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Private Health Insurance (Complying Product) Rules 2015

Authoritative Version
  • - F2015L01021
  • In force - Superseded Version
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Rules/Other as made
These rules account for the role of the private health insurance industry prudential regulator transitioning from PHIAC to APRA.
Administered by: Health
Registered 30 Jun 2015
Tabling HistoryDate
Tabled HR10-Aug-2015
Tabled Senate10-Aug-2015
Table of contents.

 

 

Private Health Insurance (Complying Product) Rules 2015

 

I SHANE PORTER, delegate of the Minister for Health, make these Rules under item 3 of the table in section 333-20 of the Private Health Insurance Act 2007.

 

 

 

Dated     29 June 2015

 

 

 

 

 

Shane Porter

Assistant Secretary

Private Health Insurance Branch

Medical Benefits Division

Department of Health

 

 

 

 

 

 

 

 

 

 

 

 


Contents

 

 

Part 1                          Preliminary                                                                                            2

1.               Name of Rules                                                                                        2

2.               Commencement                                                                                      2

3.               Revocation                                                                                             2

3A             Authority                                                                                                2

4.               Definitions                                                                                              2

Part 2                          General                                                                                                  4

5.               Insured groups                                                                                       4

6.               Maximum percentage of discount                                                            4

7.               Benefits authorised to be provided under a policy                                    5

8.               Complying products―coverage requirements                                          5

8A             Benefit requirement―nursing‑home type patients                                     7

9.               Waiting periods―former gold card holders                                              8

10.             Transfer certificates                                                                                8

11.             Performance indicators                                                                           8

Part 3                          Standard information statements                                                         10

12.             Definitions                                                                                            10

13.             Information and form                                                                             10

14.             Policies covering hospital treatment only                                                10

15.             Policies covering general treatment only                                                 10

16.             Policies covering hospital and general treatment                                     11

Part 4                          Pilot Projects                                                                                       12

17.             Kinds of pilot projects                                                                           12

18.             Requirements of pilot projects                                                               12

Schedule 1―Standard information statements: hospital treatment                                   13

Schedule 2―Standard information statements: general treatment                                    15

Schedule 3―Standard information statements: combined products                                 17

Schedule 4—Permitted content                                                                                        20


Part 1        Preliminary

1.               Name of Rules

These Rules are the Private Health Insurance (Complying Product) Rules 2015. 

2.               Commencement

These Rules commence on 1 July 2015.

3.               Revocation

The Private Health Insurance (Complying Product) Rules 2010 (No. 2) are revoked.

3A.        Authority

These Rules are made under the Private Health Insurance Act 2007.

4.               Definitions

In these Rules:

accredited podiatrist means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.

Note:         The registration requirements for an accredited podiatrist for the purpose of these Rules is the same registration requirements for podiatric surgeons as set out in rule 8 of the current Private Health Insurance (Accreditation) Rules as made from time to time under section 333-20 of the Act.

Act means the Private Health Insurance Act 2007.

certified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

certified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.

consultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

Department means the Private Health Insurance Branch of the Department of Health.

general medical services table has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

implantable cardiac event recorder includes a component of an implantable cardiac event recorder.

insulin infusion pump includes a component of an insulin infusion pump.

insurer means a private health insurer.

National Law means:

(a)          for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or

(b)          for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 that corresponds to the Health Practitioner Regulation National Law.

Note:         The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions that was made on 26 March 2008 provides for the enactment of the State and Territory legislation mentioned in this definition.

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.

professional attendance has the same meaning as in clause 1.2.3 of the general medical services table.

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:         Unless the contrary intention appears, terms used in these Rules have the same meaning as in the Act― see section 13 of the Legislative Instruments Act 2003.  These terms include:

applicable benefits arrangement
complying health insurance policy

complying health insurance product
cover
dependent child

dependent child non-student
general treatment
hospital-substitute treatment
hospital treatment

medicare benefit
policy holder
private health insurer
product subgroup
rules [of an insurer]
standard information statement
waiting period

 

Part 2        General

5.               Insured groups

(1)        For the purposes of paragraph 63-5 (2A) (b) of the Act, the following insured groups are specified:

(a)                    for policies other than a non-student policy or a policy referred to in paragraph (c), the insured groups are:

(i)                      only one person;

(ii)                    2 adults (and no-one else);

(iii)                  2 or more people, none of whom is an adult;

(iv)                  2 or more people, only one of whom is an adult;

(v)                    3 or more people, only 2 of whom are adults;

(vi)                  3 or more people, at least 3 of whom are adults;

(b)                   for policies that are a non-student policy (unless the policy is a non-student policy referred to in paragraph (c)), the insured groups are:

(i)                      2 or more people, only one of whom is an adult;

(ii)                    3 or more people, only 2 of whom are adults;

(c)                    for non-student policies which have as conditions of the policy that the dependent child non-student is not covered for general treatment, other than hospital-substitute treatment, and must have his or her own policy with the same insurer covering general treatment (other than hospital-substitute treatment), the insured groups are:

(i)                      2 or more people, only one of whom is an adult;

(ii)                    3 or more people, only 2 of whom are adults.

(2)        In this rule a non-student policy is a complying health insurance policy that covers one or more dependent child non-students.

