{"id":"F2025L01429","name":"Health Insurance (prudential standard) determination No. 1 of 2025","slug":"health-insurance-prudential-standard-determination-no-1-of-2025","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":107451,"registerId":"commonwealth-F2025L01429-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Authority","sectionType":"part","heading":"Authority","content":"# Authority\n\n1.  This Prudential Standard is made under subsection 92(1) of the Private Health Insurance (Prudential Supervision) Act 2015 (the Act).","sortOrder":0},{"sectionNumber":"Application and commencement","sectionType":"part","heading":"Application and commencement","content":"# Application and commencement\n\n1.  This Prudential Standard applies to all private health insurers except where expressly noted otherwise.\n2.  A private health insurer must apply this Prudential Standard separately to each of its health benefits funds and its general fund, unless otherwise noted. The term ‘private health insurer’ refers to the private health insurer as a whole. The term ‘fund’ refers to each health benefits fund and the general fund, unless otherwise noted.\n3.  This Prudential Standard applies to private health insurers from 1 January 2026.","sortOrder":1},{"sectionNumber":"Interpretation","sectionType":"part","heading":"Interpretation","content":"# Interpretation\n\n1.  Terms that are defined in Prudential Standard CPS 001 Defined terms appear in bold the first time they are used in this Prudential Standard.","sortOrder":2},{"sectionNumber":"Insurance Risk Charge","sectionType":"part","heading":"Insurance Risk Charge","content":"# Insurance Risk Charge\n\n1.  This Prudential Standard sets out the method for calculating the Insurance Risk Charge.\n2.  The Insurance Risk Charge for each fund is the sum of the Insurance Liability Risk Charge, the Future Exposure Risk Charge and the Deferred Claims Liability Risk Charge.","sortOrder":3},{"sectionNumber":"Insurance Liability Risk Charge","sectionType":"part","heading":"Insurance Liability Risk Charge","content":"# Insurance Liability Risk Charge\n\n1.  The Insurance Liability Risk Charge is the sum of:\n    1.  the Outstanding Claims Risk Charge as defined in paragraphs 10 to 13;\n    2.  the Premiums Liability Risk Charge as defined in paragraphs 14;\n    3.  the Risk Equalisation Risk Charge as defined in paragraphs 15 and 16; and\n    4.  the Other Insurance Liabilities Risk Charge as defined in paragraphs 17 and 18.\n2.  The Insurance Liability Risk Charge applies to the private health insurer’s health insurance business (HIB) as well as its health-related insurance business (HRIB).","sortOrder":4},{"sectionNumber":"Outstanding Claims Risk Charge","sectionType":"division","heading":"Outstanding Claims Risk Charge","content":"### Outstanding Claims Risk Charge\n\n1.  The Outstanding Claims Risk Charge relates to the risk that the value of the outstanding claims liabilities will be greater than the value determined in accordance with Prudential Standard HPS 340 Insurance Liability Valuation (HPS 340).\n2.  The risk charge is calculated by multiplying the outstanding claims liabilities[\\[1\\]](#_ftn1) excluding claims settled but not yet paid by the Outstanding claims risk size margin defined in paragraph 13.\n3.  The outstanding claims of both HIB and HRIB are subject to the risk margin defined in paragraph 13.\n4.  The Outstanding claims risk size margin of a fund is calculated as:\n\n![The minimum of 1.03 times bracket hospital treatment single equivalent units close bracket to the power of negative 0.16 comma 0.34](image.003.png)","sortOrder":5},{"sectionNumber":"Premiums Liability Risk Charge","sectionType":"division","heading":"Premiums Liability Risk Charge","content":"### Premiums Liability Risk Charge\n\n1.  The Premiums Liability Risk Charge relates to the risk that the value of the premiums liabilities will be greater than the value determined in accordance with HPS 340. The Premiums Liability Risk Charge is calculated as:\n\n![PLCR subscript HIB plus PLRC subscript HRIB](image.004.png)\n\nWhere:\n\n1.  PLRCHIB is the Premiums Liability Risk Charge of the health insurance business and is calculated as:\n\n![PL subscript HIB times HIB stress percent](image.005.png)\n\nWhere:\n\n1.  PLHIB is the health insurance business premiums liabilities determined in accordance with HPS 340.\n2.  HIB Stress % is defined in paragraph 14 (c)\n\n1.  PLRCHRIB is the Premiums Liability Risk Charge of the health-related insurance business and is calculated as:\n\n![LHHRIB times HRIB stress percent](image.006.png)\n\nWhere:\n\n1.  PLHRIB is the health-related insurance business premiums liabilities determined in accordance with HPS 340.\n2.  