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.

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.

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.

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.

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.

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.

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;

(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:
applicable benefits arrangement
complying health insurance policy

complying health insurance product
cover
dependent child

dependent child non‑student
general treatment
hospital‑substitute treatment
hospital treatment

medicare benefit
policy holder
private health insurer
product subgroup
risk equalisation jurisdiction

rules [of an insurer]
standard information statement

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 (e) 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;

(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) The following costs are excluded from the calculation of net premium in subrule (4):

(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.

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;

(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 ‑ $60.05;

(ii) New South Wales ‑ $60.65;

(iii) Northern Territory ‑ $57.85;

(iv) Queensland ‑ $60.65;

(v) South Australia ‑ $60.65;

(vi) Tasmania ‑ $60.65;

(vii) Victoria ‑ $60.65; and

(viii) Western Australia ‑ $60.65.

(b) in relation to a nursing‑home type patient at a private hospital, $60.65.

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

(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 standard 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

(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;

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.

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

1. Interpretation

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

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

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

Information and form of words for standard information statement—all policies
Item	Information and form of words
1	Policy name The name of the policy.
2	Name of private health insurer The trading or brand name of the private health insurer in the State in which the policy is being made available, together with any associated branding that the insurer elects to include.
3	Disclaimer for restricted access insurers If the policy is offered by a restricted access insurer—the following statement: “Membership of this insurer is restricted to” followed by the details.
4	Contact details A contact phone number and website address of the private health insurer.
5	State/s available in The States in which the product is available, expressed as either: (a) if: (i) the product is offered in all States; and (ii) every feature of the product (including the monthly premium referred to in item 6) is the same in each State; “All States”; or (b) otherwise—the State or States in which the product is available, expressed as whichever of the following is applicable: (i) “NSW & ACT”; (ii) “Northern Territory”; (iii) “Queensland”; (iv) “South Australia”; (v) “Tasmania”; (vi) “Victoria”; (vii) “Western Australia”.
6	Monthly premium The total monthly premium payable before any rebate, loading or discount is applied. The following words must be inserted before or following the premium amount: “before any rebate, loading or discount”. Note: This item does not limit the information that a private health insurer may give to an insured person with regard to the premium payable after any rebate, loading and/or discount is applied.
7	Corporate products If the policy is part of a corporate product—a statement to that effect, indicating either of the following, with the bracketed text replaced with the appropriate information: (a) “Employees/members of [Company/Organisation]”; (b) “Employees/members of organisations with arrangements with this health insurer”.
8	Closed products If the policy is closed so that it is no longer available to anyone except those persons who, at the time of closing, were insured under the policy—the following words: “This policy is closed to new members.”.
9	Who is covered The insured groups that may be covered, expressed as whichever of the following is applicable: (a) “only one person”; (b) “2 adults (and no-one else)”; (c) “2 or more people, none of whom is an adult”; (d) “2 or more people, only one of whom is an adult”; (e) “3 or more people, only 2 of whom are adults”; (f) “3 or more people, at least 3 of whom are adults”. Note 1: The insured groups are set out in rule 5 of these Rules. Note 2: This item does not limit the information that a private health insurer may give to an insured person with regard to the name/s of person/s covered by the policy.
10	Ambulance cover The following information: (a) whether ambulance cover is included; (b) if so: (i) the waiting period (if any); and (ii) whether the cover is: (A) emergency only; or (B) emergency and non‑emergency; and (iii) any limits on cover (dollar amount or service); and (iv) any call-out fees (if applicable); (c) for each State in which: (i) the product is available; and (ii) ambulance cover is not included; the following information: (iii) whether free ambulance services are available in that State; (iv) if so—whether they are limited to services in that State; (d) if ambulance cover were to be provided by a person other than the private health insurer who prepared the statement—whether the policy would provide a benefit for that cover.
11	Date available If, and only if, the policy is not yet available—the date from which the policy will be available.
12	Date statement issued or updated The date on which the content of the statement was issued or updated, in the following format, with the bracketed text replaced with the appropriate information: “Date statement [issued/updated]: [dd]/[month in words]/[yyyy]”
13	Unique identifier The unique identifier for the standard information statement that is generated by the privatehealth.gov.au system.

