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Rules/Other as amended, taking into account amendments up to Private Health Insurance (Reforms) Amendment Rules (No. 3) 2018
Administered by: Health
Registered 07 Jan 2019
Start Date 01 Jan 2019
To be repealed 02 Apr 2020
Repealed by Division 1 of Part 3 of Chapter 3 of the Legislation Act 2003
Table of contents.

Commonwealth Coat of Arms of Australia

Private Health Insurance (Reforms) Amendment Rules 2018

made under section 333‑20 of the

Private Health Insurance Act 2007

Compilation No. 3

Compilation date:                              1 January 2019

Includes amendments up to:            F2018L01795

Registered:                                         7 January 2019

 

About this compilation

This compilation

This is a compilation of the Private Health Insurance (Reforms) Amendment Rules 2018 that shows the text of the law as amended and in force on 1 January 2019 (the compilation date).

The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.

Uncommenced amendments

The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register (www.legislation.gov.au). The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.

Application, saving and transitional provisions for provisions and amendments

If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.

Editorial changes

For more information about any editorial changes made in this compilation, see the endnotes.

Modifications

If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.

Self‑repealing provisions

If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.

  

  

 


Contents

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

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

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

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

Schedule 1Amendments to implement age‑based discounts                                              2

Private Health Insurance (Complying Product) Rules 2015                                                         2

Schedule 2Standard information statements and private health information statements                                                                                                                                                        6

Private Health Insurance (Complying Product) Rules 2015                                                         6

Private Health Insurance (Complying Product) Rules 2015                                                       19

Private Health Insurance (Complying Product) Rules 2015                                                       23

Schedule 3Product tiers and related amendments                                                                24

Private Health Insurance (Complying Product) Rules 2015                                                       24

Private Health Insurance (Complying Product) Rules 2015                                                       57

Schedule 4Second tier administrative reforms                                                                        58

Private Health Insurance (Benefit Requirements) Rules 2011                                                    58

Private Health Insurance (Health Insurance Business) Rules 2018                                          61

Schedule 5Removal of coverage of some natural therapies                                            64

Private Health Insurance (Health Insurance Business) Rules 2018                                          64

Schedule 6Information provision                                                                                                    66

Private Health Insurance (Incentives) Rules 2012 (No. 2)                                                           66

Private Health Insurance (Lifetime Health Cover) Rules 2017                                                  67

Schedule 7—Amendments relating to accredited podiatrists                                              69

Private Health Insurance (Complying Product) Rules 2015                                                       69

Private Health Insurance (Prostheses) Rules 2018 (No. 2)                                                          69

Endnotes                                                                                                                                                               70

Endnote 1—About the endnotes                                                                                                      70

Endnote 2—Abbreviation key                                                                                                          71

Endnote 3—Legislation history                                                                                                       72

Endnote 4—Amendment history                                                                                                     73

 


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 1Amendments 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 2Standard information statements and private health information statements

Part 1Amendments 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 1Information 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 2Additional 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 3Additional 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 2Amendments 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 [the period of time expressed in years, months, days as appropriate] 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 3Amendments 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 3Product tiers and related amendments

Part 1Amendments 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 4Product 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 5Clinical 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.

2  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    13260    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    44133    50600    50604    50608    50612    50616                50620    50624    50628    50632    50636    50640    50644                51020    51021    51022    51023    51024    51025    51026                51031    51032    51033    51034    51035    51036    51041                51042    51043    51044    51045    51051    51052    51053                51054    51055    51056    51057    51058    51059    51061                51062    51063    51064    51065    51066    51071    51072                51073    51102    51103    51110    51111    51112    51113                51114    51115    51120    51130    51131    51140    51141                51145    51150    51160    51165    51170    51171

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    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    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    51011    51012    51013                51014    51015    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    45060                45061    45062    45520    45522    45523    45524    45527                45528    45530    45533    45536    45539    45542    45545                45546    45548    45551    45553    45554    45556    45558

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

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                30310    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    42505                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    42588    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    42785    42788                42791    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    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                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    36671    36672    36673    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    38806    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    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                45587    45588    45590    45593    45596    45597    45599                45602    45608    45611    45614    45617    45620    45623                45624    45625    45626    45629    45632    45635    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:                12012    12017    12021    12022    12024    14050    14100                14106    14115    14118    14124    18362    30023    30024                30026    30029    30032    30035    30038    30042    30045                30049    30052    30055    30064    30071    30099    30180                30183    30187    30189    30190    30191    30192    30196                30202    30207    30210    30216    30219    30223    30676                30679    31000    31001    31002    31003    31004    31005                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    12204    12205    12207    12208    12210    12213                12215    12217    12250    12254    12258    12261    12265                12268    12272

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 6Common 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    12001    12002    12003    12004    12005    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    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    75001    75004    75150    75153    82130    82135    82140    82150    82151                82152    82200    82205    82210    82215    82220    82221    82222    82223    82224    82225

 

 

Schedule 7Support 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    11224    11235    11237    11240    11241    11242    11243    11244                11303    11304    11306    11309    11312    11315    11318    11324    11327    11330    11332    11333    11336    11339                11503    11505    11506    11507    11508    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    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    56620    56625    56626                56659    56660    56665    56666    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    57522    57523    57524    57527    57529    57530    57532    57533    57535    57536    57537    57538                57539    57540    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    59302    59303    59304    59305    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    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    72814    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                73344    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 2Amendments 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 4Second 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 60 calendar days after 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 5Removal 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 6Information 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 7Amendments 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”.


