{"id":"F2007L04273","name":"Private Health Insurance (Benefit Requirements) Rules 2007 (No. 4)","slug":"private-health-insurance-benefit-requirements-rules-2007-no-4","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":70510,"registerId":"commonwealth-F2007L04273-current","compilationNumber":null,"startDate":"2026-04-02","status":"Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Contents","sectionType":"subdivision","heading":"Contents","content":"#### Contents\n\nPart 1 Preliminary\n\n1. Name of Rules\n\n2. Commencement\n\n3. Definitions\n\nPart 2 Minimum benefit requirements\n\n4. Psychiatric care, rehabilitation and palliative care\n\n5. Other hospital treatments\n\nSchedule 1―Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania\n\nSchedule 2―Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia\n\nSchedule 3―Same-day accommodation: hospitals in all States/Territories\n\nSchedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories\n\nSchedule 5―Second-tier default benefits\n\nSchedule 6―Outreach services","sortOrder":0},{"sectionNumber":"1. Name of Rules","sectionType":"part","heading":"1. Name of Rules","content":"# 1. Name of Rules\n\nThese Rules are the Private Health Insurance (Benefit Requirements) Rules 2007 (No. 04).","sortOrder":1},{"sectionNumber":"2. Commencement and Revocation","sectionType":"part","heading":"2. Commencement and Revocation","content":"# 2. Commencement and Revocation\n\n(1) These Rules commence on 1 November 2007.\n\n(2) These rules revoke the Private Health Insurance (Benefit Requirements) Rules 2007(No. 3).","sortOrder":2},{"sectionNumber":"3. Definitions","sectionType":"part","heading":"3. Definitions","content":"# 3. Definitions\n\nIn these Rules:\n\nAct means the Private Health Insurance Act 2007.\n\nACT means the Australian Capital Territory.\n\ncertified Type B procedure means a Type B procedure certified in accordance with clause 10 of Schedule 1.\n\ncertified overnight Type C procedure means a Type C procedure certified in accordance with clause 11 of Schedule 1.\n\ncertified Type C procedure means a Type C procedure certified in accordance with clause 7 of Schedule 3.\n\ncontinuous period of hospitalisation, for the purpose of counting days of hospital treatment, includes any two periods during which a patient was, or is, receiving hospital treatment as a patient at a hospital, whether or not the same hospital, where the periods are separated from each other by a period of not more than 7 days during which the patient was not receiving hospital treatment as a patient at any hospital.\n\ndiagnostic imaging services table means the table prescribed under subsection 4AA (1) of the Health Insurance Act 1973.\n\nfee in the MBS means the Schedule fee as defined in subsection 8 (1A) of the Health Insurance Act 1973.\n\ngeneral medical services table means the table prescribed under subsection 4 (1) of the Health Insurance Act 1973.\n\ninsurer means a private health insurer.\n\nitem has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.\n\nMBS comprises the:\n\n(a) general medical services table;\n\n(b) diagnostic imaging services table; and\n\n(c) pathology services table.\n\nNSW means the State of New South Wales.\n\nnursing-home type patient has the meaning given by Schedule 4.\n\noutreach service means a service referred to in subsection 16 (1) of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007, unless subsection 16 (2) of that Act applies to the particular service.\n\npathology services table means the table prescribed under subsection 4A (1) of the Health Insurance Act 1973.\n\npolicy means a complying health insurance policy.\n\nprivate 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.\n\nNote: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.\n\nprofessional service has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.\n\npublic 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.\n\nNote: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.\n\nType A procedure means:\n\n(a) a procedure specified in clauses 3 to 9 of Schedule 1; or\n\n(b) a certified Type B procedure; or\n\n(c) a certified overnight Type C procedure.\n\nType B procedure means:\n\n(a) a procedure specified in clauses 3 to 7 of Schedule 3 other than a certified Type B procedure; or\n\n(b) a certified Type C procedure.\n\nType C procedure means a procedure specified in clause 8 of Schedule 3 other than a certified Type C procedure.\n\nPart 2 Minimum benefit requirements","sortOrder":3},{"sectionNumber":"4. Psychiatric care, rehabilitation and ","sectionType":"part","heading":"4. Psychiatric care, rehabilitation and palliative care","content":"# 4. Psychiatric care, rehabilitation and palliative care\n\n(1) For item 1 in the table in subsection 72-1 (2) of the Act, the minimum benefit for hospital treatment specified in that item is the amount set out, or worked out using the method for working out the minimum benefit for that treatment, in Schedules 1, 2, 3, 5 or 6 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.\n\nNote: Item 1 in the table in subsection 72-1 (2) of the Act requires that each policy that covers hospital treatment must cover any part of hospital treatment that is psychiatric care, rehabilitation or palliative care if the treatment is provided in a hospital and no medicare benefit is payable for that part of the treatment.\n\n(2) Despite subrule (1), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person's policy in respect of that treatment.","sortOrder":4},{"sectionNumber":"5. Other hospital treatments","sectionType":"part","heading":"5. Other hospital treatments","content":"# 5. Other hospital treatments\n\n(1) For item 5 in the table in subsection 72-1 (2) of the Act, for a policy that covers any type of hospital treatment provided in a hospital, other than treatment referred to in rule 4, the minimum benefit for that treatment is the amount set out, or worked out using the method for working out the minimum benefit, for that treatment in Schedules 1, 2, 3, 4, 5, or 6 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.