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Rules/Other as amended, taking into account amendments up to Private Health Insurance Legislation Amendment Rules (No. 7) 2020
Administered by: Health
Registered 12 Nov 2020
Start Date 01 Nov 2020

Commonwealth Coat of Arms of Australia

Private Health Insurance (Complying Product) Rules 2015

made under item 3 of the table in subsection 333‑20(1) of the

Private Health Insurance Act 2007

Compilation No. 31

Compilation date:                              1 November 2020

Includes amendments up to:            F2020L01378

Registered:                                         12 November 2020

About this compilation

This compilation

This is a compilation of the Private Health Insurance (Complying Product) Rules 2015 that shows the text of the law as amended and in force on 1 November 2020 (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If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.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

Part 1                  Preliminary                                                                                         1

1.           Name of Rules                                                                                     1

3A         Authority                                                                                              1

4.           Definitions                                                                                           1

Part 2                  General                                                                                                5

5.           Insured groups                                                                                     5

5A         Psychiatric treatment—limitations                                                       5

6.           Maximum percentage of discount                                                        6

7.           Benefits authorised to be provided under a policy                              6

8.           Complying products―coverage requirements                                     7

8A         Benefit requirement―nursing‑home type patients                              8

9.           Waiting periods―former gold card holders                                        9

9AA      Terminating products—portability requirements                                 9

9A         Specialist psychiatric treatment—portability requirements                11

9B         Specialist psychiatric treatment—choice to have upgrade treated
in accordance with rule 9A                                                                12

10.         Transfer certificates                                                                            13

11.         Performance indicators                                                                      13

Part 2A               Age‑based discounts                                                                         14

11A.      Definitions                                                                                         14

11B.      Requirements for age‑based discount policy to be complying
health insurance policy                                                                       15

11C.      Calculation of age‑based discount                                                     15

11D.      Circumstances in which a person is entitled to age‑based discount  16

Part 2B               Requirements relating to product tiers for, and names of,
              insurance policies                                                                              17

11E.       Product tiers for insurance policies that cover hospital treatment     17

11F.       Coverage of treatments for insurance policies that cover hospital
treatment                                                                                            17

11G.      Provision of restricted and unrestricted cover                                   18

11H.      Naming of insurance policies that cover hospital treatment              19

11J.        Naming of insurance policies that cover general treatment only       19

Part 3                  Private health information statements and other information
                            that must be given                                                                            20

12.         Private health information statements                                                20

13.         Method of making private health information statements
available                                                                                             20

14.         Information relating to changes to premiums to be provided to Private Health Insurance Ombudsman                                                                                       21

15.         Information provided to insured persons                                           21

16.         Information provided to persons about product subgroups               22

Part 4                  Pilot Projects                                                                                     23

17.         Kinds of pilot projects                                                                       23

18.         Requirements of pilot projects                                                           23

Part 5                  Transitional provisions                                                                    24

19.         Transitional provisions relating to the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018                                                           24

Schedule 1―Information and form of words for private health information statement—all policies  25

Schedule 2―Additional information, and form of words, for private health information statement—hospital treatment                                                                                                                       28

Schedule 3―Additional information, and form of words, for private health information statement—general treatment                                                                                                                       31

Schedule 4—Product tiers and clinical categories                                                     36

Schedule 5—Clinical categories                                                                                   38

Schedule 6—Common treatments list                                                                         55

Schedule 7—Support treatments list                                                                           56

Endnotes                                                                                                                        58

Endnote 1—About the endnotes                                                                         58

Endnote 2—Abbreviation key                                                                            59

Endnote 3—Legislation history                                                                          60

Endnote 4—Amendment history                                                                        63

 


Part 1      Preliminary

1.         Name of Rules

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

3A       Authority

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

4.         Definitions

In these Rules:

Act means the Private Health Insurance Act 2007.

addiction medicine specialist means a specialist (within the meaning of the Health Insurance Act 1973) in relation to addiction medicine.

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.

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

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

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

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

consultant psychiatrist means a specialist (within the meaning of the Health Insurance Act 1973) in relation to psychiatry.

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

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

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.

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

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

insurer means a private health insurer.

