Commonwealth of Australia

National Health Act 1953

Health Benefits Reinsurance (Records of Organisations) Determination 1998

I, SANDY HALLEY, Commissioner of Private Health Insurance Administration, make this Determination under subsection 73BB (1) of the National Health Act 1953.

Dated 26 June 1998.

SANDY HALLEY

Commissioner of Private Health Insurance Administration

1.1 Name of Determination

 This Determination is the Health Benefits Reinsurance (Records of Organisations) Determination 1998.

1.2 Commencement

 This Determination commences on gazettal.

1.3 Definitions

 In this Determination:

 Act means the National Health Act 1953.

 quarterly return  means the form set out in the Schedule.

Note    Some expressions used in this Determination are defined in the Act (see s 4) or in the Health Insurance Act 1973 (see s 3), including:

•              contributor
•              Council
•              dependant
•              registered health benefits organisation
•              registered organisation.

1.4 Records to be maintained

 To enable the Council to perform its functions in relation to the Health Benefits Reinsurance Trust Fund, a registered health benefits organisation must maintain the following records:

 (a) the name, and age, of each contributor to the health benefits fund conducted by the registered organisation, and each dependant of a contributor;

 (b) the kind of membership that, under the rules of the organisation, each contributor and dependant has in the fund;

 (c) each benefit that is paid or payable, and the name of the contributor or dependant for whom it is payable;

 (d) details of the treatment, service or other matter for which the benefit is paid or payable;

 (e) if the benefit is a casemix episodic payment, within the meaning of subsection 73BD (4) of the Act—that fact.

1.5 Information to be given to Council

 A registered health benefits organisation must draw from its records, and give to the Council, the following information:

 (a) all of the information mentioned in section 1.4, in the form indicated in the quarterly return;

 (b) any statistical calculations and analyses requested by the Council.

1.6 When information is to be given to Council

(1) The information mentioned in paragraph 1.5 (a) is to be drawn from records quarterly and given to the Council within 4 weeks after the end of the quarter to which the information relates.

(2) In this section, quarter means the period of 3 months ending on 31 March, 30 June, 30 September or 31 December in a year.

1.7 Form in which information is to be given

(1) The information mentioned in paragraph 1.5 (a) is to be given to the Council as electronic data, and as a printed record, in the form set out in the quarterly return.

(2) The printed record of a quarterly return must be certified, in writing, to be true and correct in the information given (if that is the case) by the public officer of the registered organisation (within the meaning of section 74 of the Act).

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 Schedule  Section 1.3

PHIAC QUARTERLY RETURN

Part 1—Instructions

Division 1—Introductory

1.1 Purpose of Part

 This Part sets out information about how a quarterly return is to be prepared and presented for acceptance by the Council.

Division 2—Electronic data

2.1 Electronic format

(1) The electronic format of a quarterly return may be any format acceptable to the Council.

 Note At the time of making this Determination, PHIAC is able to accept returns created in DOS, Windows or Macintosh OS and can accept data set out on spreadsheets using Lotus (wk3 format) or Excel (any version).  On request, PHIAC will supply a diskette appropriately formatted and including various acceptable spreadsheets.

(2) A return is to be presented as an unaccompanied worksheet, and must not be coupled to any other worksheet (for example, as a workbook).

2.2 Electronic medium

 Electronic data must be provided to the Council on a 3.5 floppy diskette or by electronic mail.

Division 3—Content of return

3.1 Returns to be given on State by State basis

(1) A return for a fund is to include information relating only to 1 State (that is, relating to members whose residence, or principal place of residence, is in the same State).

(2) However, if the number of members resident in a particular State is fewer than 500 single equivalent units, information relating to those members must be included in a return relating to the State in which the largest number of members reside.

(3) Subitem (2) does not apply to a return relating to a State that, having been the State of residence for 500 single equivalent units or more, becomes the State of residence for fewer than 500, unless, at the end of 4 succeeding return periods, the membership in the State remains less than 500.

(4) For subitems (2) and (3), a single equivalent unit is any of the following members:

 (a) for a single membership—the contributor;

 (b) for a couples membership—both members of the couple;

 (c) for a single parent membership—the single parent and one other member only;

 (d) for a family membership—2 members only.

(5) In this item:

 (a) the Northern Territory is taken to be a State; and

 (b) the Australian Capital Territory is taken to be part of New South Wales.

3.2 Information about members

 Information about members of a fund that is to be given in a return is affected by the following rules:

 (a) total hospital membership means all contributors to a table of the fund that provides benefits for hospital accommodation, and dependants of those contributors;

 (b) exclusionary tables, for hospital benefits payable by a fund, means tables under which benefits for certain treatments cannot be claimed;

 (c) non-exclusionary tables, for hospital benefits payable by a fund, means all tables other than exclusionary tables, and include a table for treatment at a particular hospital, or hospitals, if the table provides benefits for all treatments;

 (d) family membership means insurance actually covering an adult couple and a dependant, or dependants, of the couple;

 (e) single parent membership means insurance actually covering an adult and a dependant, or dependants, of the adult;

 (f) couples membership means insurance actually covering 2 adults without a dependant;

 (g) hospital membership change during the quarter means the difference (if any) between the total number of members in a category of membership (within the meaning of these rules) of a fund at the beginning of a quarter and at the end of the quarter;

 (h) medical membership means insurance that provides for the cost gap for medical treatment after a payment by Medicare, but does not include in its coverage any hospital treatment (within the meaning of section 67 of the Act).

3.3 Information about benefits

 Information about benefits paid, or payable, by a fund that is to be given in a return is affected by the following rules:

 (a) episode, has the same meaning as in the Hospital Casemix Protocol mentioned in paragraph 73BD (2) (c) of the Act, namely, the period between admission and separation that a person spends in 1 hospital, and includes leave periods not exceeding 7 days;

 (b) except as mentioned in paragraph (d), an episode is to be included in the return only if it is complete (that is, the fund member concerned has separated from the hospital);

 (c) the number of days comprising an episode, for the purpose of the return, is all the days in the episode, including days for which no benefit is paid or payable, but not including leave days;

 (d) benefits paid for part of an episode that is not complete (because of an interim billing arrangement) are to be included in the return, together with information about the number of days to which the benefits relate;

 (e) schedule fee has the meaning given in subsection 8 (1A) of the Health Insurance Act 1973;

 (f) amounts entered as benefits paid are to be entered as whole dollar amounts only.

3.4 Information about age of beneficiaries

 Information about the age of persons for whom a benefit is paid by a health benefits fund must be given for all such persons under all tables of the fund.

Part 2—Form PHIAC 1