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

1. Interpretation

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

2. Additional information and form of words—hospital treatment

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

Additional information and form of words—hospital treatment
Item	Additional information and form of words
1	Information relating to policies that are available only with a general treatment policy If the policy is available only with a policy that covers general treatment—whichever of the following is applicable: (a) if the policy may be purchased with any policy that covers general treatment offered by the insurer—the statement “must be purchased with a general treatment policy”; (b) if there is a set range of policies that cover general treatment with which the policy may be combined—the statement “must be purchased with certain general treatment policies”.
2	Whether the policy exempts holders from the Medicare Levy Surcharge Whichever of the following is applicable: (a) “This policy exempts you from the Medicare Levy Surcharge”; (b) “This policy does not exempt you from the Medicare Levy Surcharge”.
3	What’s included and what’s not included in the policy An indication of: (a) treatments that are covered by the policy, consisting of the words: “This policy includes cover for” followed by the relevant treatments; and (b) treatments that are not covered by the policy, consisting of the words: “This policy does not include cover for” followed by the relevant treatments.
4	Restrictions A list of all restrictions (if any) that apply.
5	Waiting periods for new and upgrading members The waiting periods that apply under the policy before a policy holder can claim, expressed either: (a) in the following format, with the bracketed text replaced with the appropriate figures: (i) “[the number of months (up to 2)] months for palliative care, rehabilitation and psychiatric treatments”; (ii) “[the number of months (up to 12)] months for pre‑existing conditions”; (iii) if, and only if, the policy covers pregnancy and birth (obstetrics)—“[the number of months (up to 12)] months for pregnancy and birth (obstetrics)”; (iv) “[the number of months (up to 2)] months for all other treatments”; or (b) if shown in a table—for all treatments covered by the policy, the appropriate figure for the relevant waiting period. Note 1: This item does not limit the information that a private health insurer may provide with regard to an individual’s policy. Note 2: The obstetrics waiting period of up to 12 months does not apply to treatment for neonatal care.
6	Excess Whichever of the following is appropriate: (a) if there is no excess—the words “No excess”; (b) if there is an excess: (i) whichever of the following is appropriate, with the bracketed text replaced with the appropriate figure, and where the dollar amount for excess per admission is the excess for an overnight admission, if this is different from the excess for day surgery: (A) “You will have to pay an excess of $[number] per admission.”; (B) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per year.”; (C) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per year.”; (D) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per person per year.”; (E) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per person and $[number] per policy per year.”; (F) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per person and $[number] per policy per year.”; (G) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per policy per year.”; and (ii) if applicable—“Excess payments do not apply to hospital admissions for accidents, of child dependants, or for day surgery”, with any of “accidents”, “child dependants” and “day surgery” that do not apply deleted, but with the order of those terms otherwise unchanged.
7	Extra cost per day (co‑payments) If there are no co-payments—the statement “No co-payments”. If there are co-payments: (a) the statement “Every time you go to hospital you will have to pay”, followed by (with the bracketed text replaced with the appropriate figures): (i) either: (A) the statement “$[number] per day for overnight admissions”; or (B) the statements:  “$[number] per day for a shared room for overnight admissions”; and  if the policy covers accommodation in a private room—“$[number] per day for a private room for overnight admissions”; and (ii) as applicable, either: (A) the statement “$[number] for day surgery (no overnight stay)”; or (B) the statement “No co-payment for day surgery (no overnight stay)”; and (iii) the statement “– up to $[number] per hospital stay”, placed, if applicable, and if the insurer so chooses, directly after the statements referred to in subparagraph (i); and (b) if applicable—the statement “The maximum co‑payment is $[number] per year” (with the bracketed text replaced with the appropriate figures).
8	Note on out of pocket costs/doctors’ fees The following statement: “Under this policy, you may have to pay out-of-pocket costs above what you get from Medicare or your private health insurer. Before you go to hospital, you should ask your doctors, hospital and health insurer about any out-of-pocket costs that may apply to you.”.
9	Note on information relating to contracts between hospitals and insurers The following statement: “The benefits paid for hospital treatment will depend on the type of cover you purchase and whether your fund has an agreement in place with the hospital in which you are treated. See ‘Agreement Hospitals’ on privatehealth.gov.au for which hospitals have arrangements with your insurer.”.
10	Other features A statement that indicates any other features of the policy that the insurer wishes to draw attention to. The statement must consist of at most 100 words. Example: Benefits for travel or accommodation, or aged‑based or other discounts. Note: This statement (if included) is in addition to the statement (if included) that is referred to in item 9 of Schedule 3.