6.               Maximum percentage of discount

(1)        For subparagraph 66-5 (1) (c) (ii) of the Act, the maximum percentage discount allowed is 12% per annum.

(2)        The discount for a policy is the difference between the full premium and the net premium.

(3)        The full premium for a policy is the premium that would be received by the private health insurer for a policy in the same product subgroup without any reduction due to the circumstances set out in paragraphs 66-5 (3) (a) to (e) of the Act.

(4)        The net premium is the full premium less the cost, or the cost foregone, of any of the following:

(a)                    incentive payment;

(b)                   promotional payment;

(c)                    rebate; and

(d)                   any other inducement whatsoever,

made available by the insurer to another person, including to an insured person, in respect of the payment of the premium for the policy, including to induce a person to purchase or maintain a policy.

(5)        The following costs are excluded from the calculation of net premium in subrule (4):

(a)                    a brokerage fee or commission paid in respect of the policy; and

(b)                   the cost of any discount, product, service, waiver or other thing (promotion) offered to a person at the time the person first purchases a policy from the insurer if:

(i)                      the cost of the promotion does not exceed 12% of the full premium, for a year, for the policy purchased; and

(ii)                    the promotion is provided in the first year after the person purchases the policy.

7.               Benefits authorised to be provided under a policy

(1)        In this rule, specified benefit means a benefit specified in subrule (3).

(2)        If a person was entitled to a specified benefit under an applicable benefits arrangement or a table of ancillary health benefits in force at the commencement of the Act, the provision of the same specified benefit under the person's policy is authorised for the purposes of paragraph 69-1 (1) (b) of the Act as long as the person's policy continues to cover the same specified treatments and provide the same specified benefits.

Note:       Section 10 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of existing applicable benefits arrangements and tables of ancillary benefits at the commencement of the Act.

(3)        The specified benefits for this rule are:

(a)                    benefits paid in connection with the birth of a baby;

(b)                   funeral benefits;

(c)                    disability benefits.

(4)        In this rule, ancillary health benefit means ancillary health benefits within the meaning of section 67 the National Health Act 1953 as in force immediately before the commencement of the Act.

8.               Complying products―coverage requirements

(1)        For subsection 69-1 (2) of the Act, a policy of a kind specified in the following table must also cover any treatment as specified in the table.

 


 

Coverage requirements

Item

Kind of policy

Treatments the policy must cover

1

A policy that includes cover for hospital-substitute treatment.

Hospital treatment for the same types of treatment covered by the policy for hospital-substitute treatment.

2

A policy under which a person is covered, wholly or partly, for hospital treatment where:

(a) the treatment includes the provision of a prosthesis of a kind listed in the Private Health Insurance (Prostheses) Rules made under the Act; and

(b) either:

(i)  a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis; or

(ii) the provision of the prosthesis is associated with podiatric treatment by an accredited podiatrist; or

(iii) for a prosthesis that is an insulin infusion pump:

(A) the insulin infusion pump is provided during a professional service for which a medicare benefit is payable; and

(B) the professional service is a professional attendance by a consultant physician in the practice of his or her specialty; and

(C) the professional service is provided as a certified Type C procedure or certified overnight Type C procedure; and

(D) the insulin infusion pump is provided for the purpose of administering insulin.



The provision of the prosthesis.

3

A policy under which a person is covered, wholly or partly, for hospital-substitute treatment where:

(a) the treatment includes the provision of a prosthesis of a kind listed in the Private Health Insurance (Prostheses) Rules made under the Act; and

(b) a medicare benefit is payable in respect of the professional service associated with the provision of the prosthesis.

 



The provision of the prosthesis.

Note:   The Private Health Insurance (Prostheses) Rules set out the benefit requirements for prostheses listed in those Rules.

(2)        For the avoidance of doubt, a policy of a kind mentioned in the table may also be a policy that covers other types of treatment, unless excluded by rules made for the purpose of subsection 69-1 (3).

8A             Benefit requirement―nursing‑home type patients

(1)        For paragraph 72-1 (1) (b) of the Act, the requirement in subrule (2) is a benefit requirement for a policy that covers hospital treatment.

(2)        The requirement is that the amount of benefit payable under the policy in respect of hospital treatment at a hospital for a nursing-home type patient must 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 is a nursing-home type patient at the hospital.

(3)        In this rule:

nursing-home type patient has the same meaning as in the Private Health Insurance (Benefit Requirements) Rules, made under section 333-20 of the Act, as in force from time to time.

patient contribution, for each day on which the patient is a nursing-home type patient at the hospital, means:

(a)    in relation to a nursing‑home type patient at a public hospital, the  following amount for the State or Territory in which the hospital is located:

(i)                      Australian Capital Territory - $56.90;

(ii)                    New South Wales - $56.90;

(iii)                  Northern Territory - $56.90;

(iv)                  Queensland - $56.90;

(v)                    South Australia - $56.90;

(vi)                  Tasmania - $56.90;

(vii)                Victoria - $56.90;

(viii)              Western Australia $56.90;

(b)   in relation to a nursing‑home type patient at a private hospital, $56.90.