\n\n(2) Despite subrule (1), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person's policy in respect of that treatment.\n\nSchedule 1―Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania\n\nPart 1―General\n\n1. Circumstances\n\nFor rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is:\n\n(a) provided to a patient who is not a nursing-home type patient; and\n\n(b) provided to a patient:\n\n(i) at a private hospital; or\n\n(ii) as shared ward accommodation at a public hospital in Victoria or Tasmania; and\n\nNote: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.\n\n(c) provided for the purpose of permitting the provision to the patient of hospital treatment that is:\n\n(i) a Type A procedure; and\n\n(ii) for a period that includes part of an overnight stay.\n\nNote: A Type A procedure is defined to include a certified Type B procedure and a certified overnight Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.\n\n2. Minimum benefit\n\n(1) The minimum benefit for hospital treatment provided in the circumstances specified in this Schedule is the amount set out in the tables in this Schedule for that hospital treatment.\n\n(2) When counting the days referred to in the tables in this Schedule to determine the minimum benefit in respect of any particular patient, days forming part of a continuous period of hospitalisation are to be counted.\n\nTable 1―Accommodation at private hospitals in all States/Territories\n\n| Class of patient | Minimum benefit payable per night |\n| ------------------------------------- | --------------------------------- |\n| Advanced surgical patient | |\n| - first 14 days | $333 |\n| - over 14 days | $231 |\n| Surgical patient or obstetric patient | |\n| - first 14 days | $308 |\n| - over 14 days | $231 |\n| Psychiatric patient | |\n| - first 42 days | $308 |\n| - 43 – 65 days | $268 |\n| - over 65 days | $231 |\n| Rehabilitation patient | |\n| - first 49 days | $308 |\n| - 50 - 65 days | $268 |\n| - over 65 days | $231 |\n| Other patients | |\n| - first 14 days | $268 |\n| - over 14 days | $231 |\n\nTable 2― Victoria: shared ward accommodation at a public hospital\n\n| Class of patient | Minimum benefit payable per night |\n| ------------------------------------- | --------------------------------- |\n| Advanced surgical patient | |\n| - first 14 days | $333 |\n| - over 14 days | $231 |\n| Surgical patient or obstetric patient | |\n| - first 14 days | $308 |\n| - over 14 days | $231 |\n| Psychiatric | |\n| - first 42 days | $308 |\n| - 43 – 65 days | $268 |\n| - over 65 days | $231 |\n| Rehabilitation patient | |\n| - first 49 days | $308 |\n| - 50 – 65 days | $268 |\n| - over 65 days | $231 |\n| Other patients | |\n| - first 14 days | $268 |\n| - over 14 days | $231 |\n\nTable 3―Tasmania: shared ward accommodation at a public hospital\n\n| Class of patient | Minimum benefit payable per night |\n| ------------------------------------- | --------------------------------- |\n| Advanced surgical patient | |\n| - first 14 days | $333 |\n| - over 14 days | $231 |\n| Surgical patient or obstetric patient | |\n| - first 14 days | $308 |\n| - over 14 days | $231 |\n| Psychiatric patient | |\n| - first 42 days | $308 |\n| - 43 – 65 days | $268 |\n| - over 65 days | $231 |\n| Rehabilitation patient | |\n| - first 49 days | $308 |\n| - 50 – 65 days | $268 |\n| - over 65 days | $231 |\n| Other patients | |\n| - first 14 days | $268 |\n| - over 14 days | $231 |","sortOrder":5},{"sectionNumber":"Category 1 — attendances","sectionType":"section","heading":"Category 1 — attendances","content":"###### Category 1 – attendances\n\nA1:\n\n1 2 3 4 13 19 20 23 24 25 33 35 36 37 38 40 43 44 47 48 50 51 601 602\n\nA2:\n\n52 53 54 57 58 59 60 65 81 83 84 86 87 89 90 91 92 93 95 96 97 98 697 698\n\nA3:\n\n104 105 106 107 108 109\n\nA4:\n\n110 116 119 122 128 131 132 133\n\nA28:\n\n141 143 145 147\n\nA5:\n\n160 161 162 163 164\n\nA6:\n\n170 171 172\n\nA7:\n\n173 193 195 197 199\n\nA8:\n\n291 293 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 322 324 326 328 330 332 334 336 338 342 344 346 348 350 352 353 355 356 357 358 359 361 364 366 367 369 370\n\nA9:\n\n10801 10802 10803 10804 10805 10806 10807 10808 10809 10816\n\nA12:\n\n385 386 387 388\n\nA13:\n\n410 411 412 413 414 415 416 417\n\nA14:\n\n700 702 704 708 706 710 712 714 716 717 718 719\n\nA15:\n\n721 723 725 727 729 731 734 736 738 740 742 744 759 762 765 768 771 773 775 778 779 820 822 823 825 826 828 855 857 858\n\nA16:\n\n444 445 446 447 448 449\n\nA17:\n\n900 903\n\nA18:\n\n2497 2501 2503 2504 2506 2507 2509 2517 2518 2521 2522 2525 2526 2546 2547 2552 2553 2558 2559\n\nA19:\n\n2598 2600 2603 2606 2610 2613 2616 2620 2622 2624 2630 2631 2633 2635 2664 2666 2668 2673 2675 2677\n\nA20:\n\n2710 2712 2713 2721 2723 2725 2727\n\nA21:\n\n501 503 507 511 515 519 520 530 532 534 536\n\nA22:\n\n5000 5003 5007 5010 5020 5023 5026 5028 5040 5043 5046 5049 5060 5063 5064 5067\n\nA23:\n\n5200 5203 5207 5208 5220 5223 5227 5228 5240 5243 5247 5248 5260 5263 5265 5267\n\nA24\n\n2801 2806 2814 2824 2832 2840 2946 2949 2954 2958 2972 2974 3005 3010 3014 3018 3023 3028 3032 3040 3044 3051 3055 3062\n\nA25:\n\n5906 5908 5910 5912\n\nA26:\n\n6007 6009 6011 6013 6015\n\nA27:\n\n4001\n\nM3:\n\n10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970\n\nM4:\n\n10975 10976 10977\n\nM5:\n\n10988 10989\n\nM2:\n\n10993 10994 10995 10996 10997 10998 10999","sortOrder":6},{"sectionNumber":"Category 2 — diagnostic procedures & inv","sectionType":"section","heading":"Category 2 — diagnostic procedures & investigations","content":"###### Category 2 – diagnostic procedures & investigations\n\nD1:\n\n11000 11003 11006 11009 11012 11015 11018 11024 11027 11200 11203 11204 11205 11210 11211 11212 11215 11218 11221 11222 11224 11225 11235 11237 11240 11241 11242 11243 11300 11306 11309 11312 11315 11318 11321 11324 11327 11332 11333 11336 11339 11500 11503 11506 11509 11512 