day period), but a patient receiving acute care immediately after the 35-day period does not become a nursing-home type patient unless the period of acute care ends and the patient is then provided with accommodation and nursing care, as an end in itself, as part of a continuous period of hospitalisation.
Note 1: 'Continuous period of hospitalisation' is defined in rule 3 of Part 1 of these Rules.
Note 2: Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.
Note 3: If there is disagreement as to whether a patient is, or is not, a nursing‑home type patient, an insured person, a private health insurer or a health care provider may make a complaint to the Private Health Insurance Ombudsman under Part 6-2 of the Act. The Ombudsman has various powers to deal with complaints, including conducting mediation if the complainant agrees.
3. Application
(1) Clause 2 of this Schedule applies to a patient who on or after the day on which the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) commence:
(a) returns to hospital for hospital treatment at a hospital not later than 7 days after receiving hospital treatment at that hospital or another hospital; or
(b) is otherwise admitted to a hospital for hospital treatment at the hospital.
(2) If subclause (1) does not apply to a patient, the definition of 'nursing‑home type patient' in these Rules before the commencement of the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) continues to apply to that patient.
Note: Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.
4. Provision of acute care
If a nursing-home type patient is provided with acute care at the hospital (the first hospital), or at another hospital, the patient:
(a) ceases to be a nursing‑home type patient only for the days on which the acute care is provided; and
(b) again becomes a nursing‑home type patient when the provision of acute care ends and the patient is then provided with accommodation and nursing care as an end in itself, whether at the first hospital or another hospital.
5. Ceasing and resuming hospital treatment
If a nursing-home type patient, or a person referred to in paragraph 4 (a), leaves hospital but returns to a hospital, whether or not at the same hospital, not more than 7 days later and is provided with hospital treatment at the hospital, the patient is a nursing‑home type patient for each subsequent day that the patient is provided with accommodation and nursing care, as an end in itself, until the patient ceases to be provided with hospital treatment at a hospital for a period of more than 7 days.
Note: If the relevant period of hospitalisation is broken by more than 7 days, clause 2 of this Schedule may again apply to the person.
6. Minimum benefit
The minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in Table 1 or 2 of this Schedule for that hospital treatment.
Table 1
| Public hospital: State/Territory | Minimum benefit per night |
| NSW | $109.10 |
| Northern Territory | $77.47 |
| Queensland | $102.00 |
| South Australia | $108.00 |
| Tasmania | $124.90 |
| Victoria | $113.70 |
| ACT | $107.40 |
| Western Australia | $116.05 |
Schedule 5―Second-tier default benefits
1. Interpretation
(1) In this Schedule:
accredited means:
(a) assessed by an appropriate accrediting body as being fully compliant with the National Safety and Quality Health Service Standards; or
(b) a hospital that was listed in the table at clause 4 of this Schedule (the table) as in force immediately before the commencement of the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 10) until the first time from the commencement of the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 10) that hospital’s accreditation expires or otherwise ceases.
Note: Facilities are not required to be assessed against the National Safety and Quality Health Service Standards until such time as their current accreditation expires or where new accreditation is sought.
Accreditation for the purposes of paragraph (b) of this definition means the accreditation used in respect of the facility for the purposes of being listed in the table.
appropriate accrediting body means a body approved by the Australian Commission on Safety and Quality in Healthcare to accredit health care organisations or health care providers against the National Safety and Quality Health Service Standards as a 1 January 2013.
Note: The Australian Commission on Safety and Quality in Healthcare is established under section 8 of the National Health Reform Act 2011.
facility has the meaning given in clause 4.
Hospital Casemix Protocol Data means the data required to be provided by hospitals to insurers under Rule 4 of the Private Health Insurance (Health Insurance Business) Rules made under item 6 of the table in section 333-20 of the Act.
Note: Rule 4 of the Private Health Insurance (Health Insurance Business) Rules made under item 6 of the table in section 333-20 of the Private Health Insurance Act 2007, specifies the information to be provided by hospitals to the insurer.
Rule 7 of the Private Health Insurance (Health Insurance Business) Rules specifies the information to be provided by the hospital to the Department of Health and Ageing.
informed financial consent in respect of a hospital means the hospital having procedures in place to inform a patient or nominee, in writing, of what hospital charges, insurer benefits and out-of-pocket costs (where applicable) are expected in respect of the hospital treatment. A patient or nominee must be informed:
(a) for scheduled admissions – at the earliest opportunity before admission for the hospital treatment; or
(b) for unplanned admissions – as soon after the admission as the circumstances reasonably permit.