MBS item means an item that is in, or which from time to time a determination under section 3C of the Health Insurance Act 1973 deems to be 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 that Act, as in force from time to time;

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

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.

period of pre‑upgrade hospital cover has the meaning given by subrule 9A(5).

policy means a complying health insurance policy.

private hospital means a hospital in respect of which there is in force a statement under subsection 121‑5 (8) of the Act that the hospital is a private hospital.

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”.

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

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

psychiatric treatment means hospital treatment, or hospital‑substitute treatment, that is psychiatric care.

public hospital means a hospital in respect of which there is in force a statement under subsection 121‑5 (8) of the Act that the hospital is a public hospital.

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.

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.

specialist psychiatric treatment means psychiatric treatment provided to a person who is:

(a)  an admitted patient of a hospital; and

(b)  under the care of an addiction medicine specialist or consult psychiatrist.

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.

upgrade, in relation to psychiatric treatment, has the meaning given by subrules 9A(2) and (3).

Note:          Unless the contrary intention appears, terms used in these Rules have the same meaning as in the Act― see section 13 of the Legislative Instruments Act 2003.  These terms include:
adult
applicable benefits arrangement
complying health insurance policy
complying health insurance product
cover
dependent child
dependent child non‑student
general treatment
hospital cover
hospital‑substitute treatment
hospital treatment
medical practitioner
medicare benefit
policy holder
private health information statement
private health insurer
product subgroup
risk equalisation jurisdiction
rules [of an insurer]
transfer
waiting period


Part 2      General

5.         Insured groups

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

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

(i)           only one person;

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

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

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

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

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

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

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

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

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

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

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

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

5A       Psychiatric treatment—limitations

         For the purposes of paragraph 63‑10(g) of the Act, an insurance policy must not reduce a benefit for psychiatric treatment provided to a person if the reduction is because of:

(a)          the number of psychiatric treatments, for which there is or has been an entitlement to a benefit under any policy, provided to the person during a period; or

(b)          the number of a particular kind of such psychiatric treatments provided to the person during a period.

6.         Maximum percentage of discount

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

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

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

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

(a)          incentive payment;

(b)          promotional payment;

(c)          rebate; and

(d)         any other inducement whatsoever,

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

(5)    For the purposes of this rule, disregard:

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

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

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

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

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

7.         Benefits authorised to be provided under a policy

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

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

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

(3)    The specified benefits for this rule are:

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

(b)          funeral benefits;

(c)          disability benefits.

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

8.         Complying products―coverage requirements

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

 

Coverage requirements

Item

Kind of policy

Treatments the policy must cover

1

A policy that includes cover for hospital‑substitute treatment.

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

2

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

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

(b) either:

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

(ii) the provision of the prosthesis is associated with podiatric treatment by a registered podiatric surgeon; or

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

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

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

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

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

The provision of the prosthesis.

3

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

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

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

The provision of the prosthesis.

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

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

8A           Benefit requirement―nursing‑home type patients

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

(2)    The requirement is that the amount of benefit payable under the policy in respect of hospital treatment at a hospital for a nursing‑home type patient must not exceed an amount equal to the fees or charges incurred in respect of that hospital treatment less the amount of the patient contribution in relation to the patient for each day on which the patient is a nursing‑home type patient at the hospital.

(3)    In this rule:

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

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

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

              (i)           Australian Capital Territory ‑ $62.50;

              (ii)          New South Wales ‑ $62.50;

              (iii)         Northern Territory ‑ $62.50;

              (iv)         Queensland ‑ $62.50;

              (v)          South Australia ‑ $62.50;

              (vi)         Tasmania ‑ $62.50;

              (vii)        Victoria ‑ $62.50; and

              (viii)       Western Australia ‑ $62.50.

(b)  in relation to a nursing‑home type patient at a private hospital, $62.50.

9.           Waiting periods―former gold card holders

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

(2)    A policy that covers a person who:

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

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

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

(3)    In this rule:

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

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

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

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

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

9AA  Terminating products—portability requirements

             (1)  For paragraph 78‑1 (5A) (c) of the Act, the matters are:

                     (a)  that the policy forms part of a product, or belongs to a product subgroup, that is being terminated and that will not be available to any person insured under a policy that forms part of the product or that belongs to the product subgroup, as appropriate (a terminating policy); and

                     (b)  that, as a consequence, the persons insured under the policy are to be transferred to another insurance policy; and

                     (c)  the date by which the transfer is to take place (the transfer date); and

                     (d)  that:

                              (i)  before the transfer date, the persons insured under the policy may transfer to any insurance policy of their choosing; but

                             (ii)  if they do not do so before the transfer date, they will be transferred, on the transfer date, to a specified insurance policy (the default policy); and

                     (e)  the matters set out in subrule(2) that relate to the default policy; and

                      (f)  the other matters set out in subrule (3) that relate to the transfer.

