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Private Health Insurance (Reforms) Amendment Rules 2018

Authoritative Version
  • - F2018L01414
  • In force - Superseded Version
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Rules/Other as made
This instrument amends a number of Private Health Insurance Rules to make provisions for the following reforms (and related matters): age-based premium discounts for hospital cover, improving information provisions for consumers, introduction of product tiers and clinical categories for hospital cover, the administration of second-tier default benefits arrangements for hospitals, removal of coverage for some natural therapies, and technical changes to references to podiatric surgeons.
Administered by: Health
Registered 11 Oct 2018
Tabling HistoryDate
Tabled HR15-Oct-2018
Tabled Senate15-Oct-2018
To be repealed 02 Apr 2020
Repealed by Division 1 of Part 3 of Chapter 3 of the Legislation Act 2003
Table of contents.

 

Private Health Insurance (Reforms) Amendment Rules 2018

I, Susan Azmi, delegate of the Minister for Health, make the following rules.

 

Dated   11 October 2018                                 

Susan Azmi

Delegate of the Minister for Health

 

 

 


Contents

1  Name........................................................................................................................................ 1

2  Commencement........................................................................................................................ 1

3  Authority.................................................................................................................................. 1

4  Schedules................................................................................................................................. 1

Schedule 1 —Amendments to implement age‑based discounts                                 2

Private Health Insurance (Complying Product) Rules 2015                                                        2

Schedule 2 —Standard information statements and private health information statements     6

Part 1 —Amendments commencing on 1 January 2019                                           6

Private Health Insurance (Complying Product) Rules 2015                                                        6

Part 2 —Amendments commencing on 1 April 2019                                               19

Private Health Insurance (Complying Product) Rules 2015                                                      19

Part 3 —Amendments commencing on 1 April 2020                                               23

Private Health Insurance (Complying Product) Rules 2015                                                      23

Schedule 3 Product tiers and related amendments                                              24

Part 1 —Amendments commencing on 1 April 2019                                               24

Private Health Insurance (Complying Product) Rules 2015                                                      24

Part 2 —Amendments commencing on 1 April 2020                                               60

Private Health Insurance (Complying Product) Rules 2015                                                      60

Schedule 4 —Second tier administrative reforms                                                    61

Private Health Insurance (Benefit Requirements) Rules 2011                                                   61

Private Health Insurance (Health Insurance Business) Rules 2018                                          64

Schedule 5 —Removal of coverage of some natural therapies                               67

Private Health Insurance (Health Insurance Business) Rules 2018                                          67

Schedule 6 —Information provision                                                                         69

Private Health Insurance (Incentives) Rules 2012 (No. 2)                                                          69

Private Health Insurance (Lifetime Health Cover) Rules 2017                                                  70

Schedule 7 —Amendments relating to accredited podiatrists                                 71

Private Health Insurance (Complying Product) Rules 2015                                                      71

Private Health Insurance (Prostheses) Rules 2018 (No. 2)                                                         71

 

                                                                    


1  Name

                   This instrument is the Private Health Insurance (Reforms) Amendment Rules 2018.

2  Commencement

             (1)  Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.

 

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1.  Sections 1 to 4 and anything in this instrument not elsewhere covered by this table

The day after this instrument is registered.

 

2.  Schedule 1

1 April 2019

1 April 2019

3.  Part 1 of Schedule 2

1 January 2019

1 January 2019

4.  Part 2 of Schedule 2

1 April 2019

1 April 2019

5.  Part 3 of Schedule 2

1 April 2020

1 April 2020

6.  Part 1 of Schedule 3

1 April 2019

1 April 2019

7.  Part 2 of Schedule 3

1 April 2020

1 April 2020

8.  Schedule 4

1 January 2019

1 January 2019

9.  Schedule 5

1 April 2019

1 April 2019

10.  Schedule 6

1 April 2019

1 April 2019

11.  Schedule 7

The day after this instrument is registered.

 

Note:          This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.

             (2)  Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.

3  Authority

                   This instrument is made under section 333‑20 of the Private Health Insurance Act 2007.

4  Schedules

                   Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.


 

Schedule 1—Amendments to implement age‑based discounts

Private Health Insurance (Complying Product) Rules 2015

[1]       Rule 4 (note at the end of the rule)

Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, the following terms:

                     (a)  adult;

                     (b)  hospital cover.

[2]       Subrule 6(3)

Omit “(e)”, substitute “(ea)”.

[3]       Subrule 6(5)

Omit “The following costs are excluded from the calculation of net premium in subrule (4):”, substitute “For the purposes of this rule, disregard:”.

[4]       At the end of subrule 6(5)

Insert:

             ; and (c)  any age‑based discount that might apply in relation to the policy (see Part 2A).

[5]       After Part 2

Insert:

Part 2A     Age‑based discounts

Note 1:    See paragraphs 63‑10 (g) and 66‑5 (3) (ea) of the Act.

Note 2:    Nothing in this Part requires a private health insurer to:

·    make age‑based discounts available under any product; or

·    if age‑based discounts are available under a product:

–    make such discounts available for all ages between 18 and 29 (inclusive); or

–    continue to make age‑based discounts available under the product.

                Instead, an age‑based discount policy may specify the ranges of ages, between 18 and 29 (inclusive), for which such discounts will be available (see subparagraph 11B (c) (i)).

                However, under this Part:

·    if a person is receiving an age‑based discount, the person is entitled to continue to receive the full discount until the person turns 41 (unless the insurer chooses to discontinue age‑based discounts under the product, or the person transfers to a different insurance policy), and might be entitled to receive a reduced discount for a number of years after turning 41; and

·    if age‑based discounts are available in relation to particular ages or particular ranges of ages for a particular product, they must be available in relation to those ages or ranges on the same terms and conditions for all insurance policies under that product (see section 63‑5 of the Act).

11A.           Definitions

                   In this Part:

age‑based discount policy means an insurance policy that provides age‑based discounts.

discount assessment date, in relation to a person who is insured under an age‑based discount policy, means whichever of the following is applicable:

                     (a)  subject to paragraph (c), if the policy provided age‑based discounts at the date the person became insured—that date;

                     (b)  if the policy provided age‑based discounts at a date after the person became insured—the date the person was first eligible for an age‑based discount under the policy;

                     (c)  if:

                              (i)  the person transferred to the policy (the new policy) from another age‑based discount policy (the old policy); and

                             (ii)  at the time of the transfer, the new policy was stated to be a retained age‑based discount policy; and

                            (iii)  the person was not a dependent child under the old policy;

                            the person’s discount assessment date under the old policy.

eligible person, in relation to an age‑based discount policy, means a person to whom a discount applies in accordance with paragraph 11B (c).

retained age‑based discount policy means an insurance policy:

                     (a)  that is an age‑based discount policy; and

                     (b)  that states that it is a retained age‑based discount policy.

11B.           Requirements for age‑based discount policy to be complying health insurance policy

                   For paragraph 63‑10 (g) of the Act, an insurance policy must not provide for an age‑based discount (the discount) unless:

                     (a)  the policy covers:

                              (i)  hospital treatment; or

                             (ii)  hospital treatment and general treatment; and

                     (b)  the discount will be a reduction in the amount that would otherwise be payable by the person for the policy, equal to the dollar amount calculated in accordance with rule 11C; and

                     (c)  the discount will apply to each person insured under the policy who, on the discount assessment date for the person:

                              (i)  was within one or more ranges of ages, between 18 and 29 (inclusive), that are specified in the policy as eligible for the discount; and

                             (ii)  was not a dependent child under the policy; and

                     (d)  while age‑based discounts are available under the policy, the discount will continue to apply until it is reduced, in accordance with rule 11C, to zero in relation to each such person insured under the policy; and

                     (e)  the policy states whether it is a retained age‑based discount policy.

Note:          For paragraph (c), an insurer is not required to provide discounts for all ages between 18 and 29 (inclusive).

11C.           Calculation of age‑based discount

Note:       This rule deals only with the calculation of the age‑based discount. The premium that is payable in respect of a particular insurance policy is also affected by other provisions of the Act (including Part 2‑3 of the Act, which deals with lifetime health cover) and rules made under the Act (including these Rules).

             (1)  For paragraph 11B (b), the total age‑based discount that applies under an age‑based discount policy for a particular period is equal to the sum of the applicable discounts to which each eligible person who is insured under the policy is entitled for that period.

             (2)  An eligible person is entitled to an applicable discount calculated in accordance with the following formula:

                  

                   where:

applicable percentage, for a particular period, is the greater of:

                     (a)  the person’s percentage for the period, determined in accordance with the table to subrule (3); and

                     (b)  zero.

base rate for hospital cover is the amount of premiums that would be payable for hospital cover under the policy if:

                     (a)  the premiums were not increased under Part 2‑3 of the Act (lifetime health cover); and

                     (b)  there were no discounts of the kind allowed under subsection 66‑5 (2) of the Act (including under this Part of these Rules).

number of adults insured is the number of adults insured under the policy.

             (3)  For paragraph (a) of the definition of applicable percentage in subrule (2), the table is:

If, for that period, the person is aged:

the person’s percentage for the period is:

18 or older, but under 41

the person’s base percentage

41

the person’s base percentage minus 2 percentage points

42

the person’s base percentage minus 4 percentage points

43

the person’s base percentage minus 6 percentage points

44

the person’s base percentage minus 8 percentage points

45 or older

zero

             (4)  For subrule (3), a person’s base percentage is equal to:

                     (a)  for an eligible person under the policy—the percentage, as given by the following table, corresponding to the person’s age at the discount assessment date; and

Note:       See paragraph 11B (c).

                     (b)  otherwise—zero.

Person’s age at discount assessment date

Percentage

18 or older, but under 26

10%

26

8%

27

6%

28

4%

29

2%

11D.           Circumstances in which a person is entitled to age‑based discount

                   For paragraph 66‑5 (3) (ea) of the Act, a person is entitled to an age‑based discount for a particular period if:

                     (a)  the person is insured under an age‑based discount policy during that period; and

                     (b)  the person is an eligible person in relation to that policy; and

                     (c)  the person’s applicable discount for that period, as calculated in accordance with subrule 11C (2), is not equal to zero.

 


Schedule 2—Standard information statements and private health information statements

Part 1—Amendments commencing on 1 January 2019

Private Health Insurance (Complying Product) Rules 2015

[1]       Rule 4

Insert:

State, when used in Schedule 1, Schedule 2 or Schedule 3, means a risk equalisation jurisdiction.

Note:          The risk equalisation jurisdictions are set out in the Private Health Insurance (Health Benefits Fund Policy) Rules 2015. Under those rules, the area specified in each of the following paragraphs is a risk equalisation jurisdiction:

(a)     Australian Capital Territory, Norfolk Island and New South Wales;

(b)     Northern Territory;

(c)     Queensland;

(d)     South Australia;

(e)     Tasmania;

(f)      Victoria;

(g)     Western Australia and the Territory of Christmas Island and the Territory of Cocos (Keeling) Islands.

[2]       Rule 4 (note at the end of the rule)

Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, “risk equalisation jurisdiction”.

[3]       Part 3

                   Repeal the Part, substitute:

Part 3    Standard information statements and other information that must be given

Note:       This Part deals with:

·    the information and form for standard information statements, for the purposes of subsection 93‑5 (1) of the Act, and methods by which standard information statements are made available; and

·    information that must be provided to the Private Health Insurance Ombudsman relating to changes in premiums.

                This Part does not limit the information that a private health insurer may give to an insured person.

12.  Standard information statements

Note:       See rule 20 for a transitional provision relating to this rule that applies until 31 March 2020.

             (1)  For subsection 93‑5 (1) of the Act, the information to be contained in a standard information statement, and the form, for a product subgroup of a complying health insurance product, are:

                     (a)  the information and form of words set out in Schedule 1; and

                     (b)  if policies that belong to the product subgroup cover hospital treatment—the additional information, and the form of words, set out in Schedule 2; and

                     (c)  if policies that belong to the product subgroup cover general treatment—the additional information, and the form of words, set out in Schedule 3.

             (2)  However, paragraph (1)(c) does not apply if the only general treatment provided is ambulance cover.

13.  Method of making standard information statements available

             (1)  This rule is made for the purposes of subsection 93‑5 (2) and paragraph 93‑15 (1) (a) of the Act.

             (2)  If:

                     (a)  the standard information statement is accompanied by information additional to the information and form of words that are required by subrule 12 (1); and

                     (b)  the standard information statement and the additional information are set out in the same document;

                   the additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).

Example:    The document on which a standard information statement is provided might include information about ambulance cover that is additional to the information required by item 10 of the table to clause 2 of Schedule 1. The additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.

14.  Information relating to changes to premiums to be provided to Private Health Insurance Ombudsman

             (1)  This rule is made for the purposes of section 96‑25 of the Act.

             (2)  This rule applies if the Minister has approved a proposed change to the premiums charged under a complying health insurance product of a private health insurer under subsection 66‑10 (3) of the Act.

             (3)  The private health insurer must notify the Private Health Insurance Ombudsman of:

                     (a)  the premiums that applied before the approval; and

                     (b)  the premiums that apply after the approval.

             (4)  The insurer must give this information to the Ombudsman by the earlier of:

                     (a)  the day 14 days after the date of the Minister’s approval for the change; and

                     (b)  1 April of the year in which the Minister approved the change.

[4]       After rule 19

Insert:

20.              Transitional provision relating to the Private Health Insurance (Reforms) Amendment Rules 2018—standard information statements

Application of rule

             (1)  This rule applies until 31 March 2020.

Transitional provision

             (2)  A standard information statement that is in the old form is taken to contain the information, and be in the form, set out in these Rules.

             (3)  For this rule, a standard information statement is in the old form if it contains the information, and is in the form, set out in these Rules as in force immediately before the commencement of Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018.

Note:          Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 January 2019.

[5]       Schedules 1, 2, 3 and 4

                   Repeal the Schedules, substitute:

Schedule 1—Information and form of words for standard information statement—all policies

1.  Interpretation

                   In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.

2.  Information and form of words for standard information statement—all policies

                   For paragraph 12 (1) (a) of these Rules, the information and form of words are set out in the following table:

Information and form of words for standard information statement—all policies

Item

Information and form of words

1

Policy name

The name of the policy.

 

2

Name of private health insurer

The trading or brand name of the private health insurer in the State in which the policy is being made available, together with any associated branding that the insurer elects to include.

 

3

Disclaimer for restricted access insurers

If the policy is offered by a restricted access insurer—the following statement:

“Membership of this insurer is restricted to”

followed by the details.