HRIB Stress % is as defined in paragraph 14 (d).\n\n1.  ![HIB stress percent equal size stress plus additional uncertainty stress](image.007.png)\n\nWhere:\n\n1.  ![size stress equals 22.1 percent minus 1.2 percent times log bracket hospital treatment SEUs at the reporting date close bracket](image.008.png)\n2.  ![additional uncertainty stress equals 33 percent times open bracket min open bracket max open bracket growth at time t comma growth at time t minus 1 comma growth at time t minus 2 comma 2.5 percent close bracket minus 2.5 percent comma 15 percent close bracket close bracket.](image.009.png)\n\nWhere:\n\ngrowtht = HT SEU increase over last 12 months divided by HT SEUs at the reporting date.\n\ngrowtht-1 \\= HT SEU increase over prior 12 months (12-24 months) divided by HT SEUs at the reporting date.\n\ngrowtht-2 \\= HT SEU increase over prior 12 months (24-36 months) divided by HT SEUs at the reporting date.\n\nWhere a merger has occurred since t-2, growth is to be calculated on the total HT SEU’s for the merged private health insurers, such that only organic growth is captured.\n\n1.  ![HRIB stress percent equals 37.9 percent minus 1.2 percent times log open bracket dollar value of health-related insurance business accrued premium for the 12 months ending on the reporting date close bracket](image.010.png)\n\n###","sortOrder":6},{"sectionNumber":"Risk Equalisation Risk Charge","sectionType":"division","heading":"Risk Equalisation Risk Charge","content":"### Risk Equalisation Risk Charge\n\n1.  The Risk Equalisation Risk Charge relates to the risk that the value of risk equalisation transfers are less favourable than the value determined in accordance with HPS 340.\n2.  The risk equalisation risk charge is calculated as:\n\n![4 percent times unbilled calculated deficit](image.011.png)\n\nWhere:\n\nUnbilled calculated deficit means total amount that would have been payable by the insurer should each SEU been entitled to the average amount as defined in rule 11(1)(e) of the Private Health Insurance (Risk Equalisation Policy) Rules 2015 or its replacement, and under the following conditions:\n\n1.  over the period up to the reporting date;\n2.  where the risk equalisation levy has accrued but has not yet been paid; and\n3.  where an invoice, notice or receipt from APRA has not yet been received by the private health insurer, for that period.","sortOrder":7},{"sectionNumber":"Other Insurance Liabilities Risk Charge","sectionType":"division","heading":"Other Insurance Liabilities Risk Charge","content":"### Other Insurance Liabilities Risk Charge\n\n1.  The Other Insurance Liabilities Risk Charge relates to the risk that the value of other insurance liabilities will be greater than the value determined in accordance with HPS 340.\n2.  The Other Insurance Liabilities Risk Charge is calculated as:\n\nOther insurance liabilities at 99.5 per cent; less\n\nOther insurance liabilities.\n\nWhere:\n\n1.  Other insurance liabilities at 99.5 per cent is other insurance liabilities as defined by HPS 340 valued at a 99.5 per cent level of sufficiency. This means that, in the assessment of the private health insurer, there is no more than a 0.5 per cent probability that the actual cost will exceed this estimate.\n2.  Other insurance liabilities is the value of other insurance liabilities determined in accordance with HPS 340.","sortOrder":8},{"sectionNumber":"Future Exposure Risk Charge","sectionType":"part","heading":"Future Exposure Risk Charge","content":"# Future Exposure Risk Charge\n\n1.  The Future Exposure Risk Charge (FER) relates to the risk that financial performance of the HIB and HRIB may be materially worse than expected and may require capital to meet policyholder obligations. The FER is calculated as:\n\n![FER subscript HIB plus FER subscript HRIB](image.012.png)\n\nWhere:\n\n1.  FERHIB is the charge for the health insurance business, related to the Adverse Event Stress combined with the Prescribed Benefit Stress.\n2.  FERHRIB is the charge for health-related insurance business, related to the Prescribed Benefit Stress only.\n3.  Both components have a minimum value of zero, so any forecast profits after the stresses cannot be used to offset the charge of any other component.\n\n1.  The FER, for each of HIB and HRIB, is calculated by stressing:\n    1.  Benefits incurred; plus\n    2.  Other business expenses; less\n    3.  Accrued premium.\n\nThis is to be calculated for the 12 months from the reporting date using stressed assumptions as described in paragraphs 22 to 27. This is to be calculated net of any reinsurance arrangements. There is no allowance for investment income or other parts of the business other than discounting as described in paragraphs 34 and 35.\n\n1.  