9.               Waiting periods―former gold card holders

(3)        The waiting period requirements in subsection 75-1 (1) of the Act are modified in relation to insured persons referred to in subrule (2) by specifying the conditions set out in that subrule.

(4)        A policy that covers a person who:

(a)                    held a gold card, or was entitled to treatment under a gold card, before applying for the insurance; and

(b)                   applies for the insurance no longer than 2 months after the person ceased to hold, or be entitled under, the gold card,

must not apply to the person any waiting period or benefit limitation period for any hospital treatment or general treatment covered by the policy.

(5)        In this rule:

gold card has the same meaning as in section 34-15 of the Act.

benefit limitation period, in respect of the person's insurance policy, means a period:

(a)                    starting at the time the person becomes insured under the policy referred to in this rule; and

(b)                   ending at the time specified in the policy,

during which the amount of benefit in relation to any period is less than the amount for which the person would be eligible during any other period.

10.            Transfer certificates

For section 99-1 of the Act, the following periods are set out:

(a)                    for subsection 99-1 (1), certificate for the insured person―14 days;

(b)                   for subsection 99-1 (2), certificate for the new insurer―14 days;

(c)                    for subsection 99-1 (3), old insurer to provide a certificate to the new insurer on request―14 days.

11.            Performance indicators

For subsection 188-1 (1) of the Act, the following performance indicators are set out:

(a)                    the number and kind of complaints made to the Private Health Insurance Ombudsman about private health insurers;

(b)                   changes in the number of insured persons in particular age groups;

(c)                    changes in the number of episodes of hospital treatment and hospital-substitute treatment, and the average number of episodes of each, for particular age groups;

(d)                   changes in the nature of the episodes of hospital treatment and hospital-substitute treatment, for which benefits are paid in particular age groups;

(e)                    changes in the average amount of benefits paid for an insured person, or an episode of hospital treatment or hospital substitute treatment, in particular age groups.


 

Part 3        Standard information statements

12.            Definitions

In this Part:

complying product means a complying health insurance product.

permitted content means the words in italics in the column headed 'Permitted content' in the tables in Schedule 4, and the words set out in the forms in Schedules 1, 2 and 3.

13.            Information and form

(1)        For subsection 93-5 (1) of the Act, this Part and Schedules 1, 2, 3 and 4 set out the form of, and the permitted content to be contained in, a statement about a product subgroup of a complying product.

(2)        The form of the statements in Schedules 1, 2 and 3, and the permitted content for those forms, must not be added to, deleted, rearranged or modified in any way except:

(a)                    as specified in the relevant Schedules;

(b)                   to omit, when inapplicable, the grey text, or to omit text for which the grey text is the appropriate alternative; and

(c)                    to place a barcode or product code in the margin.

(3)        A statement must not exceed one A4 page, except as permitted by rule 16.

14.            Policies covering hospital treatment only

For a product subgroup of a complying product made up of policies which cover hospital treatment only:

(a)                    the statement must be in the form of the statement set out in Schedule 1; and

(b)                   the fields of that form must contain the permitted content specified in Parts 1 and 2 of Schedule 4 as is relevant to the particular product.

15.            Policies covering general treatment only

For a product subgroup of a complying product made up of policies which cover general treatment only:

(a)                    the statement must be in the form of the statement set out in Schedule 2; and

(b)                   the fields of that form must contain the permitted content specified in Parts 1 and 3 of Schedule 4 as is relevant to the particular product.

16.            Policies covering hospital and general treatment

For a product subgroup of a complying product made up of policies which cover both hospital treatment and general treatment:

(a)                    the statement must be in the form of the statement set out in Schedule 3;

(b)                   the fields of that form must contain the permitted content specified in Parts 1, 2 and 3 of Schedule 4 as is relevant to the particular product; and

(c)                    the statement must not exceed two A4 pages.


 


Part 4        Pilot Projects

17.            Kinds of pilot projects

The kinds of pilot projects specified for subsection 55-15(2) of the Act are projects that enable an insurer to trial and develop, with a limited group of policy holders, new models of service delivery or health care.  The objectives of the pilot project must be for any or all of the following:

(a)       to increase the value to consumers of their health insurance products by better meeting their needs;

(b)       to prolong health, improve quality of life and reduce expenditure on hospital benefits by preventing and reducing disease and prevent the need for hospitalisation;

(c)        to produce products that better reflect advances in medical knowledge and service delivery models.

18.            Requirements of pilot projects

For the purposes of sub-section 55-15(2) of the Act, a pilot project of a kind specified in rule 17 is to be conducted in accordance with all the following requirements:

(a)        an insurer must not charge a person to participate in the project;

(b)        participation in a pilot project must be voluntary;

(c)        a pilot project may be conducted for a maximum of two years;

(d)       an insurer may only limit participation in a pilot project on the basis of where a person lives;

(e)        an insurer must develop a written plan for a pilot project, including a timeline and evaluation process;

(f)         written notice of the details of the project, including a copy of the written plan referred to in (e), must be provided to the Department at least 28 days before the pilot project commences.

 


 

Schedule 1―Standard information statements: hospital treatment

Form of statement

             Note:   The next page of these rules appears without page number, header or footer.

             This is to allow the form to be shown in its actual size as an A4 page.