11602 11604 11605 11610 11611 11612 11614 11615 11700 11701 11702 11708 11709 11710 11711 11712 11713 11715 11718 11721 11722 11724 11727 11800 11810 11820 11830 11833 11900 11903 11906 11909 11912 11915 11917 11919 11921 12000 12003 12012 12015 12018 12021 12200 12201 12306 12309 12312 12315 12318 12321 12323\n\nD2:\n\n12500 12503 12506 12509 12512 12515 12518 12521 12524 12527 12530 12533","sortOrder":7},{"sectionNumber":"Category 3 — therapeutic procedures","sectionType":"section","heading":"Category 3 — therapeutic procedures","content":"###### Category 3 – therapeutic procedures\n\nT1:\n\n13104 13200 13203 13206 13209 13221 13290 13312 13709 13760 13839 13842 13939 13942 13945 14050 14053 14100 14106 14109 14112 14115 14118 14124 14200 14203 14206 14209 14215 14221 14227 14245\n\nT2:\n\n15000 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 15500 15503 15506 15509 15512 15515 15518 15521 15524 15527 15530 15533 15550 15553 15556 15559 15562\n\nT3:\n\n16003 16006 16009 16012 16015 16018\n\nT4:\n\n16400 16500 16514 16600\n\nT6:\n\n17610 17615 17620 17625 17640 17645 17650 17655 17680 17690\n\nT7:\n\n18213 18350 18351 18352 18354 18356 18358 18360 18362 18364 18366 18368 18370 18371 18372 18373\n\nT8:\n\n30003 30006 30026 30032 30038 30061 30062 30064 30071 30097 30185 30186 30192 30195 30196 30202 30203 30205 30207 30213 30214 30216 30219 30628 31200 31205 31210 31215 31220 32072 32115 32132 32135 32142 32500 32501 35502 35503 35554 35608 35614 35620 36800 37041 37218 37300 37303 37415 38800 39115 40862 41500 41659 41662 41698 41704 41755 41828 41846 42587 42614 42615 42617 42620 42644 42650 42667 42668 42676 42677 42744 42782 42783 42785 42786 42788 42789 42791 42792 42794 42797 42806 42807 42808 42809 42811 45021 45025 45026 45546 45799 45801 45805 45807 45829 45847 45851 45882 47471 47735 47904 47912 47916 47924 50124 50125","sortOrder":8},{"sectionNumber":"Category 4 — oral and maxillofacial","sectionType":"section","heading":"Category 4 — oral and maxillofacial","content":"###### Category 4 – oral and maxillofacial\n\nO1:\n\n51700 51703\n\nO3:\n\n52034 52036 52039 52055 52056 52133\n\nO7:\n\n53000 53004 53052\n\nO9:\n\n53458\n\nO10:\n\n53600\n\nItems in the diagnostic imaging services table\n\nThe following items are items in the diagnostic imaging services table.","sortOrder":9},{"sectionNumber":"Category 5","sectionType":"section","heading":"Category 5","content":"###### Category 5\n\nI1:\n\n55028 55029 55030 55031 55032 55033 55036 55037 55038 55039 55044 55045 55048 55049 55054 55070 55073 55076 55079, 55113 55114 55115 55116 55117 55238 55244 55246 55248 55252 55274 55276 55278 55280 55282 55284 55292 55294 55296 55700 55703 55704 55705 55706 55707 55708 55709 55712 55715 55718 55721 55723 55725 55729 55731 55733 55736 55739 55812 55814 55816 55818 55820 55822 55824 55826 55828 55830 55832 55834 55836 55838 55840 55842 55844 55846 55852 55854\n\nI2:\n\n56001 56007 56010 56013 56016 56022 56028 56030 56036 56041 56047 56050 56053 56056 56062 56068 56070 56076 56101 56107 56141 56147 56220 56221 56223 56224 56225 56226 56227 56228 56229 56230 56231 56232 56233 56234 56235 56236 56237 56238 56239 56240 56259 56301 56307 56341 56347 56401 56407 56409 56412 56441 56447 56449 56501 56507 56541 56547 56552 56554 56619 56625 56659 56665 56801 56807 56841 56847 57001 57007 57041 57047 57201 57247 57341 57345 57350 57355\n\nI3:\n\n57506 57509 57512 57515 57518 57521 57524 57527 57700 57703 57706 57709 57712 57715 57721 57901 57902 57903 57906 57909 57912 57915 57918 57921 57924 57927 57930 57933 57939 57942 57945 57960, 57963 57966 57969 58100 58103 58106 58108 58109 58112 58115 58300 58306 58500 58503 58506 58509 58521 58524 58527 58700 58706 58715 58718 58721 58900 58903 58909 58912 58915 58916 58921 58924 58927 58933 58936 59103 59300 59303 59306 59309 59312 59314 59318 59503 59700 59703 59712 59715 59718 59724 59733 59736 59739 59751 59754 59760 59763 60100 60500 60503 60918 60927\n\nI4:\n\n61302 61303 61306 61307 61310 61313 61314 61316 61317 61320 61328 61340 61348 61352 61353 61356 61360 61361 61364 61368 61372 61373 61376 61381 61383 61384 61386 61387 61389 61390 61393 61397 61401 61402 61405 61409 61413 61417 61421 61425 61426 61429 61430 61433 61434 61437 61438 61441 61442 61445 61446 61449 61450 61453 61454 61457 61458 61462 61465 61469 61473 61480 61484 61485 61495 61499 61505","sortOrder":10},{"sectionNumber":"Magnetic resonance imaging","sectionType":"section","heading":"Magnetic resonance imaging","content":"###### Magnetic resonance imaging\n\nI5:\n\n63001 63004 63007 63010 63040 63043 63046 63049 63052 63055 63058 63061 63064 63067 63070 63073 63101 63111 63114 63125 63128 63131 63151 63154 63161 63164 63167 63170 63173 63176 63179 63182 63185 63201 63204 63219 63222 63225 63228 63231 63234 63237 63240 63243 63271 63274 63277 63280 63301 63304 63307 63322 63325 63328 63331 63334 63337 63340 63361 63385 63388 63391 63401 63404 63416 63425 63428 63440 63443 63446 63461 63470 63473 63491 63494 63497\n\nItems in the pathology services table\n\nThe following items are items in the pathology services table.