Matters that relate to the default policy

             (2)  For paragraph (1) (e), the matters are:

                     (a)  the private health information statement for the default policy; and

                     (b)  details of the premium that would be payable for the default policy, including any increase in the premium under Part 2‑3 of the Act (lifetime health cover), and any discounts that might apply; and

                     (c)  details of:

                              (i)  any treatments that are covered under the terminating policy that will not be covered under the default policy; and

                             (ii)  any differences between the excesses or co‑payments payable under the terminating policy and the default policy.

Other matters that relate to the transfer

             (3)  For paragraph (1) (f), the matters are:

                     (a)  that if:

                              (i)  a person transfers from the terminating policy to another policy, or is transferred to the default policy; and

                             (ii)  there are particular hospital treatments or hospital‑substitute treatments that are covered by both the terminating policy and the policy to which the person transfers or is transferred;

                            for each such treatment, to the extent that the person has satisfied the waiting period (if any) under the terminating policy, the person will have satisfied the waiting period (if any) under the other policy; but

                     (b)  that if:

                              (i)  a person is transferred from the terminating policy to the default policy; and

                             (ii)  the person subsequently transfers from the default policy to another insurance policy (the replacement policy);

                            then:

                            (iii)  if there are any treatments that were not covered by the default policy but that are covered by the replacement policy—the person may be subject to a waiting period under the replacement policy in respect of those treatments, even if the treatments were originally covered by the terminating policy; and

                            (iv)  if the default policy had higher excesses or co‑payments than the replacement policy—those higher excesses or co‑payments might, for a period of time, continue to apply under the replacement policy.

9A       Specialist psychiatric treatment—portability requirements

(1)    For the purposes of subsection 78‑1(6) of the Act, subrules (4) to (8) of this rule modify the requirements of section 78‑1 of the Act in relation to:

(a)          an insurance policy (the new policy) to which a person transfers from another policy (the old policy), if:

(i)           the transfer is an upgrade in relation to psychiatric treatment; and

(ii)          the person chooses under rule 9B to have the upgrade treated in accordance with those subrules; and

(b)          a benefit (the higher benefit) under the new policy for specialist psychiatric treatment provided to the person.

(2)    The transfer is an upgrade, in relation to psychiatric treatment, if the benefit for psychiatric treatment under the new policy is higher than the benefit for psychiatric treatment under the old policy.

(3)    For the purposes of subrule (2), disregard any co‑payment or excess that is required to be paid under the old policy or the new policy in respect of psychiatric treatment.

Waiting periods

(4)    The new policy must not:

(a)          if the length of the person’s period of pre‑upgrade hospital cover was 2 months or longer—apply to the person a waiting period for the higher benefit; or

(b)          otherwise—apply to the person a waiting period for the higher benefit that is longer than 2 months reduced by the length of the person’s period of pre‑upgrade hospital cover.

(5)    The person’s period of pre‑upgrade hospital cover is the longest period:

(a)          that ended immediately before the upgrade; and

(b)          at all times during which the person had hospital cover.

Retrospective cover

(6)    Subrules (7) and (8) apply if the upgrade occurs:

(a)          on or after the day (the admission day) the person became an admitted patient of a hospital in relation to the specialist psychiatric treatment mentioned in paragraph (1)(b); and

(b)          on or before the fifth business day to occur on or after the admission day.

(7)    The new policy’s coverage of specialist psychiatric treatment must start no later than the admission day.

Example:         A person is admitted to hospital for specialist psychiatric treatment. The person’s insurance policy provides minimum benefits for psychiatric treatment. 3 business days later, the person upgrades to a new policy and chooses to have the upgrade treated in accordance with subrules (4) to (8). The higher benefits under the new policy for specialist psychiatric treatment must apply from the day of the admission.

