Private Health Insurance (Accreditation) Rules 2011
made under item 5 of the table in section 333‑20 of the
Private Health Insurance Act 2007
Compilation No. 3
Compilation date: 13 February 2019
Includes amendments up to: F2019L00131
Registered: 21 February 2019
About this compilation
This compilation
This is a compilation of the Private Health Insurance (Accreditation) Rules 2011 that shows the text of the law as amended and in force on 13 February 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If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.
Part 1 Preliminary
These Rules are the Private Health Insurance (Accreditation) Rules 2011.
These Rules apply in respect of all policies existing on, or issued on or after 1 July 2008.
Note: Terms used in these Rules have the same meaning as in the Act―see section 13 of the Legislative Instruments Act 2003. These terms include 'general treatment', 'hospital', 'hospital treatment' and 'medical practitioner'.
(1) In these rules:
appropriate accrediting body means a body approved by the Australian Commission on Safety and Quality in Healthcare to accredit health care organisations or health care providers against the National Safety and Quality Health Service Standards as at 1 January 2013.
Note: The Australian Commission on Safety and Quality in Healthcare is established under section 8 of the National Health Reform Act 2011.
Act means the Private Health Insurance Act 2007.
Chinese medicine practitioner means a Chinese medicine practitioner, Chinese herbal dispenser, Chinese herbal medicine practitioner, Oriental medicine practitioner or acupuncturist.
chronic disease management program has the same meaning as in rule 12 of the Private Health Insurance (Health Insurance Business) Rules made under the Act and in force from time to time.
health care organisation means an organisation that as part of its business is responsible for the clinical and administrative management of patients, but does not include a hospital. For the avoidance of doubt, an individual providing treatment to a patient as a health care provider is not a health care organisation.
Note: 'Treatment' is a defined term in these Rules.
health care provider means an individual who provides treatment, but, for the avoidance of doubt, does not include a person who is acting in the capacity of a health care organisation.
health management program has the same meaning as in subrule 11 (2) of the Private Health Insurance (Health Insurance Business) Rules made under the Act and in force from time to time.
Medical radiation practitioner means a diagnostic radiographer, medical imaging technologist, radiographer, nuclear medicine scientist, nuclear medicine technologist or radiation therapist.
National Law means:
(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or
(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 that corresponds to the Health Practitioner Regulation National Law.
Note The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions that was made on 26 March 2008 provides for the enactment of the State and Territory legislation mentioned in this definition.
National Safety and Quality Health Service Standards means the standards developed by the Australian Commission on Safety and Quality in Healthcare as at 1 January 2013.
Note: Development of the National Safety and Quality Health Service Standards is a function of the Australian Commission on Safety and Quality in Healthcare under paragraph 9(1)(e) of National Health Reform Act 2011.
treatment means treatment as referred to in section 69-5 of the Act, other than treatment :
(a) that is the provision of goods or ambulance services; or
(b) provided by a personal care attendant that is general or hospital treatment under a program of care for the patient; or
(c) that primarily takes the form of sport, recreation or entertainment and is part of:
(i) a chronic disease management program; or
(ii) a health management program; or
(d) that is a quit-smoking program or weight-loss program that is general or hospital treatment other than as provided by a person mentioned in rules 7 and 9.
Part 2
(1) These Rules specify the standards, for section 81-1 of the Act, for treatment covered by a health insurance policy.
Note: Treatment does not include the provision of goods or ambulance services―see the definition in rule 4.
(2) If a health care provider provides more than one kind of treatment, each of the treatments provided must meet the relevant standard applying to that particular treatment.
(1) In this rule:
(a) treatment provided by a hospital is taken to include treatment provided at a hospital or with the direct involvement of a hospital, including treatment provided by a health care provider who is:
(i) authorised by the hospital to provide the treatment; or
(ii) under the management or control of a health care provider referred to in subparagraph (a) (i); and
(b) treatment provided by a health care organisation is taken to include treatment provided by a health care provider who is:
(i) authorised by the organisation to provide the treatment; or
(ii) under the management or control of a health care provider referred to in subparagraph (b) (i).
(2) The standard for treatment provided by a hospital or health care organisation is that:
(a) for a hospital―if the hospital is required under a State or Territory law to have a permission or approval, or be registered, in the State or Territory in which it operates, so as to operate as a hospital and to provide the treatment in that State or Territory, it has the permission or approval, or is registered, under that law; and
Note: 'Hospital' is defined in the Act.