The stressed assumptions may be adjusted for Management Actions as defined in paragraphs 28 to 33.","sortOrder":9},{"sectionNumber":"Future Exposure Risk Charge — Health Ins","sectionType":"part","heading":"Future Exposure Risk Charge — Health Insurance Business","content":"# Future Exposure Risk Charge – Health Insurance Business\n\n1.  The Future Exposure Risk Charge for Health Insurance Business (FERHIB) is calculated as the losses occurring over the 12-months from the reporting date due to the combined Adverse Event Stress and the Prescribed Benefit Stress.","sortOrder":10},{"sectionNumber":"Adverse Event Stress","sectionType":"division","heading":"Adverse Event Stress","content":"### Adverse Event Stress\n\n1.  The Adverse Event Stress quantifies the impact of an industry lapse scenario. This stress is focused on the lapse of younger policy holders resulting in an adverse event on the insurer.\n2.  The Adverse Event Stress is based on the following parameters:\n    1.  25% of all policies where the policyholder is aged under 65 years of age lapse immediately. Where the lapsing policies provide insurance for multiple people, all insured persons within these policies also lapse immediately;\n    2.  the accrued premium and claims incurred of those who lapse are the average for their age cohort. This is to be applied equally across all states, scales, products and across hospital and general treatment. This does not focus on any particular cohort other than age;\n    3.  the calculated deficit per SEU is to be increased by 20%. This reflects the impact on risk equalisation from fewer younger policy holders. The calculated deficit is the average amount payable for each SEU as defined in sub-rule 11(1)(d) of the Private Health Insurance (Risk Equalisation Policy) Rules 2015 or its replacement; and\n    4.  other business expenses are to be reduced only by variable costs which would be lower immediately following the stress. These must reflect the other business expenses of the insurer over the 12-month period without specific management action as defined in paragraphs 28 to 33.","sortOrder":11},{"sectionNumber":"Prescribed Benefit Stress — Health Insur","sectionType":"division","heading":"Prescribed Benefit Stress — Health Insurance Business","content":"### Prescribed Benefit Stress – Health Insurance Business\n\n1.  Prescribed Benefit Stress for HIB is an additional increase in the benefits incurred and other business expenses, as calculated in the Adverse Event Stress, by the HIB Stress % as defined in paragraph 14(c).","sortOrder":12},{"sectionNumber":"Future Exposure Risk Charge — Health-rel","sectionType":"part","heading":"Future Exposure Risk Charge — Health-related Insurance Business","content":"# Future Exposure Risk Charge – Health-related Insurance Business\n\n1.  The Future Exposure Risk Charge for Health-Related Insurance Business (FERHRIB) is calculated as the losses occurring over the 12 months from the reporting date due to the Prescribed Benefits Stress.\n2.  Prescribed Benefit Stress for HRIB is an increase in forecast benefits incurred and other business expenses by the HRIB Stress % as defined in paragraph 14(d).","sortOrder":13},{"sectionNumber":"Management actions","sectionType":"part","heading":"Management actions","content":"# Management actions\n\n1.  When determining the impact of losses from the FER, a private health insurer may make allowance for the actions that it would expect to take in response to the stresses, subject to the restrictions described in paragraphs 29 to 33.\n2.  Management actions may include, but are not limited to:\n    1.  changing coverage;\n    2.  changing other business expenses;\n    3.  closing products; and\n    4.  migrating polices.\n3.  The allowances for management actions must be appropriate and justifiable. Any contractual guarantees must be taken into account in determining the management actions that would be applied.\n4.  Management actions cannot be assumed to occur within nine months of the reporting date. The nine month period must be extended if it is not sufficient time to allow the insurer to identify the event, assess the extent of the change, align to the insurer’s risk appetite, implement the actions and for the actions to take effect.\n5.  Where a private health insurer proposes to change products, the timeframes must include informing an adult insured under each policy about proposed changes a ‘reasonable time before the change takes effect’ as outlined in 93-20 (2) of the PHI Act.\n6.  