National Safety and Quality Health Service Standards means the standards developed by the Australian Commission on Safety and Quality in Healthcare
as at 1 January 2013.
Note: Development of the National Safety and Quality Health Service Standards is a function of the Australian Commission on Safety and Quality in Healthcare under paragraph 9(1)(e) of National Health Reform Act 2011.
simplified billing in respect of a hospital means:
(a) providing patients, within 1 month after the patient has been discharged from the hospital, a single account in respect of that hospital treatment, covering all hospital services and related services (not necessarily including professional services); and
(b) having processes in place that would allow the inclusion of in‑hospital medical bills in a simplified billing arrangement.
Note: The facility may also issue interim accounts where an episode of hospital treatment exceeds 7 days (excluding leave periods) and where the patient to whom the admission applies has been advised that this will occur.
(2) In this Schedule, except in subclause (4) of this clause, the ACT is taken to be part of NSW and the Northern Territory is taken to be part of the State of South Australia.
(3) In this Schedule, private hospitals are comparable if they fall within the same category from the following list:
(a) private hospitals which provide psychiatric care for at least 50% of the episodes of hospital treatment;
(b) private hospitals which provide rehabilitation care for at least 50% of the episodes of hospital treatment;
(c) private hospitals which do not fall into categories (a) or (b), with up to and including 50 licensed beds;
(d) private hospitals which do not fall into categories (a) or (b) with more than 50 licensed beds and up to and including 100 licensed beds;
(e) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit;
(f) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, with either (or both) an accident and emergency unit or a specialised cardiac care unit;
(g) private hospitals which only provide hospital treatment which does not include any part of an overnight stay.
(4) In subclause (3), a reference to licensed beds is a reference to the beds or patients that a private hospital is permitted, under State or Territory legislation in the State or Territory where the private hospital is located.
2. Circumstances
For rules 4 and 5 of Part 2 of these Rules, the circumstances for hospital treatment to which this Schedule applies are that the treatment is provided to a patient who is not a nursing-home type patient and the treatment is provided at a facility.
Note: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.
3. Minimum benefit
(1) Despite anything in Schedules 1, 2 or 3, but subject to subclause (2) of this clause, the minimum benefit for hospital treatment provided in the circumstances described in clause 2 of this Schedule is the amount worked out in accordance with this clause.
(2) Where hospital treatment is provided in the circumstances described in clause 2 of this Schedule, but:
(a) the minimum benefit worked out in accordance with this clause for the hospital treatment is below the amount determined in accordance with Schedules 1, 2 or 3 of these Rules; or
(b) an amount for the hospital treatment cannot be worked out in accordance with this clause,
the minimum benefit for that hospital treatment is the amount worked out in accordance with Schedules 1, 2 or 3 for that hospital treatment.
(3) If a hospital ceases to be a facility for the purposes of this Schedule, the minimum benefit in relation to an episode of hospital treatment for an insured person who was an admitted patient at the facility or booked for hospital treatment at the facility (as opposed to merely being on the facility’s waiting list) before the day that the hospital ceased to be a facility is the minimum benefit that would have applied if the hospital continued to be a facility at the time the treatment was provided.
(4) Subject to subclauses (2) and (8) the minimum benefit payable by an insurer for an episode of hospital treatment between 1 September of a particular year (the first year) and 31 August of the next year is an amount no less than 85% of the average charge for the equivalent episode of hospital treatment, under that insurer's negotiated agreements in force on 1 August of the first year with all such comparable private hospitals in the State in which the facility is located.
(5) The formula for calculating the average charge for the equivalent episode of hospital treatment by an insurer in each State is as follows:
Where: j = group of equivalent episodes of hospital treatment under the insurer's negotiated agreements;
i = group of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;
n= the number of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;
Rji = charge for episode of hospital treatment type j in the negotiated agreement i
Rj = average charge for episode of hospital treatment type j.
(6) In subclause (4), each episode of hospital treatment must be identified using the patient classification system and payment structure in the majority of the relevant insurer's negotiated agreements in force on 1 August of the first year with all comparable private hospitals in the State in which the facility is located.
(7) In subclause (4), for the purpose of calculating the average charge for the equivalent episode of hospital treatment in a State:
(a) the charge will include the sum of the amount payable by the insurer under that insurer's negotiated agreement and any excess or co‑payment amounts payable by members, in accordance with the insurer's rules; and
Note: Policy holders’ financial obligations under such levels of cover will still apply.
(b) must not include any charges:
(i) referred to in the insurer's negotiated agreements for prostheses; and
(ii) that are minimum benefits for prostheses as specified for the purpose of item 4 of the table in subsection 72-1 (2) of the Act, and
(iii) referred to in the insurer's negotiated agreements for hospital treatment provided to nursing-home type patients.