 

 

 

 

 

 

 

 

 

 

 


Private Health Insurance Standard Information Statement – Hospital Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this hospital policy please contact the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>
(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium:  #

$<xx.yy> (before any rebate or loading)

Available for:

Residents of <State/Territory>
Employees/Members of <Company/Organisation name>
Closed to new members

(must be purchased with certain general treatment policies)

Medicare Levy Surcharge:

<NOT> Exempt

Available From:

<dd mmm yyyy>

# You may be entitled to an Australian Government rebate on this premium. Your premium may include a Lifetime Health Cover loading and/or an insurer discount depending on your individual circumstances.  Check with your insurer for more details.

What’s covered if i have to go to hospital?

ü    <Insert appropriate text>

What services are not covered at all?
(Exclusions)

û     <Insert list of exclusions>   OR   No exclusions

What services are only covered to a limited extent?
(Restrictions, Benefit Limitation Periods)

You are not fully covered for:   OR   No restrictions  

·                     <Insert list of restrictions>

You are not fully covered for the time period listed after the services for:   OR   No benefit limitation periods

·                     <Insert list of BLP items + limitation periods>

How long are the waiting periods for new and upgrading members?

·                     <Insert list of waiting periods>

Will i have to pay anything if i go to hospital?
(Excesses, Co-payments, Medical/Hospital gaps)

Excess: <insert appropriate phrase>

Extra costs per day (co-payments): <Insert appropriate phrase(s)>   OR   No co-payments

Doctors’ and hospital bills: <X> out of 10 medical services paid for by this health insurer in <State/Territory> have no out-of-pocket expenses.     plus (optionally)    This insurer also has arrangements that may mean lower out-of-pocket expenses on doctors’ bills.    OR    Gap cover benefits are not available under this policy.

You may have to pay additional costs depending on the doctors chosen, the treatment you are having and the hospital you go to.

Before you go to hospital, you should ask your doctor, hospital and health insurer about any out-of-pocket costs that may apply to you.

What other features does this policy have?





 

 



Schedule 2―Standard information statements: general treatment

 

Form of statement

 

             Note:   The next page of these rules appears without page number, header or footer.

             This is to allow the form to be shown in its actual size as an A4 page.


Private Health Insurance Standard Information Statement – General Treatment Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this general treatment policy please contacts the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>
(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium: #

$<xx.yy> (before any rebate or loading)

Available for:

Residents of <State/Territory>
Employees/Members of <Company/Organisation name>
Closed to new members

(must be purchased with certain hospital policies)

Medicare Levy Surcharge:

NOT Exempt

Available From:

<dd mmm yyyy>

# You may be entitled to an Australian Government rebate on this premium.  Your premium may include an insurer discount. Check with your insurer for more details.

Preferred service provider arrangements: By using this health insurer’s “preferred providers” you will have lower out-of-pocket costs on <list of services>and have access to more “no gap” services. A list of preferred providers is available from the health insurer.   OR   Insurer’s own wording

 

Services

Cover

Waiting period
(months)

Benefit limits
(per 12 months)

Examples of maximum benefits

Dental

 

 

 

Periodic oral examination – $<xx.yy> OR
                                         <xx>% of charge

Scale & clean – $ OR % as above
Fluoride treatment – $ OR %

·                         General dental

·                         Major dental

 

 

 

Surgical tooth extraction – $ OR %
Full crown veneered – $ OR %

·                         Endodontic

 

 

 

Filling of one root canal - $ OR %

·                         Orthodontic

 

 

 

Braces for upper & lower teeth, including removal plus fitting of retainer – $ OR %

Optical (eg prescribed spectacles/ contact lenses)

 

 

 

Single vision lenses & frames – $ OR %
Multi-focal lenses & frames –
$ OR %

Non PBS pharmaceuticals

 

 

 

Per eligible prescription item - $ OR %

Physiotherapy

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Chiropractic

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Podiatry

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Psychology

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Acupuncture

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Naturopathy

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Remedial massage

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Hearing aids

 

 

 

Per hearing aid – $ OR %

Blood glucose monitors

 

 

 

Per monitor – $ OR %

Ambulance

 

 

 

<Insert appropriate phrase>

¬ <Special features of the product>

Other features:




Schedule 3―Standard information statements: combined products

Form of statement

             Note:   The next page of these rules appears without page number, header or footer.

             This is to allow the form to be shown in its actual size as an A4 page.

 

 

 

 


Private Health Insurance Standard Information Statement – Combined Policy              

This Statement provides basic information for the purposes of comparison only. For full explanation of this combined hospital and general treatment policy please contact the health insurer on <phone number> or visit <website URL>.

Health insurer:

<Health Insurer name>
(This insurer has membership restrictions)

Who is covered:

<Type of cover>

Product name:

<Product name>

Monthly premium:  #

:

$<xx.yy> (before any

 rebate or loading)

Available for:

Residents of <State/Territory>
Employees/Members of <Company/Organisation name>
Closed to new members

Medicare Levy Surcharge:

<NOT> Exempt

Available From:

<dd mmm yyyy>

# You may be entitled to an Australian Government rebate on this premium.  Your premium may include a Lifetime Health cover loading and/or an insurer discount depending on your individual circumstances.  Check with your insurer for more details.