(8)    Subrule (7) does not prevent the new policy from applying a waiting period in accordance with subrule (4). The reference in paragraph (5)(a) to the upgrade is taken to be a reference to the start of the new policy’s coverage of specialist psychiatric treatment.

9B       Specialist psychiatric treatment—choice to have upgrade treated in accordance with rule 9A

(1)    A person may choose to have an upgrade in relation to psychiatric treatment treated in accordance with subrules 9A(4) to (8) if the person has not previously made such a choice in relation to any such upgrade.

(2)    If:

(a)          a person transfers to an insurance policy (the new policy), and the transfer is an upgrade in relation to psychiatric treatment; and

(b)          a claim is made under the new policy for a benefit for specialist psychiatric treatment provided to the person; and

(c)          a benefit of the amount claimed is only payable under the new policy for the treatment if the person chooses to have the upgrade treated in accordance with subrules 9A(4) to (8);

         the making of the claim is sufficient evidence of the person choosing to have the upgrade treated in accordance with those subrules.

(3)    For the purposes of paragraph (2)(c) of this rule, disregard any co‑payment or excess that is required to be paid under the new policy in respect of psychiatric treatment.

10.       Transfer certificates

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

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

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

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

11.       Performance indicators

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

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

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

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

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

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


Part 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.


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

             (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

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

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

             (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 “+”.


Part 3      Private health information statements and other information that must be given

Note:       This Part deals with:

·               the information and form for private health information statements, for the purposes of subsection 93‑5 (1) of the Act, and methods by which private health 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.  Private health 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 private health 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 private health 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 private health information statement is accompanied by information additional to the information and form of words that are required by subrule 12 (1); and

(b)          the private health 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 private health 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 before the end of the day that is the later of:

(a)          1 February immediately following the day the Minister approved the change; or

(b)          20 business days after the day the Minister approved the change.

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.

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.


Part 4      Pilot Projects

17.       Kinds of pilot projects

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

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

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

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

18.       Requirements of pilot projects

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

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

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

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

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

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

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


Part 5      Transitional provisions

19.       Transitional provisions relating to the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018

Definitions

(1)    In this rule:

amending rules means the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018.

Application of subrule 9A(4)

(2)    Subrule 9A(4), as inserted by the amending rules, applies to a waiting period that ends on or after 1 April 2018, whether the upgrade occurred before, on or after 1 April 2018.

Application of subrules 9A(6) to (8)

(3)    Subrules 9A(6) to (8), as inserted by the amending rules, apply to an upgrade that occurs on or after 1 April 2018.

(4)    If a person:

(a)          became an admitted patient of a hospital in relation to specialist psychiatric treatment before 1 April 2018; and

(b)          is still an admitted patient in relation to the treatment on 1 April 2018;

the reference in paragraph 9A(6)(a), as inserted by the amending rules, to the day the person became an admitted patient of a hospital in relation to the treatment is taken to be a reference to 1 April 2018.

(5)    If subrule 9A(7), as inserted by the amending rules, would, apart from this subrule, require an insurance policy’s coverage of specialist psychiatric treatment to start before 1 April 2018, subrule 9A(7) is taken to require the coverage to start no later than 1 April 2018.


Schedule 1―Information and form of words for private health 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 private health 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 private health information statement—all policies

Item

Information and form of words

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.

 

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 private health information statement that is generated by the privatehealth.gov.au system.

 


Schedule 2—Additional information, and form of words, for private health 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”; 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.

 

4

Restrictions

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

 

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 clinical categories covered by the policy, the appropriate figure for the relevant waiting period.

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

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

 

6

Excess

Whichever of the following is appropriate:

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

   (b)  if there is an excess:

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

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

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

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

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

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

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

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

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

 

7

Extra cost per day (co‑payments)

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

 

If there are co‑payments:

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

             (i)   either:

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

                          (B)  the statements:

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

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

            (ii)   as applicable, either:

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

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

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

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

 

8

Note on out of pocket costs/doctors’ fees

The following statement:

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

 

9

Note on information relating to contracts between hospitals and insurers

The following statement:

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

 

10

Other features

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

The statement must consist of at most 100 words.

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

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


Schedule 3—Additional information, and form of words, for private health 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.