(b) for a health care organisation, including where the organisation is providing treatment on behalf of a hospital:
(i) if the organisation is required under a State or Territory law to have a permission or approval, or be registered, to provide the treatment in the State or Territory, it has the permission or approval, or is registered, under that law; and
(ii) the organisation must be:
(A) accredited or certified by an appropriate accrediting body; or
(B) formally engaged in the process of an appropriate accrediting body to be accredited or certified by that body, where 'formally engaged' means having made a valid application to the body for accreditation or certification, the application has been accepted and the applicant is undertaking the requirements of the body in the timeframes required; and
(c) the treatment must be provided by a health care provider who meets the standard in these Rules relevant to the provision of that treatment.
(d) the State and Territory law requirements referred to in subrule 6 may include the National Safety and Quality Health Service Standards.
(1) If a treatment is provided in a State or Territory where a law of that State or Territory prohibits the provision of the treatment without a permission or approval, or registration, to provide a treatment of that kind, the standard for the treatment is that the health care provider providing the treatment must have the permission or approval, or be registered, under that law.
(2) A person who has a permission, approval or registration as required by subrule (1) but also provides treatment of a type referred to in rule 8, 9 or 10 which is not of a kind covered by the permission, approval or registration must comply with rule 8, 9 or 10, as the case may be, in respect of the other treatment.
Note: This rule covers medical practitioners, allied health professionals and others who meet requirements imposed under State and Territory laws in respect of the provision of certain health services.
If the treatment is of a kind practised by a podiatric surgeon, the standard for that kind of treatment is that it must be provided by a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.
(1) If the treatment is a service within a field mentioned in section 12 of the Health Insurance Regulations 2018 as in force from time to time, the standard is that the treatment within that field must be provided by an allied health professional who is qualified in that field.
(2) In subrule (1), an allied health professional will be qualified in the field if he or she meets the qualification requirements for a service within that field as specified in Schedule 1 of the Health Insurance (Allied Health Services) Determination 2007 or if that instrument is repealed and remade, with or without modifications, the remade instrument.
(3) If the treatment is provided by an allied health professional practising in a field not mentioned in subrule (1), the standard is that the allied health professional must be a member of a professional organisation which covers health care providers who provide that type of treatment and which is an ordinary member of Allied Health Professions Australia Ltd or any successor organisation.
If the treatment is provided by a health care provider who is not referred to in subrule 7(1) or rule 8 or 9, the standard for that treatment is that the health care provider providing the treatment must be a member of a professional organisation which covers health care providers who provide that type of treatment (the profession) and which:
(a) is a national entity which has membership requirements for the profession; and
(b) provides assessment of the health care provider in terms of the appropriate level of training and education required to practise in that profession; and
(c) administers a continuing professional development scheme in which the health care provider is required, as a condition of membership, to participate; and
(d) maintains a code of conduct which the health care provider must uphold in order to continue to be a member; and
(e) maintains a formal disciplinary procedure, which includes a process to suspend or expel members, and an appropriate complaints resolution procedure.
If a treatment is provided in a State or Territory where a law of that State or Territory requires the premises in which the treatment is provided to have a permission or approval to provide a treatment of that kind, the standard for the treatment is that the premises must have the permission or approval under that law.
Notes
The Private Health Insurance (Accreditation) Rules 2011 as shown in this compilation are amended as indicated in the Tables below.
Table of Instruments
| Instrument | Date of FRLI registration | Date of commencement | Application, saving or transitional provision |
| Private Health Insurance (Accreditation) Rules 2011 | 4 November 2011 (see F2011L02241) | 5 November 2011 | |
| Private Health Insurance (Accreditation) Amendment Rules 2012 | 21 June 2012 (see F2012L01289) | 22 June 2012 | |
| Private Health Insurance (Accreditation) Amendment Rules 2012 (No. 2) | 2 January 2013 (see F2013L00004) | 3 January 2013 | |
| Private Health Insurance (Accreditation) Amendment Rules 2019 | 12 February 2019 (see F2019L00131) | 13 February 2019 | |
| | | | |
Table of Amendments
| ad. = added or inserted am. = amended LA = Legislation Act 2003 rep. = repealed
rs. = repealed and substituted |
| Provision affected | How affected |
| Part 1 | |
| Rule 2 | rep. LA s 48C and s 48D |
| Rule 4, Subrule 1 | am. F2012L01289 am. F2013L00004 |
| Part 2 Rule 6, Subrule 2 Rule 7, Subrule 3 | am. F2013L00004 am. F2012L01289 rep. F2019L00131 |
| Rule 9, Subrule 1 | am. F2019L00131 |