\n\nP1:\n\n65060 65066 65070 65072 65075 65078 65079 65081 65082 65084 65087 65090 65093 65096 65099 65102 65105 65108 65109 65110 65111 65114 65117 65120 65123 65126 65129 65137 65139 65140 65142 65144 65147 65150 65153 65156 65157 65158 65159 65162 65165 65166 65171 65175 65176 65177 65178 65179 65180 65181\n\nP2:\n\n66500 66503 66506 66509 66512 66515 66517 66518 66519 66536 66539 66542 66545 66548 66551 66554 66557 66560 66563 66566 66569 66572 66575 66578 66581 66584 66587 66590 66593 66596 66599 66602 66605 66606 66608 66609 66623 66626 66629 66632 66635 66638 66639 66641 66642 66644 66647 66650 66651 66652 66653 66655 66656 66659 66662 66663 66665 66666 66667 66671 66674 66677 66680 66683 66686 66695 66696 66697 66698 66701 66704 66707 66710 66711 66712 66714 66715 66716 66719 66722 66723 66724 66725 66728 66731 66734 66743 66749 66750 66751 66752 66755 66756 66757 66758 66761 66764 66767 66770 66773 66776 66779 66780 66782 66783 66785 66788 66789 66790 66791 66792 66800 66803 66804 66805 66806 66812 66815 66816 66817 66819 66820 66821 66822 66825 66826 66827 66828 66830\n\nP3:\n\n69300 69303 69306 69309 69312 69316 69317 69318 69319 69321 69324 69325 69327 69328 69330 69331 69333 69336 69339 69345 69354 69357 69360 69363 69379 69383 69384 69387 69390 69393 69396 69399 69400 69401 69405 69408 69411 69413 69418 69419 69445 69451 69471 69472 69474 69475 69478 69481 69482 69483 69484 69488 69489 69491 69492 69494 69495 69496 69497 69498 69499 69500\n\nP4:\n\n71057 71058 71059 71060 71062 71064 71066 71068 71069 71071 71072 71073 71074 71075 71076 71077 71079 71081 71083 71085 71087 71089 71090 71091 71092 71093 71095 71096 71097 71099 71101 71103 71106 71119 71121 71123 71125 71127 71129 71131 71133 71134 71135 71137 71139 71141 71143 71145 71146 71147 71148 71149 71151 71153 71154 71155 71156 71157 71159 71163 71164 71165 71166 71167 71168 71169 71170 71180 71183 71186 71189 71192 71195 71198 71200 71203\n\nP5:\n\n72813 72816 72817 72818 72823 72824 72825 72826 72830 72836 72838 72844 72846 72847 72848 72851 72852 72855 72856 72857\n\nP6:\n\n73043 73045 73047 73049 73051 73053 73055 73057 73059 73060 73061\n\nP7:\n\n73287 73289 73300 73305 73308 73309 73311 73312 73314 73315 73317 73318 73320 73321 73323\n\nP8:\n\n73521 73523 73525 73527 73529\n\nP9:\n\n73801 73802 73803 73804 73805 73806 73807 73808 73809 73810 73811\n\nP10:\n\n73922 73923 73924 73925 73926 73927 73928 73929 73930 73931 73932 73933 73934 73935 73936 73937 73938 73939\n\nP11:\n\n73940\n\nCategory 8 – services provided by nurses, allied and dental health professionals\n\nThe following items are items in the general medical services table.\n\nM6:\n\n80000 80005 80010 80015 80020\n\nM7:\n\n80100 80105 80110 80115 80120 80125 80130 80135 80140 80145 80150 80155 80160 80165 80170\n\nM8:\n\n81000 81005 81010.\n\nM9\n\n81100 81105 81110 81115 81120 81125\n\nCategory 9 – services provided by eligible dentists\n\nThe following items are in the dental services table\n\nN1:\n\n85011 85012 85013 85022 85025 85031 85037 85039 85047 85051\n\n85071 85111 85113 85114 85115 85117 85121 85123 85131 85141\n\n85161 85165 85171 85213 85221 85222 85225 85231 85232 85233\n\n85234 85238 85241 85245 85311 85314 85316 85322 85323 85324\n\n85326 85331 85337 85338 85341 85377 85378 85381 85384 85386\n\n85387 85391 85392 85411 85412 85414 85415 85416 85417 85418\n\n85419 85431 85432 85433 85434 85436 85437 85438 85445 85451\n\n85452 85453 85455 85457 85458 85511 85512 85513 85514 85515\n\n85521 85522 85523 85524 85525 85531 85532 85533 85534 85535\n\n85541 85542 85543 85544 85545 85551 85552 85553 85554 85555\n\n85572 85574 85575 85576 85577 85578 85595 85596 85597 85613\n\n85615 85618 85625 85627 85629 85631 85632 85642 85643 85644\n\n85645 85649 85651 85652 85653 85655 85656 85658 85659 85661\n\n85669 85671 85672 85673 85711 85712 85716 85719 85721 85722\n\n85727 85728 85731 85732 85733 85735 85736 85737 85738 85739\n\n85741 85743 85744 85745 85746 85751 85752 85753 85761 85762\n\n85763 85764 85765 85767 85768 85769 85771 85772 85773 85776\n\n85777 85811 85821 85823 85829 85831 85911 85926 85927 85949\n\n85963 85964 85965 85966 85968 85971 85972 85981 85986\n\nN2:\n\n86012 86013 86014 86015 86022 86025 86031 86035 86036 86037\n\n86038 86039 86047 86051 86071 86082 86111 86113 86114 86115\n\n86117 86121 86123 86131 86141 86161 86165 86171 86213 86221\n\n86222 86225 86231 86232 86233 86234 86235 86236 86237 86238\n\n86241 86245 86311 86314 86316 86322 86323 86324 86326 86331\n\n86332 86337 86338 86341 86343 86344 86345 86371 86373 86375\n\n86376 86377 86378 86379 86381 86382 86384 86385 86386 86387\n\n86388 86389 86391 86392 86393 86394 86395 86411 86412 86414\n\n86415 86416 86417 86418 86419 86431 86432 86433 86434 86436\n\n86437 86438 86445 86451 86452 86453 86455 86457 86458 86511\n\n86512 86513 86514 86515 86521 86522 86523 86524 86525 86531\n\n86532 86533 86534 86535 86541 86542 86543 86544 86545 86551\n\n86552 86553 86554 86555 86572 86574 86575 86576 86577 86578\n\n86595 86596 86597 86613 86615 86618 86625 86627 86629 86631\n\n86632 86642 86643 86644 86645 86649 86651 86652 86653 86655\n\n86656 86658 86659 86661 86663 86664 86666 86669 86671 86672\n\n86673 86679 86684 86688 86691 86711 86712 86716 86719 86721\n\n86722 86727 86728 86731 86732 86733 86735 86736 86737 86738\n\n86739 86741 86743 86744 86745 86746 86751 86752 86753 86761\n\n86762 86763 86764 86765 86767 86768 86769 86771 86772 86773\n\n86776 86777 86811 86821 86823 86829 86831 86862 86911 86926\n\n86927 86949 86963 86964 86965 86966 86968 86971 86972 86981\n\n86986\n\nN3:\n\n87011 87014 87071 87711 87712 87716 87719 87721 87722 87727\n\n87728 87731 87732 87733 87736 87737 87738 87739 87741 87743\n\n87744 87745 87746 87751 87752 87753 87761 87762 87763 87764\n\n87765 87767 87768 87769 87771 87776 87777\n\nSchedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories\n\n1. Circumstances\n\n(1) For rule 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided:\n\n(a) to a nursing-home type patient; and\n\n(b) at a hospital.\n\nNote: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.\n\n2. Interpretation\n\nNursing-home type patient, in relation to a hospital, means a patient who has been provided with hospital treatment whether:\n\n(a) acute care; or\n\n(b) accommodation and nursing care, as an end in itself; or\n\n(c) a mixture of both,\n\nfor a continuous period of hospitalisation exceeding 35 days (35-day period), but a patient receiving acute care immediately after the 35-day period does not become a nursing-home type patient unless the period of acute care ends and the patient is then provided with accommodation and nursing care, as an end in itself, as part of a continuous period of hospitalisation.\n\nNote 1: 'Continuous period of hospitalisation' is defined in rule 3 of Part 1 of these Rules.\n\nNote 2: Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.