 


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 categories 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, 90250, 90251, 90252, 90253, 90254, 90255, 90256, 90257, 90264, 90265, 90272, 90274, 90276, 90278, 91285, 91287, 91723, 91727, 93300, 93303, 93306, 93309, 14224, 80005, 80015, 80020, 80101, 80105, 80115, 80120, 80130, 80140, 80145, 80155, 80165, 80170

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:
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 item:

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:
6007, 6009, 6011, 6013, 6015, 14227, 14234, 14237, 18377, 35000, 35003, 35006, 35009, 35012, 35412, 35414, 39007, 39013, 39015, 39018, 39113, 39300, 39303, 39306, 39309, 39312, 39315, 39318, 39321, 39324, 39327, 39330, 39333, 39503, 39604, 39610, 39612, 39615, 39638, 39639, 39641, 39651, 39654, 39656, 39700, 39703, 39710, 39712, 39715, 39718, 39720, 39801, 39803, 39815, 39818, 39821, 39900, 39903, 39906, 40004, 40012, 40018, 40104, 40106, 40109, 40112, 40119, 40600, 40700, 40701, 40702, 40703, 40704, 40705, 40706, 40707, 40708, 40709, 40712, 40801, 40803, 40850, 40851, 40852, 40854, 40856, 40858, 40860, 40862, 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, 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, 13950, 14221, 14245, 14247, 14249, 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

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, 41501, 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, 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, 42504, 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, 32094, 32095, 32222, 32223, 32224, 32225, 32226, 32227, 32228, 32229

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, 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

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:
ss41603, 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, 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

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, 36504, 36505, 36506, 36507, 36508, 36509, 36516, 36519, 36522, 36525, 36528, 36529, 36531, 36532, 36533, 36537, 36543, 36546, 36549, 36552, 36558, 36561, 36564, 36567, 36570, 36573, 36576, 36579, 36585, 36588, 36591, 36594, 36597, 36600, 36603, 36604, 36606, 36607, 36608, 36609, 36610, 36611, 36612, 36615, 36618, 36621, 36624, 36627, 36633, 36636, 36639, 36645, 36649, 36650, 36652, 36654, 36656, 36663, 36664, 36665, 36666, 36667, 36668, 36671, 36672, 36673, 36800, 36803, 36806, 36809, 36811, 36812, 36815, 36818, 36821, 36822, 36823, 36824, 36827, 36830, 36833, 36836, 36840, 36842, 36845, 36848, 36851, 36854, 36860, 36863, 37000, 37004, 37008, 37011, 37014, 37015, 37016, 37018, 37019, 37020, 37021, 37023, 37026, 37029, 37038, 37039, 37040, 37041, 37042, 37043, 37044, 37045, 37046, 37047, 37048, 37050, 37053, 37300, 37303, 37306, 37309, 37318, 37321, 37324, 37327, 37330, 37333, 37336, 37338, 37339, 37340, 37341, 37342, 37343, 37344, 37345, 37348, 37351, 37354, 37369, 37372, 37375, 37381, 37384, 37387, 37388, 37390, 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, 30629, 30630, 30631, 30635, 30641, 30642, 30643, 30644, 30649, 30654, 30658, 30663, 30666, 37200, 37201, 37202, 37203, 37206, 37207, 37208, 37209, 37210, 37211, 37213, 37214, 37215, 37216, 37217, 37218, 37219, 37220, 37221, 37223, 37224, 37226, 37227, 37230, 37233, 37245, 37393, 37396, 37402, 37405, 37408, 37411, 37415, 37417, 37418, 37423, 37426, 37429, 37432, 37435, 37438, 37601, 37604, 37607, 37610, 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, 39109, 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, 45627, 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:
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 – table of MBS items