 

4

Contact details

A contact phone number and website address of the private health insurer.

 

5

State/s available in

The States in which the product is available, expressed as either:

   (a)  if:

             (i)   the product is offered in all States; and

            (ii)   every feature of the product (including the monthly premium referred to in item 6) is the same in each State;

          “All States”; or

   (b)  otherwise—the State or States in which the product is available, expressed as whichever of the following is applicable:

             (i)   “NSW & ACT”;

            (ii)   “Northern Territory”;

           (iii)   “Queensland”;

          (iv)   “South Australia”;

           (v)   “Tasmania”;

          (vi)   “Victoria”;

         (vii)   “Western Australia”.

 

6

Monthly premium

The total monthly premium payable before any rebate, loading or discount is applied.

The following words must be inserted before or following the premium amount: “before any rebate, loading or discount”.

Note:       This item does not limit the information that a private health insurer may give to an insured person with regard to the premium payable after any rebate, loading and/or discount is applied.

 

7

Corporate products

If the policy is part of a corporate product—a statement to that effect, indicating either of the following, with the bracketed text replaced with the appropriate information:

   (a)  “Employees/members of [Company/Organisation]”;

   (b)  “Employees/members of organisations with arrangements with this health insurer”.

 

8

Closed products

If the policy is closed so that it is no longer available to anyone except those persons who, at the time of closing, were insured under the policy—the following words:

“This policy is closed to new members.”.

 

9

Who is covered

The insured groups that may be covered, expressed as whichever of the following is applicable:

   (a)  “only one person”;

   (b)  “2 adults (and no-one else)”;

   (c)  “2 or more people, none of whom is an adult”;

   (d)  “2 or more people, only one of whom is an adult”;

   (e)  “3 or more people, only 2 of whom are adults”;

   (f)  “3 or more people, at least 3 of whom are adults”.

Note 1:    The insured groups are set out in rule 5 of these Rules.

Note 2:    This item does not limit the information that a private health insurer may give to an insured person with regard to the name/s of person/s covered by the policy.

 

10

Ambulance cover

The following information:

   (a)  whether ambulance cover is included;

   (b)  if so:

             (i)   the waiting period (if any); and

            (ii)   whether the cover is:

                          (A)  emergency only; or

                          (B)  emergency and non‑emergency; and

           (iii)   any limits on cover (dollar amount or service); and

          (iv)   any call-out fees (if applicable);

   (c)  for each State in which:

             (i)   the product is available; and

            (ii)   ambulance cover is not included;

          the following information:

           (iii)   whether free ambulance services are available in that State;

          (iv)   if so—whether they are limited to services in that State;

   (d)  if ambulance cover were to be provided by a person other than the private health insurer who prepared the statement—whether the policy would provide a benefit for that cover.

 

11

Date available

If, and only if, the policy is not yet available—the date from which the policy will be available.

 

12

Date statement issued or updated

The date on which the content of the statement was issued or updated, in the following format, with the bracketed text replaced with the appropriate information:

“Date statement [issued/updated]: [dd]/[month in words]/[yyyy]”

 

13

Unique identifier

The unique identifier for the standard information statement that is generated by the privatehealth.gov.au system.

 

Schedule 2—Additional information, and form of words, for standard information statement—hospital treatment

1.  Interpretation

                   In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.

2.  Additional information and form of words—hospital treatment

                   For paragraph 12 (1) (b) of these Rules, the additional information and form of words are set out in the following table:

Additional information and form of words—hospital treatment

Item

Additional information and form of words

1

Information relating to policies that are available only with a general treatment policy

If the policy is available only with a policy that covers general treatment—whichever of the following is applicable:

   (a)  if the policy may be purchased with any policy that covers general treatment offered by the insurer—the statement “must be purchased with a general treatment policy”;

   (b)  if there is a set range of policies that cover general treatment with which the policy may be combined—the statement “must be purchased with certain general treatment policies”.

 

2

Whether the policy exempts holders from the Medicare Levy Surcharge

Whichever of the following is applicable:

   (a)  “This policy exempts you from the Medicare Levy Surcharge”;

   (b)  “This policy does not exempt you from the Medicare Levy Surcharge”.

 

3

What’s included and what’s not included in the policy

An indication of:

   (a)  treatments that are covered by the policy, consisting of the words:

“This policy includes cover for”

          followed by the relevant treatments; and

   (b)  treatments that are not covered by the policy, consisting of the words:

“This policy does not include cover for”

          followed by the relevant treatments.

 

4

Restrictions

A list of all restrictions (if any) that apply.

 

5

Waiting periods for new and upgrading members

The waiting periods that apply under the policy before a policy holder can claim, expressed either:

   (a)  in the following format, with the bracketed text replaced with the appropriate figures:

             (i)   “[the number of months (up to 2)] months for palliative care, rehabilitation and psychiatric treatments”;

            (ii)   “[the number of months (up to 12)] months for pre‑existing conditions”;

           (iii)   if, and only if, the policy covers pregnancy and birth (obstetrics)—“[the number of months (up to 12)] months for pregnancy and birth (obstetrics)”;

          (iv)   “[the number of months (up to 2)] months for all other treatments”; or

   (b)  if shown in a table—for all treatments covered by the policy, the appropriate figure for the relevant waiting period.

Note 1:    This item does not limit the information that a private health insurer may provide with regard to an individual’s policy.

Note 2:    The obstetrics waiting period of up to 12 months does not apply to treatment for neonatal care.

 

6

Excess

Whichever of the following is appropriate:

   (a)  if there is no excess—the words “No excess”;

   (b)  if there is an excess:

             (i)   whichever of the following is appropriate, with the bracketed text replaced with the appropriate figure, and where the dollar amount for excess per admission is the excess for an overnight admission, if this is different from the excess for day surgery:

                          (A)  “You will have to pay an excess of $[number] per admission.”;

                          (B)  “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per year.”;

                          (C)  “You will have to pay an excess on admission. This is limited to a maximum of $[number] per year.”;

                          (D)  “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per person per year.”;

                          (E)  “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.”;

                           (F)  “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.”;

                          (G)  “You will have to pay an excess on admission. This is limited to a maximum of $[number] per policy per year.”; and

            (ii)   if applicable—“Excess payments do not apply to hospital admissions for accidents, of child dependants, or for day surgery”, with any of “accidents”, “child dependants” and “day surgery” that do not apply deleted, but with the order of those terms otherwise unchanged.

 

7

Extra cost per day (co‑payments)

If there are no co-payments—the statement “No co-payments”.

 

If there are co-payments:

  (a)  the statement “Every time you go to hospital you will have to pay”, followed by (with the bracketed text replaced with the appropriate figures):

             (i)   either:

                          (A)  the statement “$[number] per day for overnight admissions”; or

                          (B)  the statements:

·    “$[number] per day for a shared room for overnight admissions”; and

·    if the policy covers accommodation in a private room—“$[number] per day for a private room for overnight admissions”; and

            (ii)   as applicable, either:

                          (A)  the statement “$[number] for day surgery (no overnight stay)”; or

                          (B)  the statement “No co-payment for day surgery (no overnight stay)”; and

           (iii)   the statement “­– up to $[number] per hospital stay”, placed, if applicable, and if the insurer so chooses, directly after the statements referred to in subparagraph (i); and

   (b)  if applicable—the statement “The maximum co‑payment is $[number] per year” (with the bracketed text replaced with the appropriate figures).

 

8

Note on out of pocket costs/doctors’ fees

The following statement:

“Under this policy, you may have to pay out-of-pocket costs above what you get from Medicare or your private health insurer. Before you go to hospital, you should ask your doctors, hospital and health insurer about any out-of-pocket costs that may apply to you.”.

 

9

Note on information relating to contracts between hospitals and insurers

The following statement:

“The benefits paid for hospital treatment will depend on the type of cover you purchase and whether your fund has an agreement in place with the hospital in which you are treated. See ‘Agreement Hospitals’ on privatehealth.gov.au for which hospitals have arrangements with your insurer.”.

 

10

Other features

A statement that indicates any other features of the policy that the insurer wishes to draw attention to.

The statement must consist of at most 100 words.

Example: Benefits for travel or accommodation, or aged‑based or other discounts.

Note:       This statement (if included) is in addition to the statement (if included) that is referred to in item 9 of Schedule 3.

 

Schedule 3—Additional information, and form of words, for standard information statement—general treatment

Note:       The information and form of words set out in this Schedule are not required if the only general treatment covered by the policy is ambulance cover.

1.  Interpretation

                   In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.

2.  Additional information and form of words—general treatment

                   For paragraph 12 (1) (c) of these Rules, the additional information and form of words are set out in the following table:

Additional information and form of words—general treatment

Item

Additional information and form of words

1

Information relating to policies that are available only with a hospital policy

If the policy is available only with a policy that covers hospital  treatment—whichever of the following is applicable:

   (a)  if the policy may be purchased with any policy that covers hospital treatment offered by the insurer—the statement “must be purchased with a hospital policy”;

   (b)  if there is a set range of policies that cover hospital treatment with which the policy may be combined—the statement “must be purchased with certain hospital policies”.

 

2

Preferred service provider arrangements

Whichever of the following is appropriate:

   (a)  if the private health insurer has preferred service provider arrangements—either:

             (i)   a brief outline of the appropriate arrangements; or

            (ii)   the following statement, with the bracketed text replaced with the appropriate text: “By using [insert name of insurer]’s ‘preferred providers’ you may have lower out of pocket costs on [insert services or use “many allied health”] treatments and have access to more ‘no gap’ treatments. A list of ‘preferred providers’ is available from [insert name of insurer].”;

   (b)  otherwise—the following statement, with the bracketed text replaced with the appropriate text: “[Insert name of insurer] does not operate a preferred provider scheme.”.

 

3

Treatments covered by the policy

A complete list of treatments that are covered by the policy, expressed in terms of the following:

   (a)  general dental;

   (b)  major dental;

   (c)  endodontic;

   (d)  orthodontic;

  (e)  optical;

  (f)  non PBS pharmaceuticals;

   (g)  physiotherapy;

   (h)  chiropractic;

    (i)  podiatry;

    (j)  psychology;

   (k)  acupuncture;

    (l)  remedial massage;

  (m)  hearing aids;

   (n)  blood glucose monitors;

   (o)  for any treatment that cannot be classified as any of the above—the name of the treatment.

Note:       Insurers may cover additional treatments, for example, exercise physiology and occupational therapy.

 

4

Treatments not covered by the policy

A list of treatments that are not covered by the policy, expressed in terms of the treatments listed in item 3.

 

5

Waiting period (months)

For each treatment that is covered by the policywhichever of the following is applicable, with the bracketed text replaced with the appropriate text:

   (a)  if there is a waiting period—“[Number] months”;

   (b)  if there is no waiting period for the treatment—“None”.

Note:       If an insured person has already served all applicable waiting periods, this item does not limit the information that a private health insurer may provide with regard to the individual’s policy.

 

6

Benefit limits (per 12 months)

For each treatment that is covered by the policy—if there is no annual limit on the benefits that can be paid, the statement “No annual limit”.

 

Otherwise—the following statements, as applicable, with the bracketed text replaced with the appropriate figures or text:

   (a)  either:

             (i)   any of the following statements:

                          (A)  “$[number] per person”;

                          (B)  “$[number] per treatment”;

                          (C)  “$[number] per policy”; or

            (ii)   any combination of the statements set out in subparagraph (a) (i), linked by the words “up to”;

   (b)  if there is a limit on claims per specified number of years—whichever of the following is applicable:

             (i)   “[number] appliance(s) every [specified number] years”;

            (ii)   “[number] service(s) every [specified number] years”;

  (c)  in the case of combined limits:

             (i)   for the treatment against which the combined limit is listed— “(combined limit for [list treatments listed in item 3 in relation to which limit is combined])”; and

            (ii)   for the other treatments in relation to which the limit is combined—“(combined limit – see [treatment against which the combined limit is listed])”;

   (d)  in the case of limits for individually grouped treatments—whichever of the following statements is applicable:

             (i)   “$[number] per person (combined limit for [whichever of general dental, major dental, endodontic & orthodontic is applicable])”;

            (ii)   “$[number] lifetime limit for [whichever of general dental, major dental, endodontic & orthodontic is applicable]”;

  (e)  if a sub-limit applies on any treatment—the statement “Sub‑limits apply” (in bold font);

   (f)  if:

             (i)   there is a limit on general dental; but

            (ii)   there is no limit on preventative dental;

          the statement “(no limit on preventative dental)”;

   (g)  if none of paragraphs (a) to (f) apply—a brief outline of the applicable limits.

Note 1:    If an insured person has used a portion of lifetime limits, this item does not limit the information that a private health insurer may provide with regard to the individual’s usage of lifetime limit amounts.

Note 2:    This item does not limit the information that a private health insurer may give to an insured person. For example, if limits apply to the policy other than those listed in this item, private health insurers may provide information about those other benefit limits to insured persons.

 

7

Examples of maximum benefits—general dental, major dental, endodontic and orthodontic

For each treatment listed in paragraphs (a) to (d) of item 3 (whether or not covered by the policy):

  (a)  the following treatments, broken down into the following dental item numbers:

             (i)   for general dental:

                          (A)  “Periodic oral examination”—012; and

                          (B)  “Scale & clean”—114; and

                          (C)  “Fluoride treatment”—121; and

                          (D)  if covered under general dental—“Surgical tooth extraction”—322;

            (ii)   for major dental treatment:

                          (A)  if covered under major dental—“Surgical tooth extraction”—322; and

                          (B)  “Full crown veneered”—615;

           (iii)   for endodontic treatment—“Filling of one root canal”—417;

          (iv)   for orthodontic treatment—“Braces for upper and lower teeth, including removal plus fitting of retainer”—881; and

   (b)  if the dental item number is covered by the policy—an example of the maximum benefit that is payable when an insured person visits a practitioner who is not a preferred service provider, expressed using whichever of the following is applicable:

             (i)   “$[number]”, with the bracketed text replaced by the appropriate figure, if:

                          (A)  the benefit is a dollar figure; or

                          (B)  the insurer pays a benefit that is a percentage of the charge up to a dollar limit that is specified for the item separately from an annual limit;

            (ii)   if the only benefit limit for the item is an annual limit— “[number]% of charge”, with the bracketed text replaced by the appropriate figure; and

  (c)  if the dental item number is not covered by the policy—the statement “n/a”.

