Commonwealth Coat of Arms of Australia

 

Private Health Insurance (Health Benefits Fund Policy) Rules 2025

I, Paul McBride, delegate of the Minister for Health and Ageing, make the following rules.

Dated, 30 July 2025 

 

 

 

 

 

 

Part 1  Preliminary............................................1

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

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

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

4  Definitions...............................................1

5  Schedules................................................1

Part 2  Meaning of health-related business..............................2

6  Overseas treatment...........................................2

7  Agency business............................................2

Part 3  Risk equalisation jurisdictions.................................3

8  Areas that are risk equalisation jurisdictions............................3

Part 4  Operation of health-related businesses through health benefits funds..........3

9  Insurance for overseas students or specified temporary visa holders..............3

Schedule 1—Repeals 5

Private Health Insurance (Health Benefits Fund Policy) Rules 2015 5

 

This instrument is the Private Health Insurance (Health Benefits Fund Policy) Rules 2025.

  1.     Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.

 

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1.  The whole of this instrument

The day after this instrument is registered

 

Note:  This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.

  1.     Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.

This instrument is made under the Private Health Insurance Act 2007.

Note: A number of expressions used in this instrument are defined in the Act, including the following:

(a) general treatment;

(b) health benefits fund;

(c) hospital treatment;

(d) medicare benefit;

(e) policy holder;

(f) private health insurer.

In this instrument:

Act means the Private Health Insurance Act 2007.

Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.

 (1) For the purposes of paragraph 131-15 (1) (d) of the Act, the business described in subrule (2) is specified.

 (2) A business of undertaking of liability, by way of insurance, for the provision to a person outside Australia of treatment that is intended to manage a disease, injury or condition, but only when:

  1.     the disease, injury or condition is chronic and permanent; and
  2.     the liability is confined to treatment that would be required routinely, whether or not the person had remained in Australia; and
  3.     the amount of the liability incurred by the insurer for any particular treatment does not exceed the amount of the liability that would be incurred by the insurer for that treatment if it were provided to the person in Australia; and
  4.     the liability does not extend to any treatment administered to a person more than 60 days after the person last departed from Australia.
  1.     For the purposes of paragraph 131-15 (1) (d) of the Act, a business of the offering of goods, services or benefits by a private health insurer under an agency arrangement is specified.
  2.     In this rule agency arrangement means a written arrangement between a person (the agent) and another person (the principal) under which:
    1.     the agent is permitted to act on behalf of the principal to create legal relations between the principal and a third person in transactions to provide goods, services or benefits; and
    2.     the principal assumes liability for the transaction to the third person, including for the provision of the goods, services or benefits; and
    3.     the agent assumes no liability in respect of the transaction, other than to perform its obligations under the arrangement for and on behalf of the principal.

Note: An example of the specified business is a private health insurer offering travel insurance policies under an arrangement with an overseas travel insurance company where the principal assumes the insurable risks under the policy and responsibility for the provision of benefits under the policy, and the private health insurer takes on no such liability, except to duly perform its obligations under the contract or agreement between it and the overseas travel insurance company which establishes the agency arrangement.

 

  1.     For subsection 131-20(1) of the Act, each of the following areas are a risk equalisation jurisdiction:
    1.     the area comprising the Australian Capital Territory, Norfolk Island and New South Wales;
    2.     the Northern Territory;
    3.     Queensland;
    4.     South Australia;
    5.     Tasmania;
    6.      Victoria;
    7.     the area comprising Western Australia, the Territory of Christmas Island and the Territory of Cocos (Keeling) Islands.
  1.     This section applies if a private health insurer has a health benefits fund in respect of its health insurance business and some or all of its health-related businesses.
  2.     For section 131-25 of the Act, requirements are specified in subrule (3) relating to how the insurer must conduct that health-related business.
  3.    The private health insurer must not:
    1.     take or fail to take any action; or
    2.    in making a decision, have regard to or fail to have regard to any matter;

that would result in the insurer improperly discriminating between people who are, or wish to be, insured under an overseas student health insurance contract or specified temporary visa holder health insurance contract of the insurer.

  1.     In this rule, improper discrimination is discrimination that relates to:
    1.     the suffering by a person from a chronic disease, illness or other medical condition or from a disease, illness or medical condition of a particular kind; or
    2.     the gender, race, sexual orientation or religious belief of a person; or
    3.     the age of a person; or
    4.     where a person lives; or
    5.     any other characteristic of a person (including but not just matters such as occupation or leisure pursuits) that is likely to result in an increased need for hospital treatment or general treatment; or
    6.      the frequency with which a person needs hospital treatment or general treatment; or
    7.     the amount or extent of the benefits to which a person becomes entitled during a period under an overseas student health insurance contract or a specified temporary visa holder health insurance contract, as the case may be, except to the extent allowed by the written agreement, made between the private health insurer and the Commonwealth, referred to in the definition of overseas student health insurance contract and specified temporary visa holder health insurance contract in the Private Health Insurance (Health Insurance Business) Rules 2018.

 

  1.    In this rule, the following terms have the same meaning as in the Private Health Insurance (Health Insurance Business) Rules 2018:
  1.     overseas student;
  2.    overseas student health insurance contract;
  3.     specified temporary visa holder;  
  4.    specified temporary visa holder health insurance contract.

 

 

1  The whole of the instrument

 

Repeal the instrument.