\n\nNote 3: If there is disagreement as to whether a patient is, or is not, a nursing‑home type patient, an insured person, a private health insurer or a health care provider may make a complaint to the Private Health Insurance Ombudsman under Part 6-2 of the Act. The Ombudsman has various powers to deal with complaints, including conducting mediation if the complainant agrees.\n\n3. Application\n\n(1) Clause 2 of this Schedule applies to a patient who on or after the day on which the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) commence:\n\n(a) returns to hospital for hospital treatment at a hospital not later than 7 days after receiving hospital treatment at that hospital or another hospital; or\n\n(b) is otherwise admitted to a hospital for hospital treatment at the hospital.\n\n(2) If subclause (1) does not apply to a patient, the definition of 'nursing‑home type patient' in these Rules before the commencement of the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) continues to apply to that patient.\n\nNote: Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.\n\n4. Provision of acute care\n\nIf a nursing-home type patient is provided with acute care at the hospital (the first hospital), or at another hospital, the patient:\n\n(a) ceases to be a nursing‑home type patient only for the days on which the\n\nacute care is provided; and\n\n(b) again becomes a nursing‑home type patient when the provision of acute care ends and the patient is then provided with accommodation and nursing care as an end in itself, whether at the first hospital or another hospital.\n\n5. Ceasing and resuming hospital treatment\n\nIf a nursing-home type patient, or a person referred to in paragraph 4 (a), leaves hospital but returns to a hospital, whether or not at the same hospital, not more than 7 days later and is provided with hospital treatment at the hospital, the patient is a nursing‑home type patient for each subsequent day that the patient is provided with accommodation and nursing care, as an end in itself, until the patient ceases to be provided with hospital treatment at a hospital for a period of more than 7 days.\n\nNote: If the relevant period of hospitalisation is broken by more than 7 days, clause 2 of this Schedule may again apply to the person.\n\n6. Minimum benefit\n\nThe minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in Table 1 or 2 of this Schedule for that hospital treatment.\n\nTable 1\n\n| Public hospital: State/Territory | Minimum benefit per night |\n| -------------------------------- | ------------------------- |\n| NSW | $95.30 |\n| Northern Territory | $58.11 |\n| Queensland | $88.50 |\n| South Australia | $93.50 |\n| Tasmania | $93.72 |\n| Victoria | $95.15 |\n| ACT | $89.35 |\n| Western Australia | $97.80 |\n\nTable 2\n\n| Private hospitals | $72.05 |\n| ----------------- | ------ |\n\nSchedule 5―Second-tier default benefits\n\n1. Interpretation\n\n(1) In this Schedule:\n\nfacility means a private hospital specified in clause 4 of this Schedule.\n\nnegotiated agreement means an agreement entered into between a hospital and an insurer, that includes provisions to the effect that, except to the extent (if any) provided in the agreement, the hospital agrees to accept payment by the insurer in satisfaction of any amount that would, apart from the agreement, be owed to the hospital, in relation to an episode of hospital treatment, by an insured person under a policy.\n\n(2) In this Schedule, except in subclause (4) of this clause, the ACT is taken to be part of NSW and the Northern Territory is taken to be part of the State of South Australia.\n\n(3) In this Schedule, private hospitals are comparable if they fall within the same category from the following list:\n\n(a) private hospitals which provide psychiatric care for at least 50% of the episodes of hospital treatment;\n\n(b) private hospitals which provide rehabilitation care for at least 50% of the episodes of hospital treatment;\n\n(c) private hospitals which do not fall into categories (a) or (b), with up to and including 50 licensed beds;\n\n(d) private hospitals which do not fall into categories (a) or (b) with more than 50 licensed beds and up to and including 100 licensed beds;\n\n(e) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit;\n\n(f) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, with either (or both) an accident and emergency unit or a specialised cardiac care unit;\n\n(g) private hospitals which only provide hospital treatment which does not include any part of an overnight stay.\n\n(4) In subclause (3), a reference to licensed beds is a reference to the beds or patients that a private hospital is permitted, under State or Territory legislation in the State or Territory where the private hospital is located.\n\n2. Circumstances\n\nFor rules 4 and 5 of Part 2 of these Rules, the circumstances for hospital treatment to which this Schedule applies are that the treatment is provided to a patient who is not a nursing-home type patient and the treatment is provided at a facility.\n\nNote: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.\n\n3. Minimum benefit\n\n(1) Despite anything in Schedules 1, 2, 3 or 6, but subject to subclause (2) of this clause, the minimum benefit for an episode of hospital treatment at a facility that does not have a negotiated agreement with the insurer, is the amount specified in this Schedule (the second tier default benefit).\n\n(2) If the minimum benefit determined in accordance with this Schedule for an episode of hospital treatment is below the amount determined in accordance with Schedules 1, 2, 3 or 6 the minimum benefit is the amount determined in accordance with Schedules 1, 2, 3 or 6 for that episode of hospital treatment.\n\n(3) If a hospital ceases to be a facility for the purposes of this Schedule, the minimum benefit in relation to an episode of hospital treatment for an insured person who was an admitted patient at the facility or booked for hospital treatment at the facility (as opposed to merely being on the facility’s waiting list) before the day that the hospital ceased to be a facility is the minimum benefit that would have applied if the hospital continued to be a facility at the time the treatment was provided.