 

For paragraph (b) of this item:

   (d)  if:

             (i)   the dental item number is provided by orthodontists and general dentists; and

            (ii)   different benefits are offered for orthodontists and general dentists;

          the lower of:

           (iii)   the benefit for the orthodontist; and

          (iv)   the benefit for   the general dentist;

          must be used; and

   (e)  if examples are given for initial and subsequent visits, examples must be for individual sessions.

 

8

Examples of maximum benefits—other

For each treatment covered by the policy, other than the treatments covered by item 7—examples of the maximum benefits that are payable when an insured person visits a practitioner who is not a preferred service provider, expressed using whichever of subparagraphs (b)(i) and (ii) of item 7 is applicable.

 

For this item:

   (a)  if examples are given for initial and subsequent visits, examples must be for individual sessions; and

   (b)  if:

             (i)   optical treatment is covered; and

            (ii)   benefits for frames and lenses are paid separately;

          the example must be expressed as the sum of the benefit for each component.

Note 1:    If treatments are listed for the purposes of paragraph (o) of item 3, examples of maximum benefits for those treatments must be given.

Note 2:    This item does not limit the information that a private health insurer may give to an insured person.

Note 3:    The insurer may provide information about the benefits that apply if treatment is through a preferred provider.

 

9

Other features

A statement that indicates any other features of the policy that the insurer wishes to draw attention to.

The statement must consist of at most 100 words.

Example: Benefits for travel or accommodation, or discounts.

Note:       This statement (if included) is in addition to the statement (if included) that is referred to in item 10 of Schedule 2.

 

 


Part 2—Amendments commencing on 1 April 2019

Private Health Insurance (Complying Product) Rules 2015

[6]       After rule 14

Insert:

15.  Information provided to insured persons

             (1)  This rule is made for the purposes of section 96‑25 of the Act.

             (2)  When giving an insured person a copy of a private health information statement in accordance with section 93‑15 or subsection 93‑20 (1) of the Act, the private health insurer must inform the person of the following:

                     (a)  the name of each person who is covered by the policy;

                     (b)  if the product subgroup to which the policy belongs covers hospital treatment—the following statements for each adult who is covered by the policy and to whom a lifetime health cover loading applies, with the bracketed text replaced with the appropriate amounts:

                              (i)  “Your Lifetime Health Cover Loading is [Number]%.”;

                             (ii)  “You have [Number] years remaining until you have reached 10 continuous years of cover and your loading is removed.”.

             (3)  However, the insurer does not need to inform the person of the information referred to in subrule (2) more than once in any 12 month period.

             (4)  The information referred to in subrule (2) may be accompanied by either or both of the following:

                     (a)  information additional to the information and form of words that are required by subrule 12 (1);

                     (b)  other information about the policy and how it pertains to the person.

Example for paragraph (4) (b):      An insurer may also inform an insured person of:

·    the premium for hospital treatment and for general treatment that applies in relation to each adult insured under the policy, taking account of matters such as loadings, rebates and discounts; and

·    the remaining portion (if any) of the waiting period for any or each treatment covered by the policy.

             (5)  If the private health information statement and the additional information referred to in subrule (2) and paragraphs (4)(a) and (b) are set out in the same document, the additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).

Example:    The document on which a private health information statement is provided might include information about the monthly premium that is payable by the insured person under the policy that is additional to the information required by item 6 of the table to clause 2 of Schedule 1. That additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.

[7]       After rule 15

16.  Information provided to persons about product subgroups

                   For subsection 93‑5 (2) of the Act, if a person asks an insurer for information about a complying health insurance product, the insurer must give the person a copy of the private health information statement for a product subgroup of that product:

                     (a)  by post; or

                     (b)  if the person has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the person.

Example:    If requested by an insured person, a private health information statement may be provided in an electronic format, including via a web page.

[8]       Before subrule 20(1)

Insert:

          (1A)  This rule does not apply in relation to an insurance policy that:

                     (a)  covers hospital treatment (whether or not the policy also covers general treatment); and

                     (b)  has “gold”, “silver”, “bronze” or “basic” in its name.

[9]       Subrule 20(3)

Repeal the subrule, substitute:

             (3)  For this rule, a private health information statement is in the old form if it contains the information, and is in the form, for a standard information statement set out in these Rules as in force immediately before the commencement of Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018.

Note:          Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 January 2019.

[10]     Clause 2 of Schedule 1 (table item 1)

Repeal the item, substitute:

1

Policy name

The name of the policy.

Note 1:    See rules 11H and 11J for rules governing the naming of policies that cover hospital treatment and the naming of policies that cover general treatment.

Note 2:    See rule 21 for a transitional provision relating to this item.

 

[11]     Clause 2 of Schedule 2 (table item 3)

Repeal the item, substitute:

3

What’s included and what’s not included in the policy

An indication of:

   (a)  treatments that are covered by the policy, consisting of the words:

“This policy includes cover for”; and

   (b)  treatments that are not covered by the policy, consisting of the words:

“This policy does not include cover for”;

followed, in each case, by:

   (c)  the relevant clinical categories; and

   (d)  whichever of the following (if any) is appropriate:

             (i)   accident cover;

            (ii)   benefits for travel or accommodation.

Note:       See rule 21 for a transitional provision relating to this item.

 

[12]     Clause 2 of Schedule 2 (table item 4)

Repeal the item, substitute:

4

Restrictions

A list of all clinical categories (if any) that have restricted cover.

Note:       See rule 21 for a transitional provision relating to this item.

 

[13]     Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, paragraph (b))

Omit “treatments”, substitute “clinical categories”.

[14]     Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, after note 2)

Insert:

Note 3:    See rule 21 for a transitional provision relating to this item.

[15]     Amendments of listed provisionsprivate health information statements

 

Further amendments

Item

Provision

Omit

Substitute

1

Rule 4 (note at the end of the rule)

standard information statement

private health information statement

2

Paragraph 9AA(2)(a)

standard information statement

private health information statement

3

Part 3 (heading)

Standard information statements

Private health information statements

4

Part 3 (note to the Part heading, first bullet point)

standard information statements

private health information statements

5

Rule 12 (heading)

Standard information statements

Private health information statements

6

Subrule 12 (1)

standard information statement

private health information statement

7

Rule 13 (heading)

standard information statements

private health information statements

8

Paragraph 13 (2) (a)

standard information statement

private health information statement

9

Paragraph 13 (2) (b)

standard information statement

private health information statement

10

Subrule 13 (2) (example)

standard information statement

private health information statement

11

Rule 20 (heading)

standard information statements

private health information statements

12

Subrule 20(2)

standard information statement

private health information statement

13

Schedule 1 (heading)

standard information statement

private health information statement

14

Schedule 1, clause 2 (heading)

standard information statement

private health information statement

15

Schedule 1, clause 2 (table heading)

standard information statement

private health information statement

16

Schedule 1, clause 2, table item 13

standard information statement

private health information statement

17

Schedule 2 (heading)

standard information statement

private health information statement

18

Schedule 3 (heading)

standard information statement

private health information statement

 


Part 3—Amendments commencing on 1 April 2020

Private Health Insurance (Complying Product) Rules 2015

[16]     Rule 20

Repeal the rule.

[17]     Clause 2 of Schedule 1 (table item 1)

Repeal the item, substitute:

1

Policy name

The name of the policy.

Note:       See rules 11H and 11J for rules governing the naming of policies that cover hospital treatment and the naming of policies that cover general treatment.

 

[18]     Clause 2 of Schedule 2 (table item 3, column headed “Additional information and form of words”, note)

Repeal the note.

[19]     Clause 2 of Schedule 2 (table item 4, column headed “Additional information and form of words”, note)

Repeal the note.

[20]     Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, note 3)

Repeal the note.

 


Schedule 3—Product tiers and related amendments

Part 1—Amendments commencing on 1 April 2019

Private Health Insurance (Complying Product) Rules 2015

[1]       Rule 4

Insert:

basic policy means an insurance policy that:

                     (a)  covers hospital treatment; and

                     (b)  covers at least the treatments in all of the clinical categories indicated for a basic policy in Schedule 4; and

                     (c)  is not a gold, silver or bronze policy.

bronze policy means an insurance policy that:

                     (a)  covers hospital treatment; and

                     (b)  covers at least the treatments in all of the clinical categories indicated for a bronze policy in Schedule 4; and

                     (c)  is not a gold or silver policy.

clinical category, for hospital treatment, means a clinical category that is set out in Schedule 5.

gold policy means an insurance policy that:

                     (a)  covers hospital treatment; and

                     (b)  covers the treatments in all of the clinical categories indicated for a gold policy in Schedule 4.

MBS item means an item in any of the following:

                     (a)  the general medical services table, made under section 4 of the Health Insurance Act 1973, as in force from time to time;

                     (b)  the diagnostic imaging services table, made under section 4AA of the Health Insurance Act 1973, as in force from time to time;

                     (c)  the pathology services table, made under section 4A of the Health Insurance Act 1973, as in force from time to time.

product tier means:

                     (a)  for a gold policy—“gold”; and

                     (b)  for a silver policy—“silver”; and

                     (c)  for a bronze policy—“bronze”; and

                     (d)  for a basic policy—“basic”.

silver policy means an insurance policy that:

                     (a)  covers hospital treatment; and

                     (b)  covers at least the treatments in all of the clinical categories indicated for a silver policy in Schedule 4; and

                     (c)  is not a gold policy.

[1A]    Rule 4 (note at the end of the rule)

Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, “medical practitioner”.

[2]       After Part 2A

Insert:

Part 2B Requirements relating to product tiers for, and names of, insurance policies

Note 1:    This Part specifies additional requirements that an insurance policy must meet in order to be a complying health insurance policy, for the purposes of paragraph 63‑10 (g) of the Act.

Note 2:    Nothing in this Part affects the operation of Division 72 of the Act (which relates to benefit requirements for policies that cover hospital treatment) or the operation of the Private Health Insurance (Benefit Requirements) Rules for the calculation of minimum benefits where restricted cover is allowed under rule 11G.

11E.           Product tiers for insurance policies that cover hospital treatment

Note:       See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.

             (1)  For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).

             (2)  The policy must be one of the following:

                     (a)  a gold policy;

                     (b)  a silver policy;

                     (c)  a bronze policy;

                     (d)  a basic policy.

11F.            Coverage of treatments for insurance policies that cover hospital treatment

Note:       See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.

Application of rule

             (1)  For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).

Treatments that must be covered by policy

             (2)  The policy must cover:

                     (a)  all hospital treatments that are within the scope of cover that is identified, in Schedule 5, for each clinical category in relation to which the policy provides cover (see subrules (5) and (6)); and

                     (b)  all hospital treatments that are not within the scope of cover of such a clinical category, but that are:

                              (i)  associated treatments for complications (see subrule (7)); or

                             (ii)  associated unplanned treatments (see subrule (8)).

             (3)  However, the policy is not required to cover cosmetic surgery that is not medically necessary.

Treatments that may be covered by policy

             (4)  The policy may also provide either or both of the following:

                     (a)  accident cover;

                     (b)  benefits for travel or accommodation relating to a treatment referred to in subrule (2) or paragraph (a).

Interpretation

             (5)  For paragraph (2) (a), the scope of cover of a particular clinical category includes, but is not limited to:

                     (a)  all hospital treatments involving the provision of an MBS item listed in Schedule 5 against that clinical category; and

                     (b)  all hospital treatments:

                              (i)  that are provided in relation to a treatment of a kind referred to in paragraph (2) (a) or (5) (a); and

                             (ii)  involving the provision of an MBS item listed in:

                                        (A)  the common treatments list in Schedule 6; or

                                        (B)  the support treatments list in Schedule 7.

             (6)  Paragraph (5) (b) does not apply in relation to the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”.

             (7)  For subparagraph (2) (b) (i), a hospital treatment is an associated treatment for complications if it is:

                     (a)  provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and

                     (b)  provided for a complication that arises during that episode.

             (8)  For subparagraph (2) (b) (ii), a hospital treatment is an associated unplanned treatment if it is:

                     (a)  provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and

                     (b)  an unplanned treatment that:

                              (i)  is provided as part of planned surgery performed during that episode; and

                             (ii)  is, in the view of the medical practitioner who provides the unplanned treatment, medically necessary and urgent.

11G.           Provision of restricted and unrestricted cover

Note:       See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.

Gold policies

             (1)  A gold policy must provide unrestricted cover for all hospital treatments in all clinical categories.

Silver policies and bronze policies

             (2)  A silver policy or a bronze policy:

                     (a)  must provide restricted cover or unrestricted cover for all hospital treatments in the following clinical categories:

                              (i)  rehabilitation;

                             (ii)  hospital psychiatric services;

                            (iii)  palliative care; and

                     (b)  must provide unrestricted cover for all hospital treatments in:

                              (i)  the other clinical categories that a silver policy or a bronze policy, as appropriate, is required to cover; and

                             (ii)  any other clinical categories that the policy covers.

Basic policies

             (3)  A basic policy must provide restricted cover or unrestricted cover for all hospital treatments in:

                     (a)  all of the clinical categories that a basic policy is required to cover; and

                     (b)  any other clinical categories that the policy covers.

11H.           Naming of insurance policies that cover hospital treatment

Note:       See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.

             (1)  For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).

             (2)  The policy must include a name that contains the policy’s product tier.

             (3)  If the policy covers one or more clinical categories additional to those required for a policy of that product tier in Schedule 4, the name may also contain “plus” or “+”.

             (4)  The name must not contain:

                     (a)  the name of any other metal; or

                     (b)  the name of any gemstone or any semi-precious stone; or

                     (c)  unless permitted by subrule (3)—either “plus” or “+”.

11J.            Naming of insurance policies that cover general treatment only

             (1)  For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers general treatment only.

             (2)  The policy must include a name that does not contain:

                     (a)  the name of any metal; or

                     (b)  the name of any gemstone or any semi-precious stone; or

                     (c)  either “plus” or “+”.

[3]       After rule 20

Insert:

21.              Transitional provisions relating to the Private Health Insurance (Reforms) Amendment Rules 2018—product tiers

Application of rule

             (1)  This rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).

             (2)  This rule applies until 31 March 2020.

Transitional provisions

             (3)  If the policy does not have any of the following:

                     (a)  “gold”, “silver”, “bronze” or “basic”;

                     (b)  the name of any other metal;

                     (c)  the name of any gemstone or semi‑precious stone;

                   in its name, the policy need not comply with Part 2B.