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

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

1. Interpretation

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

2. Additional information and form of words—general treatment

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

Additional information and form of words—general treatment
Item	Additional information and form of words
1	Information relating to policies that are available only with a hospital policy If the policy is available only with a policy that covers hospital treatment—whichever of the following is applicable: (a) if the policy may be purchased with any policy that covers hospital treatment offered by the insurer—the statement “must be purchased with a hospital policy”; (b) if there is a set range of policies that cover hospital treatment with which the policy may be combined—the statement “must be purchased with certain hospital policies”.
2	Preferred service provider arrangements Whichever of the following is appropriate: (a) if the private health insurer has preferred service provider arrangements—either: (i) a brief outline of the appropriate arrangements; or (ii) the following statement, with the bracketed text replaced with the appropriate text: “By using [insert name of insurer]’s ‘preferred providers’ you may have lower out of pocket costs on [insert services or use “many allied health”] treatments and have access to more ‘no gap’ treatments. A list of ‘preferred providers’ is available from [insert name of insurer].”; (b) otherwise—the following statement, with the bracketed text replaced with the appropriate text: “[Insert name of insurer] does not operate a preferred provider scheme.”.
3	Treatments covered by the policy A complete list of treatments that are covered by the policy, expressed in terms of the following: (a) general dental; (b) major dental; (c) endodontic; (d) orthodontic; (e) optical; (f) non PBS pharmaceuticals; (g) physiotherapy; (h) chiropractic; (i) podiatry; (j) psychology; (k) acupuncture; (l) remedial massage; (m) hearing aids; (n) blood glucose monitors; (o) for any treatment that cannot be classified as any of the above—the name of the treatment. Note: Insurers may cover additional treatments, for example, exercise physiology and occupational therapy.
4	Treatments not covered by the policy A list of treatments that are not covered by the policy, expressed in terms of the treatments listed in item 3.
5	Waiting period (months) For each treatment that is covered by the policy—whichever 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.

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

	o = order(s)
ad = added or inserted	Ord = Ordinance
am = amended	orig = original
amdt = amendment	par = paragraph(s)/subparagraph(s)
c = clause(s)	/sub‑subparagraph(s)
C[x] = Compilation No. x	pres = present
Ch = Chapter(s)	prev = previous
def = definition(s)	(prev…) = previously
Dict = Dictionary	Pt = Part(s)
disallowed = disallowed by Parliament	r = regulation(s)/rule(s)
Div = Division(s)
exp = expires/expired or ceases/ceased to have	reloc = relocated
effect	renum = renumbered
F = Federal Register of Legislation	rep = repealed
gaz = gazette	rs = repealed and substituted
LA = Legislation Act 2003	s = section(s)/subsection(s)
LIA = Legislative Instruments Act 2003	Sch = Schedule(s)
(md) = misdescribed amendment can be given	Sdiv = Subdivision(s)
effect	SLI = Select Legislative Instrument
(md not incorp) = misdescribed amendment	SR = Statutory Rules
cannot be given effect	Sub‑Ch = Sub‑Chapter(s)
mod = modified/modification	SubPt = Subpart(s)
No. = Number(s)	underlining = whole or part not
	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), 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)	—

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 (Sch 1 item 1; Sch 2 item 15; Sch 3 items 1, 1A)
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
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
r 12....................	rs F2018L01414
	am F2018L01414
r 13....................	rs F2018L01414
	am F2018L01414
r 14....................	rs F2018L01414
r 15....................	rep F2018L01414
	ad F2018L01414
r 16....................	rep F2018L01414
	ad F2018L01414
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
Schedule 6
Schedule 6................	ad F2018L01414
c 1.....................	ad F2018L01414
Schedule 7
Schedule 7................	ad F2018L01414
c 1.....................	ad F2018L01414

Part 1 Preliminary

Part 2 General

8A Benefit requirement―nursing‑home type patients

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

Part 4 Pilot Projects

Part 5 Transitional provisions

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

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

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