Hospital Component

The following applies to the hospital component for the <Product name> policy from <Health Insurer name>.

What’s covered if i have to go to hospital?

ü <Insert appropriate text>

What services are not covered at all?
(Exclusions)

û <Insert list of exclusions>    OR    No exclusions

What services are only covered to a limited extent?
(Restrictions, Benefit Limitation Periods)

You are not fully covered for:    OR    No restrictions

· <Insert list of restrictions>

You are not fully covered for the time period listed after the services for:    OR    No benefit limitation periods

· <Insert list of BLP items + limitation periods>

How long are the waiting periods for new and upgrading members?

· <Insert list of waiting periods>

Will i have to pay anything if i go to hospital?
(Excesses, Co-payments, Medical/Hospital gaps)

Excess: <insert appropriate phrase>  OR    No excess

Extra costs per day (co-payments): <Insert appropriate phrase(s)>   OR    No co-payments

Doctors’ and hospital bills: <X> out of 10 medical services paid for by this health insurer in <State/Territory> have no out-of-pocket expenses.    plus (optionally)    This insurer also has arrangements that may mean lower out-of-pocket expenses on doctors’ bills.    OR    Gap cover benefits are not available under this policy.

 You may have to pay additional costs depending on

  • the doctors chosen
  • the treatment you are having and
  • the hospital you go to.

Before you go to hospital, you should ask your doctor, hospital and health insurer about any out-of-pocket costs that may apply to you.

What other features does this hospital policy have?






 

General Treatment Component

The following applies to the general treatment component for the <Product name> policy from <Health Insurer name>.

Preferred service provider arrangements: By using this health insurer’s “preferred providers” you will have lower out of pocket
 costs on <list of services> and have access to more “no gap” services. A list of preferred providers is available from the health
insurer.    OR    Insurer’s own wording

 

Services

Cover

Waiting period
(months)

Benefit limits
(per 12 months)

Examples of maximum benefits

     Dental

 

 

 

Periodic oral examination – $<xx.yy> OR
                                         xx% of charge

Scale & clean – $ OR % as above
Fluoride treatment – $ OR %

·                     General dental

·                     Major dental

 

 

 

Surgical tooth extraction – $ OR %
Full crown veneered – $ OR %

·                     Endodontic

 

 

 

Filling of one root canal -- $ OR %

·                     Orthodontic

 

 

 

Braces for upper & lower teeth, including removal plus
fitting of retainer – $ OR %

Optical (eg prescribed
spectacles/ contact lenses)

 

 

 

Single vision lenses & frames – $ OR %
Multi-focal lenses & frames –
$ OR %

Non PBS pharmaceuticals

 

 

 

Per eligible prescription item – $ OR %

Physiotherapy

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Chiropractic

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Podiatry

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Psychology

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Acupuncture

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Naturopathy

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Remedial massage

 

 

 

Initial visit – $ OR %
Subsequent visit – $ OR %

Hearing aids

 

 

 

Per hearing aid – $ OR %

Blood glucose monitors

 

 

 

Per monitor – $ OR %

Ambulance

 

 

 

<Insert appropriate phrase>

¬ <Special features of the product>



Other features:



 


Schedule 4―Standard information statements: permitted content

 

Part 1 – all statements

Field

Description

Permitted content

Date of Issue:

Date on which the content of the SIS is updated.

dd [month in words] yyyy

Health Insurer:

Trading Name or Brand Name of the health insurer in the State the product is being sold.

[Health insurer trading name]

Restricted Membership insurers:

Disclaimer to be printed directly below the health insurer name if the product is offered by a restricted membership insurer.

(This insurer has membership restrictions)

Available for:

Name of the State/Territory in which the product subgroup is available for sale.

All States can only be used where every feature of the product subgroups are identical, including the premium.

One of:

·         NSW & ACT; OR

·         Northern Territory; OR

·         Queensland; OR

·         South Australia; OR

·         Tasmania; OR

·         Victoria; OR

·         Western Australia OR

·         All States

Corporate products:

One of the following statements to be printed directly below the State name if the product is a corporate product.

One of “employees” or “members” may be deleted or both can be used.

Employees/Members of [Company/Organisation name]

OR

Employees/Members of organisations with arrangements with this health insurer

Closed Products:

Statement to be printed directly below the State name (or below the corporate product statement if applicable) if the product is not currently available for purchase.

Closed to new members

Product Name:

Marketing name of the product.

[product name]

Who is covered:

Who is covered under this policy.

 

 

One of the following:

·         One adult; OR

·         Two adults; OR

·         Dependants only; OR

·         One adult & dependant(s); OR

·         Two adults & dependant(s); OR

·         Two adults & any dependant(s); OR

·         At least 3 adults & any dependants;

Monthly Premium:

Monthly premium.  Other discounts are not to be included here.

$[xx.yy amount of premium]

Available from:

Date from which the product becomes available for purchase.  Field only to appear/be completed if the statement is provided before the product is available.  The field is to be placed beneath the monthly premium field.

dd [month in words] yyyy

Medicare Levy Surcharge:

Indicates whether or not the policy will exempt the holder from the Medicare Levy Surcharge.  The field is to be placed beneath the monthly premium field.