Endnotes

Endnote 1—About the endnotes

The endnotes provide information about this compilation and the compiled law.

The following endnotes are included in every compilation:

Endnote 1—About the endnotes

Endnote 2—Abbreviation key

Endnote 3—Legislation history

Endnote 4—Amendment history

Abbreviation key—Endnote 2

The abbreviation key sets out abbreviations that may be used in the endnotes.

Legislation history and amendment history—Endnotes 3 and 4

Amending laws are annotated in the legislation history and amendment history.

The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.

The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.

Editorial changes

The Legislation Act 2003 authorises First Parliamentary Counsel to make editorial and presentational changes to a compiled law in preparing a compilation of the law for registration. The changes must not change the effect of the law. Editorial changes take effect from the compilation registration date.

If the compilation includes editorial changes, the endnotes include a brief outline of the changes in general terms. Full details of any changes can be obtained from the Office of Parliamentary Counsel.

Misdescribed amendments

A misdescribed amendment is an amendment that does not accurately describe the amendment to be made. If, despite the misdescription, the amendment can be given effect as intended, the amendment is incorporated into the compiled law and the abbreviation “(md)” added to the details of the amendment included in the amendment history.

If a misdescribed amendment cannot be given effect as intended, the abbreviation “(md not incorp)” is added to the details of the amendment included in the amendment history.

 

Endnote 2—Abbreviation key

 

ad = added or inserted

o = order(s)

am = amended

Ord = Ordinance

amdt = amendment

orig = original

c = clause(s)

par = paragraph(s)/subparagraph(s)

C[x] = Compilation No. x

    /sub‑subparagraph(s)

Ch = Chapter(s)

pres = present

def = definition(s)

prev = previous

Dict = Dictionary

(prev…) = previously

disallowed = disallowed by Parliament

Pt = Part(s)

Div = Division(s)

r = regulation(s)/rule(s)

ed = editorial change

reloc = relocated

exp = expires/expired or ceases/ceased to have

renum = renumbered

    effect

rep = repealed

F = Federal Register of Legislation

rs = repealed and substituted

gaz = gazette

s = section(s)/subsection(s)

LA = Legislation Act 2003

Sch = Schedule(s)

LIA = Legislative Instruments Act 2003

Sdiv = Subdivision(s)

(md) = misdescribed amendment can be given

SLI = Select Legislative Instrument

    effect

SR = Statutory Rules

(md not incorp) = misdescribed amendment

Sub‑Ch = Sub‑Chapter(s)

    cannot be given effect

SubPt = Subpart(s)

mod = modified/modification

underlining = whole or part not

No. = Number(s)

    commenced or to be commenced

 

Endnote 3—Legislation history

 

Name

Registration

Commencement

Application, saving and transitional provisions

Private Health Insurance (Reforms) Amendment Rules 2018

11 Oct 2018 (F2018L01414)

Sch 1, Sch 2 (items 6–15), Sch 3 (items 1–4), Sch 5 and 6: 1 Apr 2019 (s 2(1) items 2, 4, 6, 9, 10)
Sch 2 (items 1–5) and Sch 4: 1 Jan 2019 (s 2(1) items 3, 8)
Sch 2 (items 16–20) and Sch 3 (items 5–9): 1 Apr 2020 (s 2(1) items 5, 7)
Remainder: 12 Oct 2018 (s 2(1) items 1, 11)

 

Private Health Insurance (Reforms) Amendment Rules (No. 2) 2018

30 Oct 2018 (F2018L01504)

1 Nov 2018 (s 2(1) item 1)

Private Health Insurance (Reforms) Amendment Rules (No. 3) 2018

19 Dec 2018 (F2018L01795)

Sch 1: 1 Jan 2019 (s 2(1) item 2)
Sch 2: 31 Dec 2018 (s 2(1) item 3)

 

Endnote 4—Amendment history

 

Provision affected

How affected

Schedule 2

 

Part 2

 

item 6........................................

am F2018L01795

Schedule 3

 

Part 1

 

item 4........................................

am F2018L01504; F2018L01795

Schedule 4

 

item 9........................................

am F2018L01795