Following the implementation of any management action, any estimated insurance profits on HIB or HRIB cannot be used to reduce the FER. That is, any insurance profits forecast after management action cannot offset prior losses.","sortOrder":14},{"sectionNumber":"Discounting of the Future Exposure Risk ","sectionType":"part","heading":"Discounting of the Future Exposure Risk Charge","content":"# Discounting of the Future Exposure Risk Charge\n\n1.  The determination of the FER of the fund under this standard may allow for the discounting of future cash flows in accordance with paragraph 35.\n2.  The rates to be used in discounting cash flows relating to the FER are derived from yields of Commonwealth Government Securities (CGS), as at the calculation date, for the relevant duration.","sortOrder":15},{"sectionNumber":"Deferred Claims Liability Risk Charge","sectionType":"part","heading":"Deferred Claims Liability Risk Charge","content":"# Deferred Claims Liability Risk Charge\n\n1.  The Deferred Claims Liability Risk Charge relates to the risk that the value of the deferred claims liability will be greater than the value determined in accordance with HPS 340.\n2.  The Deferred Claims Liability Risk Charge is calculated as:\n\nDeferred claims liability at 99.5 per cent; less\n\nDeferred claims liability; less\n\nDCL aggregation benefit.\n\nWhere:\n\n1.  Deferred claims liability at 99.5 per cent is the deferred claims liability valued at a 99.5 per cent level of sufficiency. This means that, in the assessment of the private health insurer, there is no more than a 0.5 per cent probability that the actual cost will exceed this estimate.\n2.  Deferred claims liability is the value of deferred claims liability determined in accordance with HPS 340.\n3.  DCL aggregation benefit is:\n\n![DCL aggregation benefit equals open bracket D plus O close bracket minus root D squared plus O squared plus 2 times the correlation of D times O.](image.013.png)\n\nWhere:\n\n1.  ‘D’ is the difference between the Deferred claims liability at 99.5 per cent and the Deferred claims liability. It is calculated as:  \n      \n    Deferred claims liability at a 99.5 per cent as defined in paragraph 37(a); less  \n      \n    Deferred claims liability determined in accordance with HPS 340 as defined in paragraph 37(b).\n2.  ‘O’ is the sum of all other components within the Insurance Risk Charge (i.e. the Insurance Liability Risk Charge and FER).\n3.  ‘correlation’ is 20 per cent.","sortOrder":16},{"sectionNumber":"Tax benefits","sectionType":"part","heading":"Tax benefits","content":"# Tax benefits\n\n1.  Each component of the Insurance Risk Charge must not incorporate any tax benefits. Tax benefits may reduce the prescribed capital amount as prescribed in Prudential Standard HPS 110 Capital Adequacy (HPS 110).","sortOrder":17},{"sectionNumber":"Adjustments and exclusions","sectionType":"part","heading":"Adjustments and exclusions","content":"# Adjustments and exclusions\n\n1.  APRA may, by notice in writing to a private health insurer, adjust or exclude a specific requirement in this Prudential Standard in relation to that private health insurer.","sortOrder":18},{"sectionNumber":"Previous exercise of discretion","sectionType":"part","heading":"Previous exercise of discretion","content":"# Previous exercise of discretion\n\n1.  An exercise of APRA’s discretion (such as an approval, waiver or direction) under a previous version of this Prudential Standard continues to have effect as though exercised pursuant to a corresponding power (if any) exercisable by APRA under this Prudential Standard.","sortOrder":19}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"},"kimi_summary":{"content_quality":"ok","complexity_score":8,"scope_assessment":{"changed":false,"description":"This appears to be a new prudential standard (No. 1 of 2025) made under the existing Private Health Insurance (Prudential Supervision) Act 2015. It consolidates or replaces previous capital adequacy requirements for calculating the Insurance Risk Charge. The scope aligns with the original intent of the Act — ensuring prudential supervision of private health insurers — and does not appear to have expanded beyond the financial safety and capital adequacy framework originally established."