\n\n(4) Subject to subclauses (2) and (8), the minimum benefit payable by an insurer for an episode of hospital treatment between 1 September of a particular year (the first year) and 31 August of the next year is an amount no less than 85% of the average charge for the equivalent episode of hospital treatment, under that insurer's negotiated agreements in force on 1 August of the first year with all such comparable private hospitals in the State in which the facility is located.\n\n(5) The formula for calculating the average charge for the equivalent episode of hospital treatment by an insurer in each State is as follows:\n\n![](image.002.png)","sortOrder":11},{"sectionNumber":"Where: j = group of equivalent episodes ","sectionType":"section","heading":"Where: j = group of equivalent episodes of hospital treatment under the insurer's negotiated agreements;","content":"##### Where: j = group of equivalent episodes of hospital treatment under the insurer's negotiated agreements;\n\ni = group of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;\n\nn= the number of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;\n\nRji = charge for episode of hospital treatment type j in the negotiated agreement i\n\nRj = average charge for episode of hospital treatment type j.\n\n(6) In subclause (4), each episode of hospital treatment must be identified using the patient classification system and payment structure in the majority of the relevant insurer's negotiated agreements in force on 1 August of the first year with all comparable private hospitals in the State in which the facility is located.\n\n(7) In subclause (4), for the purpose of calculating the average charge for the equivalent episode of hospital treatment in a State:\n\n(a) the charge will include the sum of the amount payable by the insurer under that insurer's negotiated agreement and any excess or co‑payment amounts payable by members, in accordance with the insurer's rules; and\n\nNote: Policy holders’ financial obligations under such levels of cover will still apply.\n\n(b) must not include any charges:\n\n(i) referred to in the insurer's negotiated agreements for prostheses; and\n\n(ii) that are minimum benefits for prosthesis as specified for the purpose of item 4 of the table in subsection 72-1 (2) of the Act, and\n\n(iii) referred to in the insurer's negotiated agreements for hospital treatment provided to nursing-home type patients.\n\n(8) Subject to subclause (2), if an insurer has less than 5 negotiated agreements in force on 1 August of the first year with a particular category of comparable private hospitals in a State, then all of that insurer's negotiated agreements with all classes of private hospitals in that State are to be used to calculate the minimum benefit.","sortOrder":12},{"sectionNumber":"4. Facilities","sectionType":"part","heading":"4. Facilities","content":"# 4. Facilities\n\nThe hospitals specified in the table below are facilities for the purpose of this Schedule.\n\nTable\n\n| Item | Facility Name | Address |\n| ---- | ----------------------------------------------------------------------------------- | -------------------------------------------------------------------------------------------------------------- |\n| | (Alpha) Westmead Private Hospital | Cnr of Mons and Darcy Roads, WESTMEAD NSW 2145 |\n| 2. | Aesthetic Day Surgery | 14 Kensington Street, KOGARAH NSW 2217 |\n| 3. | Adelaide Community Healthcare Alliance Inc – Ashford Campus | 55 Anzac Highway, ASHFORD SA 5035 |\n| 4. | Adelaide Community Healthcare Alliance Inc – Flinders Private Hospital Campus | Flinders Drive, BEDFORD SA 5042 |\n| 5. | Adelaide Community Healthcare Alliance Inc – The Memorial Hospital Campus | Sir Edwin Smith Avenue, NORTH ADELAIDE SA 5006 |\n| 6. | Adelaide Eye & Laser Centre | 215 Greenhill Road, EASTWOOD SA 5063 |\n| 7. | Albury-Wodonga Private Hospital | 1125 Pemberton Street, ALBURY NSW 2640 |\n| 8. | Allamanda Private Hospital | 21 Spendelove Avenue, SOUTHPORT QLD 4215 |\n| 9. | Allamanda Surgicentre | 103 Nerang Street, SOUTHPORT QLD 4215 |\n| 10. | Armidale Private Hospital | Rusden St, ARMIDALE NSW 2350 |\n| 11. | Attadale Private Hospital | 21 Hislop Road, ATTADALE WA 6156 |\n| 12. | Avenue Plastic Surgery | 20 The Avenue, WINDSOR VIC 3181 |\n| 13. | Ballina Day Surgery | 46 Tamar Street, BALLINA NSW 2478 |\n| 14. | Bankstown Primary Health Care Day Surgery | 67 Rickard Road, BANKSTOWN NSW 2200 |\n| 15. | Baringa Private Hospital | Mackay Road, COFFS HARBOUR NSW 2450 |\n| 16. | Bethesda Hospital | 25 Queenslea Drive, CLAREMONT WA 6010 |\n| 17. | Beleura Private Hospital | 925 Nepean Highway, MORNINGTON VIC 3931 |\n| 18. | Bellbird Private Hospital | 198 Canterbury Road, BLACKBURN VIC 3130 |\n| 19. | Berkeley Vale Private Hospital | 8 Lorraine Avenue, BERKELEY VALE NSW 2261 |\n| 20. | Bondi Junction Private Hospital | 21 Spring St, BONDI JUNCTION NSW 2022 |\n| 21. | Brisbane Private Hospital | 259 Wickham Terrace, BRISBANE QLD 4000 |\n| 22. | Brisbane Waters Private Hospital | 21 Vidler Avenue, WOY WOY NSW 2256 |\n| 23. | Broadmeadow Day Surgery | 1st Floor (Suite 1), 18 Lambton Road, BROADMEADOW NSW 2292 |\n| 24. | Buderim Gastroenterology Centre(Maroochydore) | Suite 5, 102 Wises Road, MAROOCHYDORE QLD 4558 |\n| 25. | Caboolture Private Hospital | McKean Street, CABOOLTURE QLD 4510 |\n| 26. | Cabrini Brighton | 243 New Street, BRIGHTON VIC 3186 |\n| 27. | Cairns Day Surgery | 1st Floor Cnr Florence & Grafton Streets CAIRNS QLD 4870 |\n| 28. | Cairns Private Hospital | 1 Upward Street, CAIRNS QLD 4870 |\n| 29. | Caloundra Private Hospital | 96 Beerburrum Street, CALOUNDRA QLD 4551 |\n| 30. | Calvary Central Districts Hospital | 25- 37 Jarvis Road, ELIZABETH VALE SA 5112 |\n| 31. | Calvary