             (4)  If the policy:

                     (a)  does not have any of the words referred to in subrule (3) in its name; and

                     (b)  does not use the clinical categories to indicate the treatments it covers;

                   each of the following:

                     (c)  item 1 of clause 2 of Schedule 1;

                     (d)  item 3 of clause 2 of Schedule 2;

                     (e)  item 4 of clause 2 of Schedule 2;

                      (f)  item 5 of clause 2 of Schedule 2;

                   as in force immediately before the commencement of Part 2 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 applies in relation to the policy.

Note:          Part 2 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 April 2019.

[4]       After Schedule 3

Add:

Schedule 4—Product tiers and clinical categories

Note:       See rule 4 and Part 2B.

1.  Product tiers and clinical categories

                   For the definition of gold policy, silver policy, bronze policy and basic policy in rule 4, and for rule 11H, the following table sets out the clinical categories that are indicated for policies of each product tier.

Clinical category

Basic

Bronze

Silver

Gold

Rehabilitation

üR

üR

üR

ü

Hospital psychiatric services

üR

üR

üR

ü

Palliative care

üR

üR

üR

ü

Brain and nervous system

RCP

ü

ü

ü

Eye (not cataracts)

RCP

ü

ü

ü

Ear, nose and throat

RCP

ü

ü

ü

Tonsils, adenoids and grommets

RCP

ü

ü

ü

Bone, joint and muscle

RCP

ü

ü

ü

Joint reconstructions

RCP

ü

ü

ü

Kidney and bladder

RCP

ü

ü

ü

Male reproductive system

RCP

ü

ü

ü

Digestive system

RCP

ü

ü

ü

Hernia and appendix

RCP

ü

ü

ü

Gastrointestinal endoscopy

RCP

ü

ü

ü

Gynaecology

RCP

ü

ü

ü

Miscarriage and termination of pregnancy

RCP

ü

ü

ü

Chemotherapy, radiotherapy and immunotherapy for cancer

RCP

ü

ü

ü

Pain management

RCP

ü

ü

ü

Skin

RCP

ü

ü

ü

Breast surgery (medically necessary)

RCP

ü

ü

ü

Diabetes management (excluding insulin pumps)

RCP

ü

ü

ü

Heart and vascular system

RCP

 

ü

ü

Lung and chest

RCP

 

ü

ü

Blood

RCP

 

ü

ü

Back, neck and spine

RCP

 

ü

ü

Plastic and reconstructive surgery (medically necessary)

RCP

 

ü

ü

Dental surgery

RCP

 

ü

ü

Podiatric surgery (provided by a registered podiatric surgeon)

RCP

 

ü

ü

Implantation of hearing devices

RCP

 

ü

ü

Cataracts

RCP

 

 

ü

Joint replacements

RCP

 

 

ü

Dialysis for chronic kidney failure

RCP

 

 

ü

Pregnancy and birth

RCP

 

 

ü

Assisted reproductive services

RCP

 

 

ü

Weight loss surgery

RCP

 

 

ü

Insulin pumps

RCP

 

 

ü

Pain management with device

RCP

 

 

ü

Sleep studies

RCP

 

 

ü

 

 

ü

Indicates the clinical category is a minimum requirement of the product tier.  The clinical category must be covered on an unrestricted basis.

üR

Indicates the clinical category is a minimum requirement of the product tier.  The clinical category may be offered on a restricted cover basis in Basic, Bronze and Silver product tiers only.

RCP

Restricted cover permitted: indicates the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories on a restricted or unrestricted basis.

 

A blank cell indicates that the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories; however it must be on an unrestricted basis.

 

Schedule 5—Clinical categories

Note 1:    Rule 11F is the principal provision that deals with what must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 6 and Schedule 7.

Note 2:    The treatments that must be covered are any hospital treatments that are in the scope of cover of a clinical category in relation to which the policy provides cover. The scope of cover includes, without limitation:

·    any hospital treatment involving the provision of an MBS item number listed in column 3 below; and

·    except for the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”—any hospital treatment:

–    that is provided in relation to a treatment within the scope of cover of a particular clinical category or that involves the provision of an MBS item number listed in column 3 below; and

–    that involves the provision of an MBS item number listed in Schedule 6 (common treatments) or Schedule 7 (support treatments).

Note 3:    MBS items are mentioned in the table below against a clinical category, or in the common treatments or support treatments lists in Schedules 6 and 7. Where an MBS item is mentioned for a clinical category in column 3 in the table below, the treatment including that MBS item is most likely to be provided under that clinical category, or a clinical category in the same or a higher product tier (according to Schedule 4). However, the mention of an MBS item against a particular category does not mean it is only covered under that clinical category.

1  Interpretation

                   In this Schedule, the scope of cover of a particular clinical category is taken not to include any treatment that is, or treatments that are, expressly stated to be listed separately under another clinical category.

Clinical categories

                   For rule 4, and Part 2B, the clinical categories are set out in the following table.


Clinical category

Scope of cover (see Note 1)

Treatments that must be covered (MBS Items) (see Notes 1, 2 and 3)

Rehabilitation

Hospital treatment for physical rehabilitation for a patient related to surgery or illness.

For example: inpatient and admitted day patient rehabilitation, stroke recovery, cardiac rehabilitation.

 

Hospital psychiatric services

Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders.

For example: psychoses such as schizophrenia, mood disorders such as depression, eating disorders and addiction therapy.

Treatments involving the provision of the following MBS items:              170         171                172         289         297         320         322         324         326         328         342                344         346         348         350         352         364         366         367         369                370         855         857         858         861         864         866         2700       2701                2712       2713       2715       2717       2721       2723       2725       2727       6018                6019       6023       6024       6025       6026       6028       6029       6031       6032                6034       6035       6037       6038       6042       14224    80000    80001    80005                80010    80011    80015    80020    80021    80100    80101    80105    80110                80111    80115    80120    80121    80125    80126    80130    80135    80136                80140    80145    80146    80150    80151    80155    80160    80161    80165                80170    80171    82000    82015

Palliative care

Hospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain.

Treatments involving the provision of the following MBS items:              3003       3005                3010       3014       3015       3018       3023       3028       3032       3040       3044                3051       3055       3062       3069       3074       3078       3083       3088       3093

Assisted reproductive services

Hospital treatment for fertility treatments or procedures.

For example: retrieval of eggs or sperm, In vitro Fertilisation (IVF), and Gamete Intra-fallopian Transfer (GIFT).

Treatment of the female reproductive system is listed separately under Gynaecology.

Pregnancy and birth-related services are listed separately under Pregnancy and birth.

Treatments involving the provision of the following MBS items:              13200    13201                13202    13203    13206    13209    13212    13215    13218    13221    13251                13290    13292    14203    14206    37605    37606

Back, neck and spine

Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion.

For example: sciatica, prolapsed or herniated disc, and spine curvature disorders such as scoliosis, kyphosis and lordosis.

Joint replacements are listed separately under Joint replacements.

Joint fusions are listed separately under Bone, joint and muscle.

Spinal cord conditions are listed separately under Brain and nervous system.

Management of back pain is listed separately under Pain management. Pain management that requires a device is listed separately under Pain management with device.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              30672    40300                40301    40309    40312    40315    40316    40318    40321    40324    40327                40330    40333    40336    40339    44133    47681    47684    47687    47690                47693    47696    47699    47702    47705    47708    47711    47714    47717                47720    47723    48600    48603    48606    48612    48613    48615    48618                48621    48624    48627    48632    48636    48639    48640    48642    48645                48648    48651    48654    48657    48660    48663    48666    48669    48672                48675    48678    48681    48684    48687    48690    48691    48692    48693                48694    50600    50604    50608    50612    50616    50620    50624    50628                50632    50636    50640    50644

Blood

Hospital treatment for the investigation and treatment of blood and blood-related conditions.

For example: blood clotting disorders and bone marrow transplants.

Treatment for cancers of the blood is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS item: 13700

Bone, joint and muscle

Hospital treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system.

For example: carpal tunnel, fractures, hand surgery, joint fusion, bone spurs, osteomyelitis and bone cancer.

Chest surgery is listed separately under Lung and chest.

Spinal cord conditions are listed separately under Brain and nervous system.

Spinal column conditions are listed separately under Back, neck and spine.

Joint reconstructions are listed separately under Joint reconstructions.

Joint replacements are listed separately under Joint replacements.

Podiatric surgery performed by a registered podiatric surgeon is listed separately under Podiatric surgery (provided by a registered podiatric surgeon).

Management of back pain is listed separately under Pain management. Pain management that requires a device is listed separately under Pain management with device.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              18350    18351                18353    18354    18360    18361    18365    30103    30107    30111    30114                30226    30229    30232    30235    30238    30241    30244    32036    39331                43500    43503    43506    43509    43512    43515    43518    43521    43524                43876    43879    44325    44328    44331    44334    44338    44342    44346                44350    44354    44358    44359    44361    44364    44367    44370    44373                44376    45605    45788    45851    45855    45857    45859    45861    45863                45867    45869    45871    45873    45875    45945    45978    45981    45987                45993    45996    46300    46303    46306    46307    46327    46330    46333                46336    46339    46342    46348    46351    46354    46357    46360    46363                46366    46369    46372    46375    46378    46381    46384    46387    46390                46393    46396    46399    46402    46405    46459    46462    46464    46465                46468    46471    46474    46477    46480    46483    47000    47003    47006                47009    47012    47015    47018    47021    47024    47027    47030    47033                47036    47039    47042    47045    47048    47051    47054    47057    47060                47063    47066    47069    47072    47301    47304    47307    47310    47313                47316    47319    47348    47351    47354    47357    47361    47362    47364                47367    47370    47373    47378    47381    47384    47385    47386    47387                47390    47393    47396    47399    47402    47405    47408    47411    47414                47417    47420    47423    47426    47429    47432    47435    47438    47441                47444    47447    47450    47451    47453    47456    47459    47462    47465                47466    47467    47468    47471    47474    47477    47480    47483    47486                47489    47492    47495    47498    47501    47504    47507    47510    47513                47516    47519    47522    47525    47528    47531    47534    47537    47540                47543    47546    47549    47552    47555    47558    47561    47564    47565                47566    47567    47570    47573    47576    47579    47582    47585    47588                47591    47594    47597    47600    47603    47606    47609    47612    47615                47618    47621    47624    47627    47630    47633    47636    47639    47642                47645    47648    47651    47654    47657    47663    47666    47672    47678                47703    47726    47729    47732    47753    47756    47762    47765    47768                47771    47774    47777    47780    47783    47786    47789    47900    47903                47920    47921    47924    47927    47930    47933    47936    47948    47951                47954    47957    47960    47963    47966    47969    47972    47975    47978                47981    47982    48200    48203    48206    48209    48212    48215    48218                48221    48224    48227    48230    48233    48236    48239    48242    48400                48403    48406    48409    48412    48415    48418    48421    48424    48427                48500    48503    48506    48509    48512    48912    48936    48939    48942                48945    48954    49100    49106    49109    49118    49200    49203    49206                49212    49218    49300    49303    49306    49360    49363    49366    49500                49509    49512    49545    49566    49569    49700    49712    49718    49721                49724    49727    49728    49800    49803    49806    49809    49812    49815                49818    49821    49824    49827    49830    49833    49836    49837    49838                49845    49848    49851    49854    49860    49863    49866    49878    50100                50102    50103    50104    50109    50112    50115    50118    50121    50130                50200    50201    50203    50206    50209    50212    50215    50218    50221                50224    50227    50230    50233    50236    50239    50300    50303    50306                50309    50312    50315    50318    50321    50324    50327    50330    50336                50339    50342    50345    50348    50349    50351    50352    50353    50354                50357    50360    50363    50366    50369    50372    50375    50378    50381                50384    50387    50390    50393    50394    50396    50399    50402    50405                50408    50426    50450    50451    50455    50456    50460    50461    50465                50466    50470    50471    50475    50476    50500    50504    50508    50512                50516    50520    50524    50528    50532    50536    50540    50544    50548                50552    50556    50560    50564    50568    50572    50576    50580    50584                50588    50650    50654    50658    52056    52057    52058    52059    52060                52061    52062    52063    52064    52066    52069    52072    52073    52075                52078    52081    52084    52087    52090    52092    52094    52095    52096                52097    52098    52099    52102    52105    52114    52126    52129    52130                52131    52180    52182    52184    52186    53200    53203    53206    53209                53212    53215    53218    53220    53221    53224    53225    53226    53227                53230    53233    53236    53239    53400    53403    53406    53409    53410                53411    53412    53413    53414    53415    53416    53418    53419    53422                53423    53424    53425    53427    53429    53439

Brain and nervous system

Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system.

For example: stroke, brain or spinal cord tumours, head injuries, epilepsy and Parkinson’s disease.

Treatment of spinal column (back bone) conditions is listed separately under Back, neck and spine.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              6004       6007                6009       6011       6013       6015       6016       14227    14230    14233    14236                14239    14242    18377    35000    35003    35006    35009    35012    35412                35414    39003    39006    39009    39012    39013    39015    39018    39300                39303    39306    39309    39312    39315    39318    39321    39324    39327                39330    39333    39500    39503    39600    39603    39606    39609    39612                39615    39640    39642    39646    39650    39653    39654    39656    39658                39660    39662    39700    39703    39706    39709    39712    39715    39718                39721    39800    39803    39806    39812    39815    39818    39821    39900                39903    39906    40000    40003    40006    40009    40012    40015    40018                40100    40103    40106    40109    40112    40115    40118    40303    40306                40331    40332    40334    40335    40342    40345    40348    40351    40600                40700    40701    40702    40703    40704    40705    40706    40707    40708                40709    40712    40800    40801    40803    40850    40851    40852    40854                40856    40858    40860    40862    40903    40905    43987    48630    52800                52803    52806    52809    52812    52815    52818    52821    52824    52826                52828    52830    52832

Breast surgery (medically necessary)

Hospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction and/or reduction following breast surgery or a preventative mastectomy.

For example: breast lesions, breast tumours, asymmetry due to breast cancer surgery, and gynecomastia.

This clinical category does not require benefits to be paid for cosmetic breast surgery that is not medically necessary.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              30299    30300                30302    30303    31500    31503    31506    31509    31512    31515    31516                31519    31524    31525    31530    31533    31536    31539    31542    31545                31548    31551    31554    31557    31560    31563    31566    45520    45522                45524    45527    45528    45530    45533    45536    45539    45542    45545                45546    45548    45551    45552    45553    45554    45555    45556    45557                45558    45559

Cataracts

Hospital treatment for surgery to remove a cataract and replace with an artificial lens.