3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 104, 105, 106, 107, 108, 109, 110, 111, 115, 116, 117, 119, 120, 122, 128, 131, 132, 133, 135, 137, 141, 143, 145, 147, 160, 161, 162, 163, 164, 173, 193, 195, 197, 199, 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, 253, 255, 257, 260, 262, 264, 266, 269, 271, 272, 276, 277, 279, 281, 282, 285, 287, 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, 385, 386, 387, 388, 410, 411, 412, 413, 414, 415, 416, 417, 585, 588, 591, 594, 599, 600, 701, 703, 705, 707, 715, 721, 723, 729, 731, 732, 733, 735, 737, 739, 743, 747, 750, 758, 820, 822, 823, 825, 826, 828, 830, 832, 834, 835, 837, 838, 871, 872, 880, 900, 903, 2100, 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, 2801, 2806, 2814, 2824, 2832, 2840, 2946, 2949, 2954, 2958, 2972, 2974, 2978, 2984, 2988, 2992, 2996, 3000, 4001, 5000, 5001, 5003, 5004, 5010, 5011, 5012, 5013, 5014, 5016, 5017, 5019, 5020, 5021, 5022, 5023, 5027, 5028, 5030, 5031, 5032, 5033, 5035, 5036, 5039, 5040, 5041, 5042, 5043, 5044, 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, 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, 13757, 13870, 13873, 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, 35551, 35552, 36502, 38456, 39000, 43915, 44130, 46324, 46325, 46519, 46525, 50127, 51700, 51703, 52012, 52015, 52018, 52144, 75001, 75004, 75150, 75153, 82130, 82135, 82140, 82200, 82205, 82210, 82215


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:

                     (a)  the MBS items set out in the following table; and

                     (b)  any MBS item that is not listed in the table or in Schedule 5 or 6 but is, at the time of the relevant treatment, listed in the diagnostic imaging services table or the pathology services table made under section 4AA or 4A of the Health Insurance Act 1973, including by reason of a determination under section 3C of that Act.

 

Support treatments – table of MBS items

6080, 6081, 10801, 10802, 10803, 10804, 10805, 10806, 10807, 10808, 10809, 10816, 10931, 10932, 10933, 10940, 10941, 10942, 10943, 10944, 11000, 11003, 11004, 11005, 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, 11705, 11713, 11715, 11718, 11719, 11720, 11721, 11724, 11725, 11726, 11727, 11728, 11729, 11730, 11731, 12200, 12201, 12306, 12312, 12315, 12320, 12321, 12322, 12325, 12326, 12500, 12533, 13300, 13303, 13306, 13309, 13312, 13318, 13319, 13703, 13706, 13750, 13755, 13815, 13818, 13830, 13832, 13834, 13835, 13837, 13838, 13839, 13840, 13842, 13848, 13851, 13854, 13857, 13876, 13881, 13882, 13885, 13888, 13899, 14255, 14256, 14257, 14258, 14259, 14260, 14263, 14264, 14265, 14266, 14270, 14272, 14277, 14278, 14280, 14283, 14285, 14288, 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, 18297, 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, 20706, 20730, 20740, 20745, 20750, 20752, 20754, 20756, 20770, 20790, 20791, 20792, 20793, 20794, 20798, 20799, 20800, 20802, 20803, 20804, 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, 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, 21930, 21935, 21936, 21939, 21941, 21942, 21943, 21945, 21949, 21952, 21955, 21959, 21962, 21965, 21969, 21970, 21973, 21976, 21980, 21990, 21992, 21997, 22002, 22007, 22008, 22012, 22014, 22015, 22020, 22025, 22031, 22036, 22041, 22042, 22051, 22055, 22060, 22065, 22075, 22900, 22905, 23010, 23025, 23035, 23045, 23055, 23065, 23075, 23085, 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, 25013, 25014, 25020, 25025, 25030, 25050, 25200, 25205, 30001, 51300, 51303, 51306, 51309, 51312, 51315, 51318, 51800, 51803, 53700, 53702, 53704, 53706, 75009, 75012, 75015, 75018, 75021, 75023, 10950, 10951, 10952, 10953, 10954, 10956, 10958, 10960, 10962, 10964, 10966, 10968, 10970, 10988, 10989, 81000, 81005, 81010


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 (Complying Product) Rules 2015

30 June 2015 (F2015L01021)

1 July 2015 (r 2)

 

Private Health Insurance (Complying Product) Amendment Rules 2015 (No.3)

17 September 2015 (F2015L01449)

20 September 2015

Private Health Insurance (Complying Product) Amendment Rules 2016 (No.1)

18 March 2016 (F2016L00353)

20 March 2016

Private Health Insurance (Complying Product) Amendment Rules 2016 (No.2)

2 June 2016 (F2016L00985)

2 June 2016

Private Health Insurance (Complying Product) Amendment Rules 2016 (No.3)