(8) Subject to subclause (2), if an insurer has less than 5 negotiated agreements in force on 1 August of the first year with a particular category of comparable private hospitals in a State, then all of that insurer's negotiated agreements with all classes of private hospitals in that State are to be used to calculate the minimum benefit.
4. Facilities
(1) A hospital is a facility for the purposes of this Schedule if it is included in the list of second-tier eligible facilities approved by the Second Tier Advisory Committee existing at the time that the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 10) commence.
(2) To be considered a second-tier eligible facility for the purposes of clause 4, the hospital must be assessed by the Second Tier Advisory Committee as:
(a) being a private hospital within the meaning of subsection 121-5(8) of the Act;
(b) being accredited;
(c) providing simplified billing;
(d) providing informed financial consent; and
(e) submitting Hospital Casemix Protocol Data to health insurers electronically, where possible, with claims.
Notes
The Private Health Insurance (Benefit Requirements) Rules 2011 as shown in this compilation are amended as indicated in the Tables below.
Table of Instruments
| Instrument | Date of FRLI registration | Date of commencement | Application, saving or transitional provision |
| Private Health Insurance (Benefit Requirements) Rules 2011 | 31 Oct 2011 (see F2011L02160) | 1 November 2011 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2011(No.10) | 19 Dec 2011 (see F2011L02731) | 20 December 2011 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 1) | 20 March 2012 (see F2012L00604) | 20 March 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 2) | 11 April 2012 (see F2012L00822) | 12 April 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3) Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 4) | 20 April 2012 (see F2012L00905) 20 June 2012 (see F2012L01264) | 21 April 2012 1 July 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 5) | 18 Sept 2012 (see F2012L01887) | 20 September 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 6) | 31 Sept 2012 (see F2012l02111) | 1 November 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 7) | 31 Sept 2012 (see F2012L02114) | 1 November 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 8) | 7 Nov 2012 (see F2012L02151) | 8 November 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 9) | 17 Dec 2012 (see F2012L02502) | 18 December 2012 | |
| Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 10) | 2 Jan 2013 (see F2013L00003) | 3 January 2013 | |
Table of Amendments
| ad. = added or inserted am. = amended rep. = repealed rs. = repealed and substituted |
| Provision affected | How affected |
| Schedule 1 | |
| Part 1, Subclause 2(2) | am. F2012L01264 |
| Part 2, Subclause 6(3) | am. F2012L00604 |
| Part 2, Subclause 6(3) | am. F2012L01264 |
| Part 2, Subclause 4(3) | am. F2012L02114 |
| Part 2, Subclause 4(3) | am. F2012L02151 |
| Part 2, Subclause 6(3) | am. F2012L02114 |
| Part 2, Subclause 6(3) | am. F2012L02502 |
| Schedule 2 Clause 2, Table | am. F2012L01264 |
| Schedule 3 | |
| Part 1, Subclause 2( 2), Table 1 | am. F2012L01264 |
| Part 1, Subclause 2( 2), Table 2 | am. F2012L01264 |
| Part 2, Paragraph 4(1)(a) | am. F2012L00604 |
| Part 2, Subclause 5(1) | am. F2012L00604 |
| Part 2, Subclause 5(1) | am. F2012L01264 |
| Part 2, Subclause 5(1) | am. F2012L00905 |
| Part 2, Subclause 5(1) | am. F2012L02114 |
| Part 2, Subclause 5(1) | am. F2012L02502 |
| Part 3, Subclause 8 | am. F2012L00604 |
| Part 3, Subclause 8, Category 2 | am. F2012L02114 |
| Part 3, Subclause 8, Category 3 | am. F2012L00905 |
| Part 3, Subclause 8, Category 5 | am. F2012L02114 |
| Part 3, Subclause 8, Category 6 | am. F2012L01264 |
| Part 3, Subclause 8, Category 6 | am. F2012L02114 |
| Schedule 4 | |
| Clause 6, Table 1 | am. F2012L00604 |
| Clause 6, Table 1 | am. F2012L01264 |
| Clause 6, Table 1 | am. F2012L01887 |
| Clause 6, Table 1 | am. F2012L02111 |
| Clause 6, Table 2 | am. F2012L00604 |
| Clause 6, Table 2 | am. F2012L01887 |
| Schedule 5 | |
| Clause 1, Subclause 1 | am. F2013L00003 |
| Clause 4, Table | am. F2011L02731 am. F2012L00604 am. F2012L00822 am. F2012L01264 am. F2012L01887 am. F2012L02502 am. F2013L00003 |