Treatments involving the provision of the following MBS items:              42698    42701                42702    42703    42704    42705    42707    42710    42713    42716

Chemotherapy, radiotherapy and immunotherapy for cancer

Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours.

Surgical treatment of cancer is listed separately under each body system.

Treatments involving the provision of the following MBS items:              13760    13915                13918    13921    13924    13927    13930    13933    13936    13939    13942                13945    13948    14221    14245    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    15275    15303    15304    15307    15308    15311    15312    15315                15316    15319    15320    15323    15324    15327    15328    15331    15332                15335    15336    15338    15339    15342    15345    15348    15351    15354                15357    15500    15503    15506    15509    15512    15513    15515    15518                15521    15524    15527    15530    15533    15536    15539    15550    15553                15555    15556    15559    15562    15565    15600    15700    15705    15710                15715    15800    15850    15900    16003    16006    16009    16012    16015                16018    30400    34521    34524    34527    34528    34529    34530    34533                34534    34539    34540    35404    35406    35408    50950    50952

Dental surgery

Hospital treatment for surgery to the teeth and gums.

For example: surgery to remove wisdom teeth, and dental implant surgery.

Treatments involving the provision of the following MBS items:              75006    75030                75033    75034    75036    75037    75039    75042    75045    75048    75049                75050    75051    75156    75200    75203    75206    75400    75403    75406                75409    75412    75415    75600    75603    75606    75609    75612    75615                75618    75621    75800    75803    75806    75809    75812    75815    75818                75821    75824    75827    75830    75833    75836    75839    75842    75845                75848    75851    75854

Diabetes management

(excluding insulin pumps)

Hospital treatment for the investigation and management of diabetes.

For example: stabilisation of hypo- or hyper- glycaemia, contour problems due to insulin injections.

Treatment for diabetes-related conditions is listed separately under each body system affected. For example, treatment for diabetes-related eye conditions is listed separately under Eye.

Treatment for ulcers is listed separately under Skin.

Provision and replacement of insulin pumps is listed separately under Insulin pumps.

Treatments involving the provision of the following MBS items:              31346    81100                81105

Dialysis for chronic kidney failure

Hospital treatment for dialysis treatment for chronic kidney failure.

For example: peritoneal dialysis and haemodialysis.

Treatments involving the provision of the following MBS items:              13100    13103                13104    13106    13109    13110    13112

Digestive system

Hospital treatment for the investigation and treatment of the digestive system, including the oesophagus, stomach, gall bladder, pancreas, spleen, liver and bowel.

For example: oesophageal cancer, irritable bowel syndrome, gall stones and haemorrhoids.

Endoscopy is listed separately under Gastrointestinal endoscopy.

Hernia and appendicectomy procedures are listed separately under Hernia and appendix.

Bariatric surgery is listed separately under Weight loss surgery.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              11800    11801                11810    13506    14212    30373    30375    30376    30378    30379    30382                30384    30385    30387    30392    30393    30396    30397    30399    30402                30406    30408    30409    30411    30412    30414    30415    30416    30417                30418    30419    30421    30422    30425    30427    30428    30430    30431                30433    30434    30436    30437    30438    30439    30440    30441    30442                30443    30445    30446    30448    30449    30450    30451    30452    30454                30455    30457    30458    30460    30461    30463    30464    30466    30467                30469    30472    30481    30482    30483    30492    30495    30496    30497                30499    30500    30502    30503    30505    30506    30508    30509    30515                30517    30518    30520    30521    30523    30524    30526    30527    30529                30530    30532    30533    30535    30536    30538    30539    30541    30542                30544    30545    30547    30548    30550    30551    30553    30554    30556                30557    30559    30560    30562    30563    30564    30565    30566    30575                30577    30578    30580    30581    30583    30584    30586    30587    30589                30590    30593    30594    30596    30597    30599    30600    30601    30602                30603    30605    30606    30608    30619    30621    30622    30623    30626                30627    30636    30637    30639    31450    31452    31454    31456    31458                31460    31462    31464    31466    31468    31470    31472    32000    32003                32004    32005    32006    32009    32012    32015    32018    32021    32024                32025    32026    32028    32029    32030    32033    32039    32042    32045                32046    32047    32051    32054    32057    32060    32063    32066    32069                32096    32099    32102    32103    32104    32105    32106    32108    32111                32112    32114    32115    32117    32120    32123    32126    32129    32131                32132    32135    32138    32139    32142    32145    32147    32150    32153                32156    32159    32162    32165    32166    32168    32171    32174    32175                32177    32180    32183    32186    32200    32203    32206    32209    32210                32212    32213    32214    32215    32216    32217    32218    32220    32221                41816    41822    41825    41828    41831    41832    43801    43804    43807                43810    43813    43816    43819    43822    43825    43828    43831    43834                43840    43843    43846    43849    43852    43855    43858    43864    43867                43870    43873    43900    43903    43906    43930    43933    43936    43942                43945    43948    43951    43954    43957    43960    43963    43966    43969                43972    43975    43978    43990    43993    43996    43999    44101    44102                44104    44105

Ear, nose and throat

Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck.

For example: damaged ear drum, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer.

Tonsils, adenoids and grommets are listed separately under Tonsils, adenoids and grommets.

The implantation of a hearing device is listed separately under Implantation of hearing devices.

Orthopaedic neck conditions are listed separately under Back, neck and spine.

Sleep studies are listed separately under Sleep studies.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

 

Treatments involving the provision of the following MBS items:              11300    18368                30104    30105    30246    30247    30250    30251    30253    30255    30256                30259    30262    30266    30269    30272    30275    30278    30281    30283                30286    30287    30289    30293    30294    30296    30297    30306    30308                30309    30310    30313    30314    30315    30317    30318    30320    30326                30618    31400    31403    31406    31409    31412    31420    31423    31426                31429    31432    31435    31438    41500    41503    41506    41509    41512                41515    41518    41521    41524    41527    41530    41533    41536    41539                41542    41545    41548    41551    41554    41557    41560    41563    41564                41566    41569    41572    41575    41576    41578    41579    41581    41584                41587    41590    41593    41596    41599    41608    41611    41614    41615                41620    41623    41626    41629    41635    41638    41641    41644    41647                41650    41653    41656    41659    41662    41668    41671    41672    41674                41677    41683    41686    41689    41692    41698    41701    41704    41707                41710    41713    41716    41719    41722    41725    41728    41729    41731                41734    41737    41740    41743    41746    41749    41752    41755    41764                41767    41770    41773    41776    41779    41782    41785    41786    41787                41804    41807    41810    41813    41834    41837    41840    41843    41846                41855    41858    41861    41864    41867    41868    41870    41873    41876                41879    41880    41881    41884    41885    41886    41889    41892    41895                41898    41901    41904    41905    41907    41910    43832    45645    45646                47735    47738    47741    51900    51902    52021    52024    52025    52027                52030    52033    52034    52035    52055    52132    52133    52135    52138                52141    52147    52148    52158    53000    53003    53004    53006    53009                53012    53015    53016    53017    53019    53052    53054    53056    53058                53060    53062    53064    53068    53070    53458    53459    53460

Eye (not cataracts)

Hospital treatment for the investigation and treatment of the eye and the contents of the eye socket.

For example: retinal detachment, tear duct conditions, eye infections and medically managed trauma to the eye.

Cataract procedures are listed separately under Cataracts.

Eyelid procedures are listed separately under Plastic and reconstructive surgery.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              18366    18369                18370    18372    18374    42503    42506    42509    42510    42512    42515                42518    42521    42524    42527    42530    42533    42536    42539    42542                42543    42545    42548    42551    42554    42557    42563    42569    42572                42573    42574    42575    42576    42581    42584    42587    42590    42593                42596    42599    42602    42605    42608    42610    42611    42614    42615                42617    42620    42622    42623    42626    42629    42632    42635    42638                42641    42644    42647    42650    42651    42652    42653    42656    42662                42665    42667    42668    42672    42673    42676    42677    42680    42683                42686    42689    42692    42695    42719    42725    42731    42734    42738                42739    42740    42741    42743    42744    42746    42749    42752    42755                42758    42761    42764    42767    42770    42773    42776    42779    42782                42783    42785    42786    42788    42789    42791    42792    42794    42801                42802    42805    42806    42807    42808    42809    42810    42811    42812                42815    42818    42821    42824    42833    42836    42839    42842    42845                42848    42851    42854    42857    42869    43021    43022    43023

Gastrointestinal endoscopy

Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope.

For example: colonoscopy, gastroscopy, endoscopic retrograde cholangiopancreatography (ERCP).

Non-endoscopic procedures for the digestive system are listed separately under Digestive system.

Treatments involving the provision of the following MBS items:              11820    11823                30473    30475    30478    30479    30484    30485    30488    30490    30491                30494    30568    30569    30680    30682    30684    30686    30687    30688                30690    30692    30694    32023    32072    32075    32084    32087    32088                32089    32090    32093    32094    32095

Gynaecology

Hospital treatment for the investigation and treatment of the female reproductive system.

For example: endometriosis, polycystic ovaries, female sterilisation and cervical cancer.

Fertility treatments are listed separately under Assisted reproductive services.

Pregnancy and birth-related conditions are listed separately under Pregnancy and birth.

Miscarriage or termination of pregnancy is listed separately under Miscarriage and termination of pregnancy.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              30062    35410                35500    35502    35503    35506    35507    35508    35509    35513    35517                35518    35520    35523    35527    35530    35533    35534    35536    35539                35542    35545    35548    35551    35554    35557    35560    35561    35562                35564    35565    35566    35568    35569    35570    35571    35572    35573                35577    35578    35581    35582    35585    35595    35596    35597    35599                35602    35605    35608    35611    35612    35613    35614    35615    35616                35618    35620    35622    35623    35626    35627    35630    35633    35634                35635    35636    35637    35638    35641    35644    35645    35646    35647                35648    35649    35653    35657    35658    35661    35664    35667    35670                35673    35680    35684    35688    35691    35694    35697    35700    35703                35706    35709    35710    35713    35717    35720    35723    35726    35729                35730    35750    35753    35754    35756    35759

Heart and vascular system

Hospital treatment for the investigation and treatment of the heart, heart-related conditions and vascular system.

For example: heart failure and heart attack, monitoring of heart conditions, varicose veins and removal of plaque from arterial walls.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              13400    32500                32501    32504    32507    32508    32511    32514    32517    32520    32522                32523    32526    32528    32529    32700    32703    32708    32710    32711                32712    32715    32718    32721    32724    32730    32733    32736    32739                32742    32745    32748    32751    32754    32757    32760    32763    32766                32769    33050    33055    33070    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    33545    33548    33551    33554    33800                33803    33806    33810    33811    33812    33815    33818    33821    33824                33827    33830    33833    33836    33839    33842    33845    33848    34100                34103    34106    34109    34112    34115    34118    34121    34124    34127                34130    34142    34145    34148    34151    34154    34157    34160    34163                34166    34169    34172    34175    34500    34503    34506    34509    34512                34515    34518    34800    34803    34806    34809    34812    34815    34818                34821    34824    34827    34830    34833    35100    35103    35200    35202                35300    35303    35306    35307    35309    35312    35315    35317    35319                35320    35321    35324    35327    35330    35331    35360    35361    35362                35363    38200    38203    38206    38209    38212    38213    38215    38218                38220    38222    38225    38228    38231    38234    38237    38240    38241                38243    38246    38256    38270    38272    38273    38274    38275    38276                38285    38286    38287    38288    38290    38293    38300    38303    38306                38309    38312    38315    38318    38350    38353    38356    38358    38359                38362    38365    38368    38371    38384    38387    38390    38393    38447                38449    38450    38452    38470    38473    38475    38477    38478    38480                38481    38483    38485    38487    38488    38489    38490    38493    38495                38496    38497    38498    38500    38501    38503    38504    38505    38506                38507    38508    38509    38512    38515    38518    38550    38553    38556                38559    38562    38565    38568    38571    38572    38577    38588    38600                38603    38609    38612    38613    38615    38618    38621    38624    38627                38637    38650    38653    38654    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    59903    59912    59925    59971    59972                59973

Hernia and appendix

Hospital treatment for the investigation and treatment of a hernia or appendicitis.

Digestive conditions are listed separately under Digestive system.

Treatments involving the provision of the following MBS items:              30571    30572                30574    30609    30614    30615    30640    30645    30646    43805    43835                43837    43838    43841    43939    44108    44111    44114

Implantation of hearing devices

Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device.

Stapedectomy is listed separately under Ear, nose and throat.

Treatments involving the provision of the following MBS items:              41603    41604                41617    41618

Insulin pumps

Hospital treatment for the provision and replacement of insulin pumps for treatment of diabetes.

 

Joint reconstructions

Hospital treatment for surgery for joint reconstructions.

For example: torn tendons, rotator cuff tears and damaged ligaments.

Joint replacements are listed separately under Joint replacements.

Bone fractures are listed separately under Bone, joint and muscle.

Procedures to the spinal column are listed separately under Back, neck and spine.

Podiatric surgery performed by a registered podiatric surgeon is listed separately under Podiatric surgery (provided by a registered podiatric surgeon).

Treatments involving the provision of the following MBS items:              46345    46408                46411    46414    46417    46420    46423    46426    46429    46432    46435                46438    46441    46442    46444    46447    46450    46453    46456    46492                46494    46495    46498    46500    46501    46502    46503    46504    46507                46510    46522    48900    48903    48906    48909    48930    48933    48948                48951    48957    48960    49103    49121    49215    49221    49224    49227                49503    49506    49536    49539    49542    49548    49551    49557    49558                49559    49560    49561    49562    49563    49564    49703    49706    49709                50106    50333

Joint replacements

Hospital treatment for surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses.

For example: replacement of shoulder, wrist, finger, hip, knee, ankle, or toe joint, spinal disc replacement.

Joint fusions are listed separately under Bone, joint and muscle.

Spinal fusions are listed separately under Back, neck and spine.

Joint reconstructions are listed separately under Joint reconstructions.

Podiatric surgery performed by a registered podiatric surgeon is listed separately under Podiatric surgery (provided by a registered podiatric surgeon).

Treatments involving the provision of the following MBS items:              46309    46312                46315    46318    46321    46324    46325    48915    48918    48921    48924                48927    49112    49115    49116    49117    49209    49210    49211    49309                49312    49315    49318    49319    49321    49324    49327    49330    49333                49336    49339    49342    49345    49346    49515    49517    49518    49519                49521    49524    49527    49530    49533    49534    49554    49715    49716                49717    49839    49842    49857    50127

Kidney and bladder

Hospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder.