29 June 2016 (F2016L01102)

1 July 2016

Private Health Insurance (Complying Product) Amendment Rules 2016 (No.4)

16 September 2016 (F2016L01447)

20 September 2016

Private Health Insurance (Complying Product) Amendment Rules 2016 (No.5)

20 September 2016 (F2016L01464)

20 September 2016

Private Health Insurance (Complying Product) Amendment Rules 2016 (No.6)

22 November 2016 (F2016L01790)

23 November 2016

Private Health Insurance (Complying Product) Amendment Rules 2017 (No.1)

17 March 2017 (F2017L00243)

20 March 2017

Private Health Insurance (Complying Product) Amendment Rules 2017 (No.2)

28 June 2017 (F2017L00776)

1 July 2017

Private Health Insurance (Complying Product) Amendment Rules 2017 (No.3)

28 June 2017 (F2017L01219)

20 September 2017

Private Health Insurance (Complying Product) Amendment Rules 2018 (No.1)

19 March 2018 (F2018L00314)

20 March 2018

Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018

26 March 2018 (F2018L00393)

1 April 2018

Private Health Insurance (Complying Product) (ACT Nursing Home Type Patient) Amendment Rules 2018

28 June 2018 (F2018L00918)

1 July 2018 (s 2)

Private Health Insurance (Complying Product) Amendment (Terminating Products) Rules 2018

17 Sept 2018 (F2018L01304)

Sch 1: 22 Sept 2018 (s 2(1) item 2)

Private Health Insurance (Complying Product) Amendment Rules 2018 (No. 5)

19 Sept 2018 (F2018L01316)

20 Sept 2018 (s 2)

Private Health Insurance (Reforms) Amendment Rules 2018

11 Oct 2018 (F2018L01414)

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

as amended by

 

 

 

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

30 Oct 2018 (F2018L01504)

1 Nov 2018 (s 2(1))

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

19 Dec 2018 (F2018L01795)

Sch 1: 1 Jan 2019 (s 2(1) item 2)

Private Health Insurance (Complying Product) Amendment Rules (No. 2) 2019

20 Mar 2019 (F2019L00328)

Sch 2: 1 July 2019 (s 2(1) item 3)
Remainder: 20 Mar 2019 (s 2(1) items 1, 2)

as amended by

 

 

 

Private Health Insurance Legislation Amendment Rules (No. 1) 2019

29 Apr 2019 (F2019L00639)

Sch 4: 30 Apr 2019 (s 2(1) item 5)

Private Health Insurance (Complying Product) Amendment Rules (No. 1 ) 2019

29 Mar 2019 (F2019L00464)

30 Mar 2019 (s 2(1) item 1)

Private Health Insurance (Complying Product) Amendment Rules (No. 3) 2019

29 Mar 2019 (F2019L00481)

1 Apr 2019 (s 2(1) item 2)

Private Health Insurance Legislation Amendment Rules (No. 1) 2019

29 Apr 2019 (F2019L00639)

Sch 3: 1 May 2019 (s 2(1) item 4)

Private Health Insurance Legislation Amendment (No. 2) Rules 2019

28 June 2019 (F2019L00925)

Sch 2: 1 July 2019 (s 2(1) item 1)

Private Health Insurance Legislation Amendment (No. 3) Rules 2019

19 Sept 2019 (F2019L01221)

Sch 2: 20 Sept 2019 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 4) 2019

30 Oct 2019 (F2019L01384)

Sch 2: 1 Nov 2019 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 1) 2020

28 Feb 2020 (F2020L00190)

Sch 2: 1 Mar 2020 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 2) 2020

19 Mar 2020 (F2020L00272)

Sch 2: 20 Mar 2020 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 3) 2020

30 Apr 2020 (F2020L00539)

Sch 2: 1 May 2020 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 4) 2020

30 June 2020 (F2020L00862)

Sch 2 and 3: 1 July 2020 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 5) 2020

31 July 2020 (F2020L00978)

Sch 2: 1 Aug 2020 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 6) 2020

29 Sep 2020 (F2020L01244)

Sch 2: 30 Sept 2020 (s 2(1) item 1)