Exempt OR

NOT exempt

<product code>

A unique identifying code for the standard information statement

A product code generated by the PrivateHealth.gov.au system.

 


Part 2―hospital treatment

 

Field

Description

Permitted content

[If available with general treatment policy only]:

The statement is to be placed below the premium on the hospital SIS if the policy cannot be purchased on its own.  Not required for a combined policy.

(must be purchased with a general treatment policy) (where the hospital policy can be purchased with any general treatment policy offered by the insurer)

OR

(must be purchased with certain general treatment policies) (where there is a set range of general treatment policies the hospital policy can be combined with)

What’s covered if I have to go to hospital?

Outline of treatment, accommodation and services covered.

Order of content cannot be changed.

 

One of the following:

ü Hospital treatment, including accommodation as a private patient in a private or public hospital OR

ü Hospital treatment, including accommodation as a private patient in a public hospital only OR

ü Hospital treatment, including accommodation as a private patient in a shared room in a private or public hospital OR

ü Hospital treatment, including accommodation as a private patient in a shared room in a public hospital only OR

ü Hospital treatment, including accommodation as a private patient in a public hospital and shared room accommodation only in a private hospital OR

ü A limited number of services is covered, see below (for policies that restrict or exclude all items except for a list of up to 10 items)

AND (the following can be added directly in front of the hospital statement if applicable)

[number]% of charge for hospital… (where the product covers a set percentage of hospital bills.  Maximum allowed percentage is 90%)

AND

limited to [number] days per year (added to any of the above options if required);

ü Doctors’ bills in hospital (see below)

AND one of (if applicable):

Ambulance:

For state specific policies:

û Not covered OR

ü Covered, conditions may apply, contact insurer for details OR

(Ambulance covered by State Government)

For all-state policies:

û Not covered (state government cover in QLD and TAS) OR

ü Covered (state government cover in QLD and TAS, other states contact insurer for details)

AND (the following can be added directly after the ambulance statement if applicable)

– [number] day waiting period OR

– [number] month waiting period

What services are not covered at all?

A list of excluded services.

Order of content cannot be changed.

Only one joint replacement item can be used.

If additional services are excluded, use other services.

No exclusions OR

Any of the following:

û Cardiac and cardiac related services

û Cataract and eye lens procedures

û Pregnancy and birth related services

û Assisted reproductive services

û Joint replacements i.e. shoulder, knee, hip and elbow including revisions

û Hip and knee replacements

û Hip replacements

û Dialysis for chronic renal failure

û Gastric banding and related services

û Sterilisation

û Non-cosmetic plastic surgery

û Hospital treatment for which Medicare pays no benefit eg most cosmetic surgery

û Other services (see insurer for details)

What services are only covered to a limited extent?

A list of restrictions and benefit limitation periods.

Restrictions are to be listed before benefit limitation periods.

Order of content cannot be changed.

For benefit limitation periods, after each service listed insert the number of months.

Only one joint replacement item can be used.

If additional services are restricted or have benefit limitation periods, use other services. These can be listed under other services without having to prior select a service form the list of available services.

No restrictions or benefit limitation periods. OR

No restrictions/benefit limitation periods

No restrictions OR

If the policy has no restrictions but has benefit limitation periods

No benefit limitation periods OR

If the policy has no benefit limitation periods but has restrictions

You are not fully covered for: AND/OR

Restrictions

You are not fully covered for the time period listed after the services for:

benefit limitation periods

List any of the following for restrictions:

·      Cardiac and cardiac related services

·      Cataract and eye lens procedures

·      Pregnancy and birth related services

·      Assisted reproductive services

·      Joint replacements i.e. shoulder, knee, hip and elbow including revisions

·      Hip and knee replacements

·      Hip replacements

·      Dialysis for chronic renal failure

·      Gastric banding and related services

·      Sterilisation

·      Non-cosmetic plastic surgery

·      Rehabilitation

·      Psychiatric services

·      Palliative care

·      Hospital treatment for which Medicare pays no benefit eg most cosmetic surgery

·      Other services (see insurer for details)

List any of the following for benefit limitation periods:

·      Cardiac and cardiac related services – [number] months

·      Cataract and eye lens procedures – [number] months

·      Pregnancy and birth related services – [number] months

·      Assisted reproductive services – [number] months

·      Joint replacements i.e. shoulder, knee, hip and elbow including revisions – [number] months

·      Hip and knee replacements – [number] months

·      Hip replacements – [number] months

·      Dialysis for chronic renal failure – [number] months

·      Gastric banding and related services  – [number] months

·      Sterilisation– [number] months

·      Non-cosmetic plastic surgery – [number] months

·      Rehabilitation – [number] months

·      Psychiatric services – [number] months

·      Palliative care – [number] months

·      Hospital treatment for which Medicare pays no benefit eg most cosmetic surgery – [number] months

·      Other services (see insurer for details) – [number] months

How long are the waiting periods for new and upgrading members?

Waiting periods that apply before a member can claim.

Must be provided in the order listed.

The waiting period for obstetrics must be deleted if the product does not cover obstetrics.