Day Procedure Centre | 329, 331, 333 Edward Street, WAGGA WAGGA NSW 2650 |\n| 32. | Calvary Health Care ACT | Calvary Public and Private Hospital, Haydon Drive, BRUCE ACT 2617 |\n| 33. | Calvary Health Care (St Luke’s Campus) | 24 Lyttleton Street, LAUNCESTON TAS 7250 |\n| 34. | Calvary Health Care (St Vincent’s Campus) | 5 Frederick Street, LAUNCESTON TAS 7250 |\n| 35. | Calvary Health Care Sydney – Hurstville Community | 37 Gloucester Road, HURSTVILLE NSW 2220 |\n| 36. | Calvary Hospital Adelaide | 89 Strangways Terrace, NORTH ADELAIDE SA 5006 |\n| 37. | Calvary Hospital (Lenah Valley Campus) | 49 Augusta Road, LENAH VALLEY TAS 7008 |\n| 38. | Calvary Hospital (St John’s Campus) | 30 Cascade Road, SOUTH HOBART TAS 7004 |\n| 39. | Calvary Private Hospital (Riverina) | Hardy Ave, WAGGA WAGGA NSW 2650 |\n| 40. | Campbelltown Private Hospital | 42 Parkside Crescent, CAMPBELLTOWN NSW 2560 |\n| 41. | Canada Bay Private Hospital | 55-57 Burwood Road, CONCORD NSW 2137 |\n| 42. | Capital Day Surgery Centre | Calvary Clinic, Mary Potter Circuit, BRUCE ACT 2617 |\n| 43. | Caringbah Day Surgery | 42 President Avenue, CARINGBAH NSW 2229 |\n| 44. | Castle Hill Hospital | 72-74 Cecil Avenue, CASTLE HILL NSW 2154 |\n| 45. | Castlecrag Private Hospital | 150 Edinburgh Road, CASTLECRAG NSW 2068 |\n| 46. | Chasely Day Surgery | Wesley Medical Centre, 40 Chasely Street, AUCHENFLOWER QLD 4066 |\n| 47. | Chesterville Day Hospital | 26-28 Chesterville Road, CHELTENHAM VIC 3192 |\n| 48. | Cliveden Hill Private Hospital | 29 Simpson Street, EAST MELBOURNE VIC 3002 |\n| 49. | Coffs Harbour Day Surgery Centre | 69 Albany Street, COFFS HARBOUR NSW 2450 |\n| 50. | Colin Street Day Surgery | 51 Colin Street, WEST PERTH WA 6005 |\n| 51. | Como Private Hospital | 152 Como Parade West, PARKDALE VIC 3194 |\n| 52. | Coolenberg Clinic | 60 Lake Rd, PORT MACQUARIE NSW 2444 |\n| 53. | Cotham Private Hospital | 209 Cotham Road, KEW VIC 3101 |\n| 54. | Dalcross Private Hospital | 28 Stanhope Road, KILLARA NSW 2071 |\n| 55. | Dandenong Eye Clinic & Day Surgery Centre | 1-3 Falkiner Crescent, DANDENONG VIC 3175 |\n| 56. | Darwin Private Hospital | Rocklands Drive, TIWI NT 0810 |\n| 57. | Delmar Private Hospital | 58 Quirk Street, DEE WHY NSW 2099 |\n| 58. | Delmont Private Hospital | 298 Warrigal Road, GLEN IRIS VIC 3146 |\n| 59. | Donvale Rehabilitation Hospital | 1119-1121 Doncaster Road, DONVALE VIC 3111 |\n| 60. | Dorset Rehabilitation Hospital | 146 Derby Street, PASCOE VALE VIC 3044 |\n| 61. | Dudley Private Hospital | 261 March Street, ORANGE NSW 2800 |\n| 62. | Eastern Suburbs Private Hospital | 8 Chapel Street, RANDWICK NSW 2031 |\n| 63. | Epworth Eastern Hospital | 1 Arnold Street, BOX HILL VIC 3128 |\n| 64. | Elsternwick Private Hospital | 494 Glenhuntly Road, ELSTERNWICK VIC 3185 |\n| 65. | Epping Surgery Centre | 3/44 Oxford Street, EPPING NSW 2121 |\n| 66. | Epworth Freemasons | 166 Clarendon Street & 320 Victoria Parade, EAST MELBOURNE VIC 3002 |\n| 67. | Epworth Hospital | 89 Bridge Road, RICHMOND VIC 3121 |\n| 68. | Epworth Rehabilitation Brighton | 85-91 Wilson Street, BRIGHTON VIC 3186 |\n| 69. | Epworth Rehabilitation Camberwell | 888 Toorak Road, CAMBERWELL VIC 3184 |\n| 70. | Essendon Day Procedure Centre | Level 2, 665 Mount Alexander Road, MOONEE PONDS VIC 3039 |\n| 71. | Essendon Private Hospital | 35 Rosehill Road, ESSENDON WEST VIC 3040 |\n| 72. | Eye-Tech Day Surgeries | Level 3, St Andrew's Place, North Street, SPRING HILL QLD 4000 |\n| 73. | Eye-Tech Day Surgeries Southside | 22-26 Sanders Street, UPPER MOUNT GRAVATT QLD 4122 |\n| 74. | Figtree Private Hospital | 1 Suttor Place, FIGTREE NSW 2525 |\n| 75. | Frances Perry Private Hospital | 285 Cardigan Street, CARLTON 3053 |\n| 76. | Frankston Private Day Surgery | 24-28 Frankston-Flinders Road, FRANKSTON VIC 3199 |\n| 77. | Friendly Society Private Hospital | 19-23 Bingera Street, BUNDABERG QLD 4670 |\n| 78. | Fullarton Private Hospital | 293-295 Fullarton Road, PARKSIDE SA 5063 |\n| 79. | Geelong Private Hospital | Cnr Ryrie & Bellarine Streets, GEELONG VIC 3220 |\n| 80. | GI Clinic, Perth | Units 9 & 10, 16 Hulme Court, MYAREE WA 6154 |\n| 81. | Glenferrie Private Hospital | 25 Linda Crescent, HAWTHORN VIC 3122 |\n| 82. | Glengarry Private Hospital | 53 Arnisdale Road, DUNCRAIG WA 6023 |\n| 83. | Greenslopes Private Hospital | Newdegate Street, GREENSLOPES QLD 4120 |\n| 84. | Griffith Rehabilitation Hospital | 13 Dunrobin Road, HOVE SA 5045 |\n| 85. | Griffiths Road Day Surgery | 182 Christo Road, WARATAH NSW 2298 |\n| 86. | Harley Place Day Surgery | Suite 605, 251 Oxford Street, BONDI JUNCTION NSW 2022 |\n| 87. | Hastings Day Surgery | Cnr Parker & Savoy Streets, PORT MACQUARIE NSW 2444 |\n| 88. | Hawkesbury District Health Service | Cnr Macquarie and Day Streets, WINDSOR NSW 2756 |\n| 89. | Healthwoods Specialist Centre | 53 Cowper Street, GRANVILLE NSW 2142 |\n| 90. | Hervey Bay Surgical Centre | Cnr O’Rourke Street & Boat Harbour Drive, PIALBA QLD 4655 |\n| 91. | Hillcrest-Rockhampton Private Hospital | 4 Talford Street, ROCKHAMPTON QLD 4700 |\n| 92. | Hills Private Hospital | 499 Windsor Road, BAULKHAM HILLS NSW 2153 |\n| 93. | Hobart Private Hospital | Argyle Street, HOBART TAS 7000 |\n| 94. | Hollywood Private Hospital | Monash Avenue, NEDLANDS WA 6009 |\n| 95. | Holroyd Private Hospital | 123-129 Chetwynd Road, GUILDFORD NSW 2161 |\n| 96. | Holy Spirit Northside | 627 Rode Road, CHERMSIDE QLD 4032 |\n| 97. | Hopetoun Rehabilitation Hospital | 2-6 Hopetoun Street, ELSTERNWICK VIC 3185 |\n| 98. | Hopewell Hospice | 11 Dunkirk Close, ARUNDEL QLD 4214 |\n| 99. | Hunters Hill Private Hospital | 9 Mount Street, HUNTERS HILL NSW 2110 |\n| 100. | Hunter Valley Private Hospital | 20 Mawson Street SHORTLAND NSW 2307 |\n| 101. | Inner West Endoscopy Centre | 311 Marrickville Road, MARRICKVILLE NSW 2204 |\n| 102. | Ivanhoe Private Rehabilitation Hospital | 134-142 Ford Street, IVANHOE VIC 3079 |\n| 103. | John Fawkner Private Hospital | 275 Moreland Road, COBURG VIC 