For example: kidney stones, adrenal gland tumour and incontinence.

Dialysis is listed separately under Dialysis for chronic kidney failure.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              11900    11903                11906    11909    11912    11915    11917    11919    11921    12524    12527                18375    18379    30324    36500    36503    36506    36509    36516    36519                36522    36525    36526    36527    36528    36529    36531    36532    36533                36537    36540    36543    36546    36549    36552    36558    36561    36564                36567    36570    36573    36576    36579    36585    36588    36591    36594                36597    36600    36603    36604    36605    36606    36607    36608    36609                36612    36615    36618    36621    36624    36627    36630    36633    36636                36639    36642    36645    36648    36649    36650    36652    36654    36656                36663    36664    36665    36666    36667    36668    36800    36803    36806                36809    36811    36812    36815    36818    36821    36824    36825    36827                36830    36833    36836    36840    36842    36845    36848    36851    36854                36857    36860    36863    37000    37004    37008    37011    37014    37020                37023    37026    37029    37038    37040    37041    37042    37043    37044                37045    37047    37050    37053    37300    37303    37306    37309    37315                37318    37321    37324    37327    37330    37333    37336    37338    37339                37340    37341    37342    37343    37345    37348    37351    37354    37369                37372    37375    37381    37384    37387    37390    37444    37800    37801                37842    37845    37848    37851    37854    43981    43984

Lung and chest

Hospital treatment for the investigation and treatment of the lungs, lung-related conditions, mediastinum and chest.

For example: lung cancer, respiratory disorders such as asthma, pneumonia, and treatment of trauma to the chest.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              30090    30696                30710    34133    34136    34139    38415    38418    38421    38424    38427                38430    38436    38438    38440    38441    38446    38448    38453    38455                38460    38462    38464    38466    38468    38469    38640    38643    38647                38656    38800    38803    38809    38812    43861    43909    43912

Male reproductive system

Hospital treatment for the investigation and treatment of the male reproductive system including the prostate.

For example: male sterilisation, circumcision and prostate cancer.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              30628    30631                30635    30641    30642    30643    30644    30649    30654    30658    30663                30666    37200    37201    37202    37203    37206    37207    37208    37209                37210    37211    37212    37215    37217    37218    37219    37220    37221                37223    37224    37227    37230    37233    37245    37393    37396    37402                37405    37408    37411    37415    37417    37418    37420    37423    37426                37429    37432    37435    37438    37601    37604    37613    37616    37619                37623    37803    37804    37806    37807    37809    37810    37812    37813                37815    37816    37818    37819    37821    37822    37824    37825    37827                37828    37830    37831    37833    37834    37836    37839

Miscarriage and termination of pregnancy

Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.

Treatments involving the provision of the following MBS items:              16530    16531                35640    35643    35674    35677    35678

Pain management

Hospital treatment for pain management that does not require the insertion or surgical management of a device.

For example: treatment of nerve pain and chest pain due to cancer by injection of a nerve block.

Pain management using a device (for example an infusion pump or neurostimulator) is listed separately under Pain management with device.

Treatments involving the provision of the following MBS items:              39100    39106                39109    39112    39115    39118    39121    39124    39140    39323    45939

Pain management with device

Hospital treatment for the implantation, replacement or other surgical management of a device required for the treatment of pain.

For example: treatment of nerve pain, back pain, and pain caused by coronary heart disease with a device (for example an infusion pump or neurostimulator).

Treatment of pain that does not require a device is listed separately under Pain management.

Treatments involving the provision of the following MBS items:              14218    39125                39126    39127    39128    39130    39131    39133    39134    39135    39136                39137    39138    39139

Plastic and reconstructive surgery

(medically necessary)

Hospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether acquired as a result of illness or accident, or congenital.

For example: burns requiring a graft, cleft palate, club foot and angioma.

Plastic surgery that is medically necessary relating to the treatment of a skin-related condition is listed separately under Skin.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              30003    30006                30010    30014    30017    30020    30176    38457    38458    42860    42863                42866    42872    43882    45000    45003    45006    45009    45012    45015                45018    45019    45020    45021    45024    45025    45026    45027    45030                45033    45035    45036    45039    45042    45045    45048    45051    45054                45200    45201    45202    45203    45206    45207    45209    45212    45215                45218    45221    45224    45227    45230    45233    45236    45239    45240                45400    45403    45406    45409    45412    45415    45418    45439    45442                45445    45448    45451    45460    45461    45462    45464    45465    45466                45468    45469    45471    45472    45474    45475    45477    45478    45480                45481    45483    45484    45485    45486    45487    45488    45489    45490                45491    45492    45493    45494    45496    45497    45498    45499    45500                45501    45502    45503    45504    45505    45506    45512    45515    45518                45519    45560    45561    45562    45563    45564    45565    45566    45568                45569    45570    45572    45575    45578    45581    45584    45585    45586                45587    45588    45590    45593    45596    45597    45599    45602    45608                45611    45614    45617    45620    45623    45624    45625    45626    45629                45632    45635    45638    45639    45641    45644    45647    45650    45652                45653    45656    45659    45660    45661    45662    45665    45668    45669                45671    45674    45675    45676    45677    45680    45683    45686    45689                45692    45695    45698    45701    45704    45707    45710    45713    45714                45716    45720    45723    45726    45729    45731    45732    45735    45738                45741    45744    45747    45752    45753    45754    45755    45758    45761                45767    45770    45773    45776    45779    45782    45785    45791    45794                45797    45799    45801    45803    45805    45807    45809    45811    45813                45815    45817    45819    45821    45823    45825    45827    45829    45831                45833    45835    45837    45839    45841    45843    45845    45847    45849                45853    45865    45877    45879    45882    45885    45888    45891    45894                45897    45900    45975    45984    45990    50411    50414    50417    50420                50423    51904    51906    52010    52036    52045    52048    52106    52108                52111    52117    52120    52122    52123    52300    52303    52306    52309                52312    52315    52318    52319    52321    52324    52327    52330    52333                52336    52337    52339    52342    52345    52348    52351    52354    52357                52360    52363    52366    52369    52372    52375    52378    52379    52380                52382    52420    52424    52430    52440    52442    52444    52446    52450                52452    52456    52458    52460    52480    52482    52484    52600    52603                52606    52609    52612    52615    52618    52621    52624    52626    52627                52630    52633    52636    53242    53453    53455    75024    75027

Podiatric surgery

(provided by a registered podiatric surgeon)

Hospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon, but limited to cover for:

      ·  accommodation; and

      ·  the cost of a prosthesis as listed in the prostheses list set out in the Private Health Insurance (Prostheses) Rules, as in force from time to time.

Note:       Insurers are not required to pay for any other benefits for hospital treatment for this clinical category but may choose to do so.

 

Pregnancy and birth

Hospital treatment for investigation and treatment of conditions associated with pregnancy and child birth.

Treatment for the baby is covered under the clinical category relevant to their condition. For example, respiratory conditions are covered under Lung and chest.

Female reproductive conditions are listed separately under Gynaecology.

Fertility treatments are listed separately under Assisted reproductive services.

Miscarriage and termination of pregnancy is listed separately under Miscarriage and termination of pregnancy.

Treatments involving the provision of the following MBS items:              16399    16400                16401    16404    16406    16407    16408    16500    16501    16502    16505                16508    16509    16511    16512    16514    16515    16518    16519    16520                16522    16527    16528    16533    16534    16564    16567    16570    16571                16573    16590    16591    16600    16603    16606    16609    16612    16615                16618    16621    16624    16627    82100    82105    82110    82115    82120                82125

Skin

Hospital treatment for the investigation and treatment of skin, skin-related conditions and nails. The removal of foreign bodies is also included. Plastic surgery that is medically necessary and relating to the treatment of a skin-related condition is also included.

For example: melanoma, minor wound repair and abscesses.

Removal of excess skin due to weight loss is listed separately under Weight loss surgery.

Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.

Treatments involving the provision of the following MBS items:              14050    14053                14100    14106    14109    14112    14115    14118    14124    18362    30023                30024    30026    30029    30032    30035    30038    30042    30045    30049                30052    30055    30064    30071    30099    30180    30183    30185    30186                30187    30189    30190    30192    30195    30196    30197    30202    30203                30205    30207    30210    30213    30214    30216    30219    30223    30676                30679    31000    31001    31002    31206    31211    31216    31220    31221                31225    31245    31250    31340    31345    31356    31357    31358    31359                31360    31361    31362    31363    31364    31365    31366    31367    31368                31369    31370    31371    31372    31373    31374    31375    31376    44136                46486    46489    46513    46516    46528    46531    46534    47904    47906                47912    47915    47916    47918    52000    52003    52006    52009    52039                52042    52051    52054

Sleep studies

Hospital treatment for the investigation of sleep patterns and anomalies.

For example: sleep apnoea and snoring.

Treatments involving the provision of the following MBS items:              12203    12207                12210    12213    12215    12217    12250

Tonsils, adenoids and grommets

Hospital treatment of the tonsils, adenoids and insertion or removal of grommets.

Treatments involving the provision of the following MBS items:              41632    41789                41793    41797    41801

Weight loss surgery

Hospital treatment for surgery that is designed to reduce a person’s weight, remove excess skin due to weight loss and reversal of a bariatric procedure.

For example: gastric banding, gastric bypass, sleeve gastrectomy.

Treatments involving the provision of the following MBS items:              30165    30168                30171    30172    30177    30179    31569    31572    31575    31578    31581                31584    31587    31590

 

 

 


Schedule 6—Common treatments list

Note:       Rule 11F is the principal provision that deals with what hospital treatments must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 5 and Schedule 7.

1  Common treatments list

                   For sub‑subparagraph 11F (5) (b) (ii) (A), the common treatments list is set out in the following table:

Common treatments list

3              4              20           23           24           35           36           37           43           44                47           51           52           53           54           57           58           59           60                65           92           93           95           96           99           104         105         106                107         108         109         110         111         112         113         114         116                117         119         120         122         128         131         132         133         135                137         139         141         143         145         147         149         160         161                162         163         164         173         179         181         183         185         187                188         189         191         193         195         197         199         202         203                206         212         214         215         218         219         220         221         222                223         224         225         226         227         228         229         230         231                232         233         235         236         237         238         239         240         243                244         245         249         251         252         253         254         255         256                257         259         260         261         262         263         264         265         266                268         269         270         271         272         276         277         279         281                282         283         285         286         287         288         291         293         296                299         300         302         304         306         308         310         312         314                316         318         319         330         332         334         336         338         353                355         356         357         358         359         361         384         385         386                387         388         389         410         411         412         413         414         415                416         417         501         503         507         511         515         519         520                530         532         534         536         585         588         591         594         599                600         701         703         705         707         715         721         723         729                731         732         733         735         737         739         741         743         745                747         750         758         761         763         766         769         772         776                788         789         792         812         820         822         823         825         826                827         828         829         830         832         834         835         837         838                867         868         869         871         872         873         876         880         881                885         891         892         900         903         2100       2122       2125       2126                2137       2138       2143       2147       2179       2195       2199       2220       2497                2501       2503       2504       2506       2507       2509       2517       2518       2521                2522       2525       2526       2546       2547       2552       2553       2558       2559                2598       2600       2603       2606       2610       2613       2616       2620       2622                2624       2631       2633       2635       2664       2666       2668       2673       2675                2677       2799       2801       2806       2814       2820       2824       2832       2840                2946       2949       2954       2958       2972       2974       2978       2984       2988                2992       2996       3000       4001       5000       5003       5010       5020       5023                5028       5040       5043       5049       5060       5063       5067       5200       5203                5207       5208       5220       5223       5227       5228       5260       5263       5265                5267       6051       6052       6057       6058       6059       6060       6062       6063                6064       6065       6067       6068       6071       6072       6074       6075       6087                10905    10907    10910    10911    10912    10913    10914    10915                10916    10918    10921    10922    10923    10924    10925    10926                10927    10928    10929    10930    10945    10946    10947    10948                11830    11833    12000    12003    13015    13020    13025    13030                13210    13757    13870    13873    14200    14201    14202    14209                17615    17620    17625    17640    17645    17650    17655    18216                18219    18282    18284    18286    18288    18290    18292    18294                18296    18298    30058    30061    30068    30072    30075    30078                30081    30084    30087    30093    30094    30096    30097    30224                30225    30321    30323    30329    30330    30332    30335    30336                30388    30390    30391    30394    30403    30405    30611    31350                31355    34538    36502    37607    37610    38456    39000    43915                44130    46519    46525    51700    51703    52012    52015    52018                52144    53600    75001    75004    75150    75153    82130    82135                82140    82150    82151    82152    82200    82205    82210    82215                82220    82221    82222    82223    82224    82225

 

 

Schedule 7—Support treatments list

Note:       Rule 11F is the principal provision that deals with what hospital treatments must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 5 and Schedule 6.