·      [number (maximum 2)] months for palliative care, rehabilitation and psychiatric treatments

·      [number (maximum 12)] months for treatments relating to other pre-existing ailments

·      [number (maximum 12)] months for obstetric treatments

·      [number (maximum 2)] months for all other treatments

Will I have to pay anything if I go to hospital?

This box covers excesses, co-payments and medical/hospital gaps.

Each of these appear in separate sub-boxes

 

Excess:

Choose appropriate statement and insert dollar figures.

The dollar amount for excess per admission is the excess for an overnight admission (if different from the excess for day surgery).

If no excess:

·         No excess

If there is an excess:

You will have to pay an excess of $[number] per admission. OR

You will have to pay an excess of $[number] per admission.  This is limited to a maximum of $[number] per year. OR

You will have to pay an excess on admission.  This is limited to a maximum of $[number] per year. OR

You will have to pay an excess of $[number] per admission.  This is limited to a maximum of $[number] per person per year. OR

You will have to pay an excess on admission.  This is limited to a maximum of $[number] per person per year. OR

You will have to pay an excess of $[number] per admission.  This is limited to a maximum of $[number] per person and $[number] per policy per year.

You will have to pay an excess on admission.  This is limited to a maximum of $[number] per person and $[number] per policy per year.

AND (if required)

·         Excess payments do not apply to hospital admissions for accidents, child dependents or day surgery (delete any that do not apply but do not change the order)

Extra Cost per day (co-payments):

Insert dollar amounts for the appropriate co-payment amount.

If no co-payment

·         No co-payments

If there is a co-payment:

Every time you go to hospital you will have to pay:

·         $[number] per day for overnight admissions

OR

·         $[number] per day for a shared room AND

·         $[number] per day for a private room (must be deleted if the policy does not cover accommodation in a private room)

AND

·         $[number] for day surgery (no overnight stay) OR

·         No co-payment for day surgery (no overnight stay)

AND (The following can be added directly after the shared and private room co-payment descriptions if applicable)

– up to $[number] per hospital stay

AND (If applicable)

The maximum co-payment is $[number] per year.

Doctors’ and Hospital Bills

This provides information on the proportion of no gap medical services for the insurer.

The percentage of medical services with no gap is the figure for the state in which the product is available.

The information related to the percentage of medical services with no gap is the information submitted to the Australian Prudential Regulation Authority (APRA) for the year ending 30 June for “Total Services with No Gap” divided by “Total All Services”.

The information required is that released by APRA for the most recent year ending 30 June. If the product is an “All States” product, the national average of medical services with no gap is to be used.

Health insurers who participate in the Australian Health Services Alliance’s gap cover arrangements may use the percentage of services with no gap (by state) for the Alliance as a whole.

As per the form.  The percentage of medical services with no gap is to be expressed as per the example below:

·         greater than or equal to 69% and less than or equal to 71% – 7 out of 10

·         greater than 71%  but less than 75% – More than 7 out of 10

·         greater than or equal to 75% but less than 79% – Almost 8 out of 10

[State] is to be the same as “available to” field

If insurer has known gap arrangements, then insert the following after the first sentence:

This insurer also has arrangements that may mean lower out-of-pocket expenses on doctors’ bills.

If gap cover benefits are not available with this policy, then substitute first two sentences with:

Gap cover benefits are not available under this policy.

A new health insurer that does not have available figures for gap cover benefits must use the following (if the new insurer participates in the Australian Health Services Alliance’s gap cover arrangements, they may use the Alliance’s figure):

Gap cover benefit figures are not yet available.

What other features does this policy have?

The total text in this box must not exceed 4 lines.

If the hospital policy pays full benefits for 10 or fewer specific services, those services MUST be listed in this box.

This box may also be used to describe (for example):

·         disease management programs and other programs that support healthy lifestyles

·         discounts for direct debit, paying in advance etc

·         loyalty bonus/incentive schemes

·         waiver(s) of co-payments

·         any other significant product features

Free text up to 4 lines

INCLUDING (if applicable)

This policy only provides full benefits for [list services].

 

 


Part 3―general treatment

 

Field

Description

Permitted content

[If available with hospital policy only]:

The statement is to be placed below the premium on the general treatment SIS if the policy cannot be purchased on its own.  Not required for a combined policy.

(must be purchased with a hospital policy) (where the general treatment policy can be purchased with any hospital policy offered by the insurer)

OR

(must be purchased with certain hospital policies) (where there is a set range of hospital policies the general policy can be combined with)

Preferred Service Provider

Arrangements: 

(box)

Describes special arrangements with particular providers.

Text in this box must not exceed 3 lines, including the line with the heading.

Free text up to 3 lines (including the line with the heading)

OR

By using this health insurer’s “preferred providers” you will have lower out of pocket costs on [insert services or use many allied health] services and have access to more “no gap” services.  A list of “preferred providers” is available from the health insurer.

Insurers that do not have preferred provider arrangements must use this phrase.

This health insurer does not operate a preferred provider scheme.

‘Services’ column:

A list of a number of services covered by general treatment.

As provided in form.  Additions, deletions, modifications or rearrangements not permitted

‘Covered’ column:

Indicates if the service is covered or not.