},"complexity_factors":["Extensive mathematical formulas with logarithmic functions, nested min/max operations, and statistical confidence intervals (99.5% sufficiency levels)","Multiple nested calculation layers: Insurance Risk Charge splits into three components, which further split into sub-components (e.g., Insurance Liability Risk Charge has 4 sub-parts, each with distinct calculation methods)","Cross-references to at least two other prudential standards (HPS 340 Insurance Liability Valuation and HPS 110 Capital Adequacy) and the Private Health Insurance (Risk Equalisation Policy) Rules 2015","Conditional logic and temporal dependencies: stress calculations depend on growth rates over three time periods (t, t-1, t-2), with special merger-adjustment rules","Defined terms used throughout with specific technical meanings (HIB, HRIB, SEU, HT SEU, etc.) requiring reference to CPS 001 Defined Terms","Complex interaction between components: DCL aggregation benefit formula involves correlation coefficients and square root calculations combining multiple risk charges","Multiple constraints and restrictions on management actions (9-month minimum delay, notification requirements under PHI Act section 93-20)","Dual application requirements: must be applied separately to health benefits funds and general funds, with different stress percentages for HIB vs HRIB"],"plain_english_summary":"Australia's law requires private health insurers (and each fund they run) to hold an extra capital buffer — the Insurance Risk Charge — to cover underestimated claims, worsening business over the next year, and deferred claims. By prescribing a rigorous, stress-tested calculation and allowing regulator adjustments, it aims to keep insurers solvent through shocks (e.g., loss of young members or cost spikes) and protect policyholders. Effective 1 Jan 2026."},"flash_summary":{"complexity_score":7,"scope_assessment":{"changed":false,"description":"The instrument explicitly states its scope: it applies to all private health insurers and must be applied separately to each health benefits fund and the general fund, effective 1 January 2026 (Application and commencement ¶1–3). The text contains no provision that narrows or expands that stated application beyond granting APRA the power to adjust or exclude specific requirements for particular insurers (Adjustments and exclusions ¶1) and preserves prior discretions (Previous exercise of discretion ¶1)."},"complexity_factors":["Multiple interdependent components to compute (Insurance Risk Charge = Insurance Liability Risk Charge + Future Exposure Risk Charge + Deferred Claims Liability Risk Charge) (Insurance Risk Charge; Insurance Liability Risk Charge).","Detailed mathematical formulas including minima, logarithms and non-linear sizing margins for outstanding claims and premiums (Outstanding Claims Risk Charge ¶4; Premiums Liability Risk Charge ¶14 (size stress formula)).","Time-series growth calculations with special treatment for mergers (Premiums Liability Risk Charge ¶14 (growtht, growtht-1, growtht-2)).","Two-layer stress testing: Adverse Event Stress (lapse scenario) and Prescribed Benefit Stress with parametrised percentage impacts and scope differences for HIB and HRIB (Adverse Event Stress; Prescribed Benefit Stress sections).","Permitted management actions subject to timing and justificatory constraints (cannot assume occurrence within 9 months; obligations to inform insureds) and prohibition on offsetting post-action profits against stressed losses (Management actions ¶1–6).","Discounting rules tied to Commonwealth Government Securities yields for relevant durations and limited allowance (Discounting of the Future Exposure Risk Charge ¶1–2).","Aggregation and diversification formula for Deferred Claims Liability with an explicit 20% correlation parameter (Deferred Claims Liability Risk Charge ¶3, DCL aggregation benefit formula).","Regulatory interactions and dependencies: reliance on valuations under HPS 340 and capital rules in HPS 110, 99.5% sufficiency requirement, exclusion of tax benefits, and APRA discretion to adjust or exclude requirements (multiple sections: Insurance Liability Risk Charge; Deferred Claims; Tax benefits; Adjustments and exclusions)."],"plain_english_summary":"**Summary:** Sets the precise formulas insurers must use to calculate the Insurance Risk Charge per fund, covering outstanding claims, premiums liabilities, risk‑equalisation, other insurance liabilities, future exposure and deferred claims, and disallows tax benefits. It applies to all private health insurers and to each health benefits fund and the general fund separately from 1 January 2026. It matters because it determines capital needs, constrains allowable management actions and discounting, and gives APRA power to adjust or exclude requirements."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-prudential-standard-determination-no-1-of-2025","history":"/api/acts/health-insurance-prudential-standard-determination-no-1-of-2025/history","analysis":"/api/acts/health-insurance-prudential-standard-determination-no-1-of-2025/analysis","conflicts":"/api/acts/health-insurance-prudential-standard-determination-no-1-of-2025/conflicts","importantCases":"/api/acts/health-insurance-prudential-standard-determination-no-1-of-2025/important-cases","documents":"/api/acts/health-insurance-prudential-standard-determination-no-1-of-2025/documents"}}