3058 |\n| 104. | John Flynn-Gold Coast Private Hospital | 42 Inland Drive, TUGUN QLD 4224 |\n| 105. | Joondalup Private Hospital | Cnr Grand Boulevard and Shenton Avenue, JOONDALUP WA 6027 |\n| 106. | Kahlyn Private Hospital | 40 Briant Road, MAGILL SA 5072 |\n| 107. | Kareena Private Hospital | 86 Kareena Road, CARINGBAH NSW 2229 |\n| 108. | Kawana Private Hospital | Suite 14, Level 1, Innovation Parkway, BIRTINYA QLD 4575 |\n| 109. | Knox Private Hospital | 262 Mountain Highway, WANTIRNA VIC 3152 |\n| 110. | Lady Davidson Private Hospital | Bobbin Head Road, TURRAMURRA NSW 2074 |\n| 111. | Lake Macquarie Private Hospital | 3 Sydney Street, GATESHEAD NSW 2290 |\n| 112. | Lawrence Hargrave Private Hospital | 72 Phillip Street, THIRROUL NSW 2515 |\n| 113. | Linacre Private Hospital | 12 Linacre Road, HAMPTON VIC 3188 |\n| 114. | Liverpool Day Surgery | 105-119 Longstaff Avenue, MOOREBANK NSW 2170 |\n| 115. | Logan Endoscopy Services | Unit 2/32 76 Beaudesert Road, BROWN PLAINS QLD 4118 |\n| 116. | Logan Surgery Centre | Unit 12, 13-21 Mayes Avenue, LOGAN CENTRAL QLD 4114 |\n| 117. | Longueville Private Hospital | 47 Kenneth Street, LONGUEVILLE NSW 2066 |\n| 118. | Macarthur Private Hospital | 92-96 Dumaresq Street, CAMPBELLTOWN NSW 2560 |\n| 119. | Maitland Private Hospital | 173 Chisholm Road, EAST MAITLAND NSW 2323 |\n| 120. | Manly Waters Private Hospital | 17 Cove Avenue, MANLY NSW 2095 |\n| 121. | Manningham Day Procedure Centre | Level 3, 200 High Street, LOWER TEMPLESTOWE VIC 3107 |\n| 122. | Marie Stopes International - Caboolture | 40 Cresthaven Drive, MORAYFIELD QLD 4506 |\n| 123. | Marie Stopes International - Canberra | Level 1, Cnr Moore & Alinga Streets, CANBERRA CITY ACT 2601 |\n| 124. | Marie Stopes International - Salisbury | 11 Hayling Street, SALISBURY QLD 4107 |\n| 125. | Marie Stopes International- Westmead | 27 Railway Parade, WESTMEAD NSW 2145 |\n| 126. | Maryvale Private Hospital | McDonald Street, MORWELL VIC 3840 |\n| 127. | Masada Private Hospital | 26 Balaclava Road, EAST ST KILDA VIC 3183 |\n| 128. | Mater Hospital Yeppoon | 55 Cliff Street, YEPPOON QLD 4703 |\n| 129. | Mater Misericordiae Day Unit (Mackay) | 1 Wellington Street, MACKAY QLD 4740 |\n| 130. | Mater Misericordiae Hospital Bundaberg | 313 Bourbong Street, BUNDABERG QLD 4670 |\n| 131. | Mater Misericordiae Hospital Gladstone | Rossella Street, GLADSTONE QLD 4680 |\n| 132. | Mater Misericordiae Hospital Mackay | 76 Willetts Road, NORTH MACKAY QLD 4740 |\n| 133. | Mater Misericordiae Hospital Rockhampton | cnr Ward & Jessie Streets, ROCKHAMPTON QLD 4700 |\n| 134. | Mater Misericordiae Private Hospital | 35 Rocklands Road, CROWS NEST NSW 2065 |\n| 135. | Mater Misericordiae Private Hospital (South Brisbane) | 301 Vulture Street, SOUTH BRISBANE QLD 4101 |\n| 136. | Mater Misericordiae Private Hospital Townsville | 21 Fulham Road, PIMLICO QLD 4810 |\n| 137. | Mater Misericordiae Women’s & Children’s Private Health Service (Children’s Campus) | Cnr Raymond Terrace & Stanley Street, SOUTH BRISBANE QLD 4101 |\n| 138. | Mater Misericordiae Women’s & Children’s Private Health Service (Women’s Campus) | Raymond Terrace, SOUTH BRISBANE QLD 4101 |\n| 139. | Mater Private Hospital Redland | Weippin Street, CLEVELAND QLD 4163 |\n| 140. | Mayo Private Hospital | Lot 1, Potoroo Drive, Kolodong, VIA TAREE NSW 2430 |\n| 141. | Melbourne Oral & Facial Surgery | Level 12, 63 Exhibition Street, Scala House, MELBOURNE VIC 3000 |\n| 142. | Metropolitan Rehabilitation Hospital | 275 Addison Road, PETERSHAM NSW 2049 |\n| 143. | Minchinbury Community Hospital | Rupertswood Road, MT DRUITT NSW 2770 |\n| 144. | Mitcham Private Hospital | 27 Doncaster East Road, MITCHAM VIC 3132 |\n| 145. | Montserrat Day Hospital (Gaythorne) | 383 – 391 Samford Road, GAYTHORNE QLD 4051 |\n| 146. | Montserrat Day Hospital (Indooroopilly) | 12 Riverview Terrace, INDOOROOPILLY QLD 4068 |\n| 147. | Montserrat Day Hospital (Spring Hill) | Level 2, 35 Astor Terrace, BRISBANE QLD 4000 |\n| 148. | Mosman Private Hospital | 1 Ellamatta Avenue, MOSMAN NSW 2088 |\n| 149. | Mount Hospital | 150 Mounts Bay Road, PERTH WA 6000 |\n| 150. | Mount Olivet Hospital | 411 Main Street, KANGAROO POINT QLD 4169 |\n| 151. | Mt Lawley Private Hospital | 14 Alvan Street, MOUNT LAWLEY WA 6050 |\n| 152. | Mt Wilga Private Hospital | 2 Manor Road, HORNSBY NSW 2077 |\n| 153. | Murdoch Surgicentre | 100 Murdoch Drive, MURDOCH WA 6150 |\n| 154. | Murray Valley Private Hospital | Nordsvan Drive, WODONGA VIC 3690 |\n| 155. | Nambour Selangor Private Hospital | 62 Netherton Street, NAMBOUR QLD 4560 |\n| 156. | National Capital Private Hospital | Gilmore Crescent & Hospital Road, GARRAN ACT 2605 |\n| 157. | Nepean Private Hospital | Barber Avenue, PENRITH NSW 2750 |\n| 158. | New Farm Private Hospital | 22 Sargent Street, NEW FARM QLD 4005 |\n| 159. | Newcastle Private Hospital | 2 Lookout Road, NEW LAMBTON NSW 2305 |\n| 160. | Ngala Family Resource Centre | 9 George Street, KENSINGTON WA 6151 |\n| 161. | Noosa Private Hospital | 111 Goodchap Street, NOOSAVILLE QLD 4566 |\n| 162. | North Eastern Private Hospital | 580 Lower North East Road, CAMPBELLTOWN SA 5074 |\n| 163. | North Shore Private Hospital | Westbourne Street, ST LEONARDS NSW 2065 |\n| 164. | North West Brisbane Private Hospital | 137 Flockton Street, EVERTON PARK QLD 4053 |\n| 165. | Northpark Private Hospital | Greenhills Road, BUNDOORA VIC 3083 |\n| 166. | Northside Clinic Private Hospital | 2 Greenwich Road, GREENWICH NSW 2065 |\n| 167. | Northside Cremorne Clinic | 3 Harrison Street, CREMORNE NSW 2090 |\n| 168. | Northside West Clinic | 23-27 Lytton Street, WENTWORTHVILLE NSW 2145 |\n| 169. | Nowra Private Hospital | Weeroona Place, NOWRA NSW 2541 |\n| 170. | Olympia Private Rehabilitation Hospital | 12 Francis Grove, THORNBURY VIC 3071 |\n| 171. | Ophthalmic Surgery Centre | Suite 6, 12-14 Malvern Avenue, CHATSWOOD NSW 2067 |\n| 172. | Orange Day Surgery Centre | 60 McNamara Street, ORANGE NSW 2800 |\n| 173. | Pacific Day Surgery | 38 