1  Support treatments list

                   For sub‑subparagraph 11F (5) (b) (ii) (B), the support treatments list is set out in the following table:

Support treatments list

6080       6081       10801    10802    10803    10804    10805    10806    10807                10808    10809    10816    10931    10932    10933    10940    10941                10942    10943    10944    10950    10951    10952    10953    10954                10956    10958    10960    10962    10964    10966    10968    10970                10984    10987    10988    10989    10990    10991    10992    10997                11000    11003    11004    11005    11006    11009    11012    11015                11018    11021    11024    11027    11200    11204    11205    11210                11211    11215    11218    11219    11220    11221    11222    11224                11225    11235    11237    11240    11241    11242    11243    11244                11303    11304    11306    11309    11312    11315    11318    11324                11327    11330    11332    11333    11336    11339    11503    11506                11509    11512    11600    11602    11604    11605    11610    11611                11612    11614    11615    11627    11700    11701    11702    11708                11709    11710    11711    11712    11713    11715    11718    11719                11720    11721    11722    11724    11725    11726    11727    11728                12200    12201    12306    12312    12315    12320    12321    12322                12325    12326    12500    12503    12506    12509    12512    12515                12518    12521    12530    12533    13300    13303    13306    13309                13312    13318    13319    13703    13706    13709    13750    13755                13815    13818    13830    13839    13842    13847    13848    13851                13854    13857    13876    13881    13882    13885    13888    17610                17680    17690    18213    18222    18225    18226    18227    18228                18230    18232    18233    18234    18236    18238    18240    18242                18244    18248    18250    18252    18254    18256    18258    18260                18262    18264    18266    18268    18270    18272    18274    18276                18278    18280    20100    20102    20104    20120    20124    20140                20142    20143    20144    20145    20146    20147    20148    20160                20162    20164    20170    20172    20174    20176    20190    20192                20210    20212    20214    20216    20220    20222    20225    20230                20300    20305    20320    20321    20330    20350    20352    20355                20400    20401    20402    20403    20404    20405    20406    20410                20420    20440    20450    20452    20470    20472    20474    20475                20500    20520    20522    20524    20526    20528    20540    20542                20546    20548    20560    20600    20604    20620    20622    20630                20632    20634    20670    20680    20690    20700    20702    20703                20704    20705    20706    20730    20740    20745    20750    20752                20754    20756    20770    20790    20791    20792    20793    20794                20798    20799    20800    20802    20803    20804    20805    20806                20810    20815    20820    20830    20832    20840    20841    20842                20844    20845    20846    20847    20848    20850    20855    20860                20862    20863    20864    20866    20867    20868    20880    20882                20884    20886    20900    20902    20904    20905    20906    20910                20911    20912    20914    20916    20920    20924    20926    20928                20930    20932    20934    20936    20938    20940    20942    20943                20944    20946    20948    20950    20952    20953    20954    20956                20958    20960    21100    21110    21112    21114    21116    21120                21130    21140    21150    21155    21160    21170    21195    21199                21200    21202    21210    21212    21214    21216    21220    21230                21232    21234    21260    21270    21272    21274    21275    21280                21300    21321    21340    21360    21380    21382    21390    21392                21400    21402    21403    21404    21420    21430    21432    21440                21445    21460    21461    21462    21464    21472    21474    21480                21482    21484    21486    21490    21500    21502    21520    21522                21530    21532    21535    21600    21610    21620    21622    21630                21632    21634    21636    21638    21650    21652    21654    21656                21670    21680    21682    21685    21700    21710    21712    21714                21716    21730    21732    21740    21756    21760    21770    21772                21780    21785    21790    21800    21810    21820    21830    21832                21834    21840    21842    21850    21860    21865    21870    21872                21878    21879    21880    21881    21882    21883    21884    21885                21886    21887    21900    21906    21908    21910    21912    21914                21915    21916    21918    21922    21925    21926    21927    21930                21935    21936    21939    21941    21942    21943    21945    21949                21952    21955    21959    21962    21965    21969    21970    21973                21976    21980    21981    21990    21992    21997    22001    22002                22007    22008    22012    22014    22015    22018    22020    22025                22031    22036    22040    22045    22050    22051    22055    22060                22065    22070    22075    22900    22905    23010    23021    23022                23023    23031    23032    23033    23041    23042    23043    23051                23052    23053    23061    23062    23063    23071    23072    23073                23081    23082    23083    23091    23101    23111    23112    23113                23114    23115    23116    23117    23118    23119    23121    23170                23180    23190    23200    23210    23220    23230    23240    23250                23260    23270    23280    23290    23300    23310    23320    23330                23340    23350    23360    23370    23380    23390    23400    23410                23420    23430    23440    23450    23460    23470    23480    23490                23500    23510    23520    23530    23540    23550    23560    23570                23580    23590    23600    23610    23620    23630    23640    23650                23660    23670    23680    23690    23700    23710    23720    23730                23740    23750    23760    23770    23780    23790    23800    23810                23820    23830    23840    23850    23860    23870    23880    23890                23900    23910    23920    23930    23940    23950    23960    23970                23980    23990    24100    24101    24102    24103    24104    24105                24106    24107    24108    24109    24110    24111    24112    24113                24114    24115    24116    24117    24118    24119    24120    24121                24122    24123    24124    24125    24126    24127    24128    24129                24130    24131    24132    24133    24134    24135    24136    25000                25005    25010    25015    25020    25025    25030    25050    25200                25205    30001    51300    51303    51306    51309    51312    51315                51318    51800    51803    53700    53702    53704    53706    55005                55007    55008    55010    55011    55013    55014    55016    55017                55019    55023    55025    55026    55028    55029    55030    55031                55032    55033    55036    55037    55038    55039    55048    55049                55054    55059    55060    55061    55062    55063    55064    55065                55067    55068    55069    55070    55073    55076    55079    55084                55085    55113    55114    55115    55116    55117    55118    55119                55120    55121    55122    55123    55125    55130    55131    55135                55136    55220    55221    55222    55223    55224    55226    55227                55228    55229    55230    55232    55233    55235    55236    55238                55244    55246    55248    55252    55274    55276    55278    55280                55282    55284    55292    55294    55296    55600    55601    55603                55604    55700    55701    55702    55703    55704    55705    55706                55707    55708    55709    55710    55711    55712    55713    55714                55715    55716    55717    55718    55719    55720    55721    55722                55723    55724    55725    55726    55727    55729    55730    55735                55736    55737    55739    55759    55760    55762    55763    55764                55765    55766    55767    55768    55769    55770    55771    55772                55773    55774    55775    55800    55801    55802    55803    55804                55805    55806    55807    55808    55809    55810    55811    55812                55813    55814    55815    55816    55817    55818    55819    55820                55821    55822    55823    55824    55825    55826    55827    55828                55829    55830    55831    55832    55833    55834    55835    55836                55837    55838    55839    55840    55841    55842    55843    55844                55845    55846    55847    55848    55849    55850    55851    55852                55853    55854    55855    56001    56007    56010    56013    56016                56022    56028    56030    56036    56041    56047    56050    56053                56056    56062    56068    56070    56076    56101    56107    56141                56147    56219    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    56452    56501    56507    56541    56547    56553                56555    56619    56625    56659    56665    56801    56807    56841                56847    57001    57007    57041    57047    57201    57247    57341                57345    57350    57351    57355    57356    57360    57361    57362                57363    57506    57509    57512    57515    57518    57521    57524                57527    57529    57530    57532    57533    57535    57536    57538                57539    57700    57702    57703    57705    57706    57708    57709                57711    57712    57714    57715    57717    57721    57723    57901                57902    57903    57906    57909    57911    57912    57914    57915                57917    57918    57920    57921    57923    57924    57926    57927                57929    57930    57932    57933    57935    57938    57939    57941                57942    57944    57945    57947    57950    57953    57956    57959                57960    57962    57963    57965    57966    57968    57969    58100                58102    58103    58105    58106    58108    58109    58111    58112                58114    58115    58117    58120    58121    58123    58124    58126                58127    58300    58302    58306    58308    58500    58502    58503                58505    58506    58508    58509    58511    58521    58523    58524                58526    58527    58529    58700    58702    58706    58708    58715                58717    58718    58720    58721    58723    58900    58902    58903                58905    58909    58911    58912    58914    58915    58916    58917                58920    58921    58923    58927    58929    58933    58935    58936                58938    58939    58941    59103    59104    59300    59301    59303                59304    59306    59307    59309    59310    59312    59313    59314                59315    59318    59319    59700    59701    59703    59704    59712                59713    59715    59716    59718    59719    59724    59725    59733                59734    59739    59740    59751    59752    59754    59755    59763                59764    59970    59974    60000    60001    60003    60004    60006                60007    60009    60010    60012    60013    60015    60016    60018                60019    60021    60022    60024    60025    60027    60028    60030                60031    60033    60034    60036    60037    60039    60040    60042                60043    60045    60046    60048    60049    60051    60052    60054                60055    60057    60058    60060    60061    60063    60064    60066                60067    60069    60070    60072    60073    60075    60076    60078                60079    60100    60101    60500    60501    60503    60504    60506                60507    60509    60510    60918    60927    61109    61110    61302                61303    61306    61307    61310    61313    61314    61316    61317                61320    61328    61340    61348    61352    61353    61356    61360                61361    61364    61368    61369    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    61461    61462    61469    61473    61480    61484    61485                61495    61499    61505    61523    61529    61538    61541    61553                61559    61565    61571    61575    61577    61598    61604    61610                61620    61622    61628    61632    61640    61646    61647    61650                61651    61652    61653    61654    61655    61656    61657    61658                61659    61660    61661    61662    61663    61664    61665    61666                61667    61668    61669    61670    61671    61672    61673    61674                61675    61676    61677    61678    61679    61680    61681    61682                61683    61684    61685    61686    61687    61688    61689    61690                61691    61692    61693    61694    61695    61696    61697    61698                61699    61700    61701    61702    61703    61704    61705    61706                61707    61708    61709    61710    61712    61713    61714    61715                61716    61717    61718    61719    61729    63001    63004    63007                63010    63013    63014    63016    63017    63040    63043    63046                63049    63052    63055    63058    63061    63064    63067    63070                63073    63074    63075    63076    63077    63078    63079    63080                63081    63082    63083    63084    63085    63101    63104    63111                63114    63117    63119    63125    63128    63131    63134    63135                63136    63151    63154    63157    63158    63161    63164    63167                63170    63173    63176    63179    63182    63185    63186    63187                63188    63189    63190    63191    63192    63193    63194    63201                63204    63207    63208    63219    63222    63225    63228    63231                63234    63237    63240    63243    63257    63258    63259    63260                63261    63262    63263    63264    63265    63271    63274    63277                63280    63282    63283    63284    63285    63301    63304    63307                63310    63311    63313    63322    63325    63328    63331    63334                63337    63340    63341    63342    63343    63345    63346    63347                63348    63361    63364    63385    63388    63391    63392    63393                63394    63395    63396    63397    63398    63401    63404    63407                63408    63416    63419    63425    63428    63432    63433    63440                63443    63446    63447    63448    63449    63455    63457    63458                63461    63464    63467    63470    63473    63476    63479    63481                63482    63484    63486    63487    63488    63489    63490    63491                63494    63497    63498    63499    63501    63502    63504    63505                63507    63508    63510    63511    63513    63514    63516    63517                63519    63520    63522    63523    63541    63542    63543    63544                63547    63548    63551    63552    63554    63555    63557    63558                63560    63561    63740    63741    63743    63744    63746    63747                64990    64991    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    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    66605                66606    66607    66610    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    66833    66834    66835    66836    66837    66838                66839    66840    66841    66900    69300    69303    69306    69309                69312    69316    69317    69318    69319    69321    69324    69325                69327    69328    69330    69331    69333    69336    69339    69345                69354    69357    69360    69363    69378    69379    69380    69381                69382    69383    69384    69387    69390    69393    69396    69400                69401    69405    69408    69411    69413    69415    69445    69451                69471    69472    69474    69475    69478    69481    69482    69483                69484    69488    69489    69491    69492    69494    69495    69496                69497    69498    69499    69500    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                72813    72816    72817    72818    72823    72824    72825    72826                72827    72828    72830    72836    72838    72844    72846    72847                72848    72849    72850    72851    72852    72855    72856    72857                72858    72859    73043    73045    73047    73049    73051    73059                73060    73061    73062    73063    73064    73065    73066    73067                73070    73071    73072    73073    73074    73075    73076    73287                73289    73290    73291    73292    73293    73294    73295    73296                73297    73300    73305    73308    73309    73311    73312    73314                73315    73317    73318    73320    73321    73323    73324    73325                73326    73327    73332    73333    73334    73335    73336    73337                73338    73339    73340    73341    73342    73343    73345    73346                73347    73348    73349    73350    73521    73523    73525    73527                73529    73801    73802    73803    73804    73805    73806    73807                73808    73809    73810    73811    73828    73829    73830    73831                73832    73833    73834    73835    73836    73837    73839    73840                73844    73899    73900    73920    73922    73923    73924    73925                73926    73927    73928    73929    73930    73931    73932    73933                73934    73935    73936    73937    73938    73939    73940    74990                74991    74992    74993    74994    74995    74996    74997    74998                74999    75009    75012    75015    75018    75021    75023    81000                81005    81010    81110    81115    81120    81125    81300    81305                81310    81315    81320    81325    81330    81335    81340    81345                81350    81355    81360    82005    82010    82020    82025    82030                82035    82300    82306    82309    82312    82315    82318    82324                82327    82332

 


Part 2—Amendments commencing on 1 April 2020

Private Health Insurance (Complying Product) Rules 2015

[5]       Rule 11E (note to section heading)

Repeal the note.

[6]       Rule 11F (note to section heading)

Repeal the note.

[7]       Rule 11G (note to section heading)

Repeal the note.

[8]       Rule 11H (note to section heading)

Repeal the note.

[9]       Rule 21

Repeal the rule.

 


Schedule 4—Second tier administrative reforms

Private Health Insurance (Benefit Requirements) Rules 2011

[1]       Clause 1 of Schedule 5

Repeal the clause, substitute:

1.  Interpretation

             (1)  In this Schedule:

authorised officer means a departmental officer authorised by the Secretary of the Department to make a determination under subclause 1A (2), (3) or (4) or to review a determination under subclause 1B (3).

comparable has the meaning given by subclause 1A (6).

Hospital Casemix Protocol Data has the meaning given by rule 4 of the Private Health Insurance (Health Insurance Business) Rules 2018.

second-tier eligible hospital means a hospital in the class set out in rule 7A of the Private Health Insurance (Health Insurance Business) Rules 2018.

             (2)  In this Schedule, except in subclauses 1A (8) and (9), the Australian Capital Territory is taken to be part of New South Wales, and the Northern Territory is taken to be part of South Australia.

[2]       After clause 1 of Schedule 5

Insert:

1A. Categorisation of private hospitals

             (1)  If, as at 1 January 2019, a departmental officer authorised by the Secretary of the Department for the purpose has, in anticipation of the commencement of this provision, caused to be published on the Department’s website a list of all the hospitals for which a declaration is in force under subsection 121-5 (6) of the Act that places each hospital in a category set out in subclause (7), then each hospital is taken to be determined to be in that category.

             (2)  If such a list has not been published, then as soon as practicable an authorised officer must determine which category of hospital from the categories set out in subclause (7) each private hospital for which a declaration is in force under subsection 121-5 (6) of the Act is to be placed in, and cause a list of the hospitals in each category to be published on the Department’s website.

Note:          If a patient is admitted to a hospital between 1 January 2019 and 31 August 2019 insurers may continue to work out the average charge on the basis of the provisions of this Schedule as in force immediately before the commencement of Schedule 4 to the Private Health Insurance (Reforms) Amendment Rules 2018. However, insurers must use the Department’s published list of hospitals under subclause (1) or (2) to determine in which category a hospital claiming second-tier default benefits is placed.