A service is considered to be covered if a benefit is paid for at least one of the examples in the “examples of maximum benefits” columns.

 

All services except Ambulance:

ü (service is covered)

û (service is not covered)

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

Ambulance:

For state specific policies:

ü Covered, conditions may apply, contact insurer for details OR

(Ambulance covered by State Government) OR

û Not covered OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

For all-state policies:

ü Covered (state government cover in QLD and TAS, other states contact insurer for details) OR

û Not covered (state government cover in QLD and TAS) OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

‘Waiting Period (Months)’ column:

The maximum period of time before a member can claim benefits.

Waiting periods for ambulance can be expressed in days or months.

Choose one of…:

When…

-

the service is not covered

[number]

waiting period in months

None

no waiting period

[x days]

short term waiting period for ambulance cover

‘Benefit Limits (per 12 months)’ column:

Limits on benefits.

If there is a limit on general dental, but not on preventative dental, the “(no limit on preventative dental)” words should be used.

If services with combined limits are in adjacent rows in the table, lines between the boxes can be deleted and the limit and list of combined services only written once.

If a sub limit applies on any of these services, use “Sub-limits apply”.

Combined limits for services in non-adjacent boxes must be written in this field in the first occurrence; thereafter “(Combined limit – see [service])”, inserting the name of the service where the list first occurs.

If benefit limits increase over time for any services, only the lowest payable benefit is to be used.

Any combination of:

·         $[number] per person

·         $[number] per service

·         $[number] per policy

If more than one of the above phrases is used, they are to be linked by the words “up to” eg $X per person up to $Y per service up to $Z per policy.

The following may also be used:

·         $[number] lifetime limit AND/OR

·         ([number] appliance(s)/service(s) [delete one] every [number] years (if there is a limit on claims every X years) AND/OR

·         (combined limit for [list services]) OR

·         (combined limit – see [service]) AND/OR

·         Sub-limits apply AND/OR

·         (no limit on preventative dental) OR

·         No annual limit OR

·         - (service is not covered)

For combined limits, choose from services:

·         general dental

·         major dental

·         endodontic

·         orthodontic

·         optical

·         non PBS pharmaceuticals

·         physiotherapy

·         chiropractic

·         podiatry

·         psychology

·         acupuncture

·         naturopathy

·         remedial massage

·         hearing aids

·         blood glucose monitors

·         ambulance

·         other services

OR

Lifetime limits for individually grouped services:

$[number] per person (combined limit for [a] general dental, major dental, endodontic & orthodontic)

$[number] lifetime limit for [b]

a.      insurers may choose any combination of the following services: general dental, major dental, endodontic & orthodontic

b.      insurers may choose any one of the following services: general dental, major dental, endodontic & orthodontic

‘Examples of Maximum Benefits’ column:

Examples of the maximum benefit paid for the listed treatments when an insured person visits a practitioner who is not a ‘preferred service provider’.

Only the examples listed may be used.

A percentage figure can only be used where the insurer does not have a maximum limit on the particular item, other than an annual limit. If an insurer pays a benefit that is a percentage of the charge up to a specified dollar limit (i.e. a limit for that item, separately specified from the annual limit), then the specified dollar limit must be used.

General dental, major dental and endodontic examples must be listed even if the service is not covered.

Other examples should be deleted if not covered.

The maximum benefit paid on the following dental item numbers are to be used for the listed examples:

Periodic oral examination – 012

Scale & clean – 114

Fluoride treatment – 121

Surgical tooth extraction – 322

Full crown veneered – 615

Filling of one root canal – 417

Braces for upper & lower teeth, including removal plus fitting of retainer – 881

If surgical tooth extraction is covered under general dental instead of major dental, this example can be moved to the general dental box.

Orthodontics – if different benefits are offered for treatments provided for orthodontists and general dentists, the maximum benefit for an orthodontist should be used.

Optical – if benefits for frames and lenses are paid separately, add together the maximum benefit for each component.

Initial/subsequent visit examples are for individual sessions.

If there is no maximum benefit for the examples listed, the annual benefit limit figure should be used.

$[xx.yy number]

amount of maximum benefit

[number]% of charge

where there is no maximum benefit limit on the particular item, other than an annual limit.

n/a

For general dental, major dental and endodontic if not covered

-

Other services if not covered – delete example(s)

Ambulance – one of:

For state specific policies:

ü Covered, conditions may apply, contact insurer for details OR

(Ambulance covered by State Government) OR

û Not covered OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

¬ (see note below)

For all-state policies:

ü Covered (state government cover in QLD and TAS, other states contact insurer for details) OR

û Not covered (state government cover in QLD and TAS) OR

û Not available on this product (for policies that cover only one type of service, such as e.g. dental cover)

·      ¬ (see note below)

¬ Special Features:

This space must be used to describe special features of the product where ¬ is used.

Free text up to 4 lines.

Other Features: (box)

OPTIONAL – this box may be used to describe (for example):

·         services covered that are not listed in the first column of the main table

·         discounts for direct debit, paying in advance etc

·         preventative health/health management programs

·         loyalty bonus/incentive schemes

·         other significant product features

Free text up to 4 lines, including the line with the heading.