Private Health Insurance Legislation Amendment Rules (No. 7) 2020

30 Oct 2020 (F2020L01378)

Sch 3: 1 Nov 2020 (s 2(1) item 1)

 

Endnote 4—Amendment history

 

Provision affected

How affected

Part 1

 

r 2.............................................

rep LA s 48D

r 3.............................................

rep LA s 48C

r 4.............................................

am F2018L00393; F2018L01414; F2019L00481

Part 2

 

r 5A..........................................

am F2018L00393

r 6.............................................

am F2018L01414

r 8.............................................

am F2018L01414

r 8A..........................................

am F2015L01449; F2016L00353; F2016L00985; F2016L01447; F2016L01464; F2017L00243; F2017L00776; F2017L01219; F2018L00314; F2018L00918; F2018L01316

 

ed C13

 

am F2019L00328

 

ed C17

 

am F2019L00328; F2019L00925

 

ed C21

 

am F2019L01221

 

ed C22

 

am F2020L00272

 

ed C25

 

am F2020L00862

r 9AA........................................

ad F2018L01304

 

am F2018L01414

r 9A..........................................

ad F2018L00393

r 9B...........................................

ad F2018L00393

Part 2A

 

Part 2A......................................

ad F2018L01414

r 11A........................................

ad F2018L01414

r 11B.........................................

ad F2018L01414

r 11C.........................................

ad F2018L01414

r 11D........................................

ad F2018L01414

Part 2B

 

Part 2B......................................

ad F2018L01414

r 11E.........................................

ad F2018L01414

 

am F2018L01414

r 11F.........................................

ad F2018L01414

 

am F2018L01414

r 11G........................................

ad F2018L01414

 

am F2018L01414

r 11H........................................

ad F2018L01414

 

am F2018L01414

r 11J..........................................

ad F2018L01414

Part 3

 

Part 3 heading...........................

am F2018L01414

Part 3........................................

rs F2018L01414

 

am F2018L01414

 

ed C19

r 12...........................................

rs F2018L01414

 

am F2018L01414

r 13...........................................

rs F2018L01414

 

am F2018L01414

r 14...........................................

rs F2018L01414

 

am F2019L01384; F2020L00862

r 15...........................................

rep F2018L01414

 

ad F2018L01414 (as am by F2018L01795)

r 16...........................................

rep F2018L01414

 

ad F2018L01414

Part 4

 

r 18...........................................

am F2019L00464

Part 5

 

r 19...........................................

ad F2018L00393

r 20...........................................

ad F2018L01414

 

am F2018L01414

 

rep F2018L01414

r 21...........................................

ad F2018L01414

 

rep F2018L01414

Schedule 1

 

Schedule 1 heading...................

am F2018L01414

Schedule 1................................

rs F2018L01414

c 1.............................................

ad F2018L01414

c 2.............................................

ad F2018L01414

 

am F2018L01414

Schedule 2

 

Schedule 2 heading...................

am F2018L01414

Schedule 2................................

rs F2018L01414

c 1.............................................

ad F2018L01414

c 2.............................................

ad F2018L01414

 

am F2018L01414

Schedule 3

 

Schedule 3 heading...................

am F2018L01414

Schedule 3................................

rs F2018L01414

c 1.............................................

ad F2018L01414

c 2.............................................

ad F2018L01414

Schedule 4

 

Schedule 4................................

rep F2018L01414

 

ad F2018L01414

c 1.............................................

ad F2018L01414

Schedule 5

 

Schedule 5................................

ad F2018L01414

c 1.............................................

ad F2018L01414

c 2.............................................

ad F2018L01414 (as am by F2018L01504)

 

am F2019L00639; F2019L00925; F2019L01384; F2020L00190; F2020L00539; F2020L01244; F2020L01378

Schedule 6

 

Schedule 6................................

ad F2018L01414

c 1.............................................

ad F2018L01414 (as am by F2018L01504)

 

am F2019L00481; F2019L00925; F2019L01384; F2020L00190; F2020L01378

Schedule 7

 

Schedule 7................................

ad F2018L01414

 

rs F2019L00481

c 1.............................................

ad F2018L01414 (as am by F2018L01504; F2018L01795)

 

rs F2019L00481

 

am F2019L00925; F2019L01384; F2020L00190; F2020L00539; F2020L00978

 

ed C29

 

am F2020L01378