             (3)  If a private hospital is declared under subsection 121-5 (6) of the Act after 1 January 2019, an authorised officer must determine which category of hospital from the categories set out in subclause (7) that private hospital is to be placed in.

             (4)  If a hospital has been placed in a category by a determination under this clause, an authorised officer may before 1 June of a particular year determine a different category of hospital from the categories set out in subclause (7) that the private hospital is to be placed in.

             (5)  A list of the hospitals in each category as of 1 August of each year must be published on the Department’s website.

             (6)  Private hospitals are comparable if they are placed in the same category by a determination made under subclause (1), (2), (3) or (4).

             (7)  For the purposes of this clause, the categories are the following:

                     (a)  private hospitals that provide psychiatric care, including treatment of addictions, for at least 50% of the episodes of hospital treatment, and do not fall into category (g);

                     (b)  private hospitals that provide rehabilitation care for at least 50% of the episodes of hospital treatment, and do not fall into categories (a) or (g);

                     (c)  private hospitals that do not fall into categories (a), (b) or (g), with up to and including 50 licensed beds;

                     (d)  private hospitals that do not fall into categories (a), (b) or (g), with more than 50 licensed beds and up to and including 100 licensed beds;

                     (e)  private hospitals that do not fall into categories (a), (b) or (g), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit or an intensive care unit;

                      (f)  private hospitals that do not fall into categories (a), (b) or (g), with more than 100 licensed beds, with either (or any combination of) an accident and emergency unit or a specialised cardiac care unit or an intensive care unit;

                     (g)  private hospitals that provide episodes of hospital treatment only for periods of not more than 24 hours.

             (8)  If State or Territory legislation in the State or Territory where the private hospital is located regulates the number of beds or patients that a private hospital is permittedin subclause (7), 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.

             (9)  If State or Territory legislation in the State or Territory where the private hospital is located does not regulate the number of beds or patients that a private hospital is permittedin subclause (7), a reference to licensed beds is a reference to the beds and bed equivalents the private hospital operates.

           (10)  An authorised officer must calculate proportions for the purposes of paragraphs (7) (a) and (b):

                     (a)  if Hospital Casemix Protocol Data is available for the private hospital—using the most recent year of Hospital Casemix Protocol Data available to the Department for the private hospital; and

                     (b)  otherwise—on the basis of any relevant information available to the Department about the episodes of hospital treatment at the private hospital.

1B. Internal review of a categorisation determination

             (1)  A private hospital subject to a determination made under subclause 1A (1), (2), (3) or (4) may request internal review of its categorisation by the determination.

             (2)  An application for internal review under subclause (1) must be made in writing within 28 days after the day the determination is notified to the hospital.

             (3)  If an application for internal review is made, an authorised officer (who must not be the authorised officer who made the original determination) must:

                     (a)  review the determination; and

                     (b)  either confirm the determination or make a fresh one within 28 days after the day on which the application was received by the Department.

[3]       At the end of clause 2 of Schedule 5

Omit “facility”, insert “second-tier eligible hospital”.

[4]       Subclause 3(3) of Schedule 5

Repeal the subclause, substitute:

             (3)  If a hospital ceases to be a second-tier eligible hospital 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 hospital or booked for hospital treatment at the hospital (as opposed to merely being on the hospital’s waiting list) before the day that the hospital ceased to be a second-tier eligible hospital is the minimum benefit that would have applied if the hospital continued to be a second-tier eligible hospital at the time the treatment was provided.

[5]       Subclause 3(4) of Schedule 5

Repeal the subclause, substitute:

             (4)  Subject to subclauses (2) and (8), the minimum benefit payable by an insurer for an episode of hospital treatment at a second-tier eligible hospital for which the admission date was 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 as in force on 1 August of the first year, with all private hospitals:

                     (a)  that:

                              (i)  if the second-tier eligible hospital is on the list published on the Department’s website under subclause 1A (5)—were comparable on 1 August of the first year with the second-tier eligible hospital; and

                             (ii)  otherwise—are in the same category as the second-tier eligible hospital in the list published on the Department’s website under subclause 1A (5) as at 1 August of the first year; and

                     (b)  that are in the same State as the second-tier eligible hospital.

Note:          See clause 4 for a transitional arrangement for admissions to second‑tier eligible hospitals between 1 January 2019 and 31 August 2019.

[6]       Subclause 3(6) of Schedule 5

Omit “facility”, substitute “second-tier eligible hospital”.

[7]       Clause 4 of Schedule 5

Repeal the clause, substitute:

4. Transitional

             (1)  If a patient is admitted to a second-tier eligible hospital between 1 January 2019 and 31 August 2019:

                     (a)  an insurer may instead work out the average charge on the basis of the repealed provisions; and

                     (b)  if the insurer does so, comparable has the same meaning as in the repealed provisions.

             (2)  For subclause (1), the repealed provisions are the provisions of this Schedule as in force immediately before the commencement of Schedule 4 to the Private Health Insurance (Reforms) Amendment Rules 2018.

Note:          For the purpose of determining which category the second-tier eligible hospital to which the patient was admitted is placed in, an insurer must use the Department’s determination in respect of that hospital under subclause 1A (1), (2), (3) or (4). 

Private Health Insurance (Health Insurance Business) Rules 2018

[8]       Rule 3

Insert:

accredited means assessed as being fully compliant with the National Safety and Quality Health Service Standards by a body approved by the Australian Commission on Safety and Quality in Health Care to assess health service organisations against the National Safety and Quality Health Service Standards.

Hospital Casemix Protocol Data means the data provided by hospitals to insurers that is the subject of rule 4.

makes provision for informed financial consent: a hospital makes provision for informed financial consent if it has 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 admissionsat the earliest opportunity before admission for the hospital treatment; or

                     (b)  for unplanned admissionsas soon after the admission as the circumstances reasonably permit.

minimum benefit means the minimum benefit calculated in accordance with clause 3 of Schedule 5 of the Private Health Insurance (Benefit Requirements) Rules 2011.

National Safety and Quality Health Service Standards means the standards developed by the Australian Commission on Safety and Quality in Health Care.

Note:          Development of the National Safety and Quality Health Service Standards is a function of the Australian Commission on Safety and Quality in Health Care under paragraph 9 (1) (e) of National Health Reform Act 2011.

[9]       After Part 2

Insert:

Part 2A Second-tier eligible hospitals class

7A. Second-tier eligible hospitals class

                   For the purposes of subsection 121-8 (1) of the Act, second-tier eligible hospitals constitutes a class of hospital (the second-tier eligible hospitals class).

7B. Application fee

                   For the purposes of paragraph 121-8 (2) (b) of the Act, the application fee is $850 for each hospital that the application seeks to have included in the second-tier eligible hospitals class.

7C. Assessment criteria

                   For the purposes of subsection 121-8A (1) of the Act, to be included in the second-tier eligible hospitals class, a hospital must:

                     (a)  be a private hospital; and

                     (b)  be accredited; and

                     (c)  not bill patients directly for the minimum benefit payable by the patient’s insurer; and

                     (d)  make provision for informed financial consent; and

                     (e)  submit Hospital Casemix Protocol Data to health insurers electronically with every claim for second-tier default benefits.

Note:       If a hospital is included in the second-tier eligible hospitals class by the Minister under section 121-8A of the Act, it will be a second-tier eligible hospital for the purposes of Schedule 5 to the Private Health Insurance (Benefit Requirements) Rules 2011, and therefore eligible to claim second-tier default benefits as specified in that Schedule.

7D. Notification of change in circumstances

                   A hospital that is included in the second-tier eligible hospitals class must notify the Department in writing of any change in circumstances that may prevent that hospital from continuing to meet the assessment criteria set out in rule 7C as soon as practicable.

7E. Transitional arrangements

             (1)  A hospital that is a facility for the purposes of clause 4 of Schedule 5 to the Private Health Insurance (Benefit Requirements) Rules 2011 immediately before the commencement of Schedule 4 to the Private Health Insurance (Reforms) Amendment Rules 2018 is taken to be included in the second-tier eligible hospitals class.

             (2)  A hospital referred to in subrule (1) is taken to be included in the second-tier eligible hospitals class until the eligibility expiry date for that hospital.

             (3)  Despite subrule (2), if the date on which a hospital’s accreditation will expire falls within the 12 months following the hospital’s eligibility expiry date, then the hospital is taken to be included in the second-tier eligible hospitals class until the day on which that hospital’s accreditation will expire. 

             (4)  In this rule:

eligibility expiry date means the date on which the hospital’s approval on the list of second-tier eligible facilities existing on 1 January 2019 expires.

Note:          Hospitals that are specified in the Second Tier Advisory Committee approved list on 1 January 2019 will be second-tier eligible hospitals for the purposes of Schedule 5 of the Private Health Insurance (Benefit Requirements) Rules 2011, and therefore eligible to claim second-tier default benefits as specified in that Schedule. Unless subrule (3) applies, when the approval under the pre-existing arrangements expires, the hospital will be required to apply under s 121-8 of the Act to be included in the second-tier eligible hospitals class.

 


Schedule 5—Removal of coverage of some natural therapies

Private Health Insurance (Health Insurance Business) Rules 2018

[1]       Rule 3

Insert:

excluded natural therapy treatment means any of the following treatments:

                     (a)  Alexander technique;

                     (b)  aromatherapy;

                     (c)  Bowen therapy;

                     (d)  Buteyko;

                     (e)  Feldenkrais;

                      (f)  Western herbalism;

                     (g)  homeopathy;

                     (h)  iridology;

                      (i)  kinesiology;

                      (j)  naturopathy;

                     (k)  Pilates;

                      (l)  reflexology;

                    (m)  Rolfing;

                     (n)  shiatsu;

                     (o)  tai chi;

                     (p)  yoga.

[2]       At the end of Rule 8

Add:

             ; and (e)  excluded natural therapy treatment.

[3]       Rule 11   

Repeal the rule, substitute:

11.  General treatment—excluded treatment

             (1)  For paragraph 121-10 (3) (b) of the Act, the following treatments or classes of treatment are specified:

                     (a)  treatment which primarily takes the form of sport, recreation or entertainment, other than treatment that is part of a chronic disease management program or a health management program if the programs have been approved by the private health insurer;

                     (b)  excluded natural therapy treatment.

             (2)  In this rule:

health management program means a program that is intended to ameliorate a person’s specific health condition or conditions, but does not include treatment that is excluded natural therapy treatment.


Schedule 6—Information provision

Private Health Insurance (Incentives) Rules 2012 (No. 2)

[1]       Rule 4 (note)

Omit “standard information statement”, substitute “private health information statement”.

[2]       Rule 4 (definition of Australian Government Rebate on private health insurance)

Repeal the definition, substitute:

Australian Government Rebate on private health insurance means:

                     (a)  the premiums reduction scheme; or

                     (b)  the private health insurance tax offset.

[3]       Rule 7

Repeal the rule.

[4]       Paragraph 8(1)(a)

Repeal paragraph 8(1)(a), substitute:

                     (a)  if a participant in respect of a complying health insurance policy on issue from the insurer during any time in the previous financial year requests the following information from a participating insurer:

                              (i)  the amount of the premium paid for the policy during the previous financial year;

                             (ii)  the reduction, under the premiums reduction scheme, for the premium;

                            the participating insurer must issue to the participant a statement in accordance with rule 9;

[5]       Subparagraph 8(1)(c)(ii)

Omit “annual”.

[6]       Rule 9

Repeal the rule, substitute:

9.                Requirements for statements to participants

             (1)  A statement under paragraph 8 (1) (a) must:

                     (a)  be in writing; and

                     (b)  set out, clearly and distinctly:

                              (i)  if requested by the participant—the amount of the premium paid for the policy during a particular financial year; and

                             (ii)  if requested by the participant—the amount of the reduction under the premiums reduction scheme for the premium; and

                     (c)  be provided within 14 days of receipt of the request; and

                     (d)  be provided:

                              (i)  by post; or

                             (ii)  if the participant has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the participant.

Example:    If requested by the participant, the information may be provided in an electronic format, including via a web page.

             (2)  A statement under paragraph 8 (1) (a) may           be accompanied by other information.

Private Health Insurance (Lifetime Health Cover) Rules 2017

[7]       Subrule 8(1)

Repeal the subrule, substitute:

              1)  For the purposes of paragraph 40 (1) (a) of the Act, the following requirements are specified:

                     (a)  the insurer must provide information about increases under Part 2-3 in the amounts of premiums payable for the policy holder’s hospital cover in respect of the policy holder, if requested by the policy holder;

                     (b)  the insurer must provide the following information to a policy holder affected by section 34-1 or section 34-5 of the Act, if requested by the policy holder:

                              (i)  the amount by which the policy holder’s premiums payable for hospital cover are increased as a result of the operation of those sections;

                             (ii)  the private health insurer’s record of the number of days the policy holder has not had hospital cover since his or her lifetime health cover base day, other than days to which paragraph 34-20 (1) (a) of the Act applies.

Note:          Paragraph 34-20 (1) (a) of the Act deals with permitted days without hospital cover.

[8]       Subrule 8(3)

Repeal the subrule, substitute:

              3)  The information required to be provided by subrule 8 (1) must:

                     (a)  be provided:

                              (i)  by post; or

                             (ii)  if the policy holder has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the policy holder; and

                     (b)  in the case of joint policy holders, set out the details applying to the joint policy holder making the request; and

                     (c)  be provided to the policy holder within 14 days of receipt of the request.

Example:    For subparagraph (a) (ii), if requested by the policy holder, the information may be provided in an electronic format, including via a web page.


Schedule 7—Amendments relating to accredited podiatrists

Private Health Insurance (Complying Product) Rules 2015

[1]       Rule 4 (definition of accredited podiatrist)

Repeal the definition (including the note).

[2]       Rule 4

Insert:

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

Note:          The registration requirements for a registered podiatric surgeon for the purpose of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules as made from time to time.

[3]       Subrule 8(1) (table item 2, column headed “Kind of policy”, subparagraph (b)(ii))

Omit “an accredited podiatrist”, substitute “a registered podiatric surgeon”.

Private Health Insurance (Prostheses) Rules 2018 (No. 2)

[4]       Rule 4 (definition of accredited podiatrist)

Repeal the definition (including the note).

[5]       Rule 4

Insert:

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

Note:          The registration requirements for a registered podiatric surgeon for the purpose of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules as made from time to time.

[6]       Paragraph 7(a)

Omit “an accredited podiatrist”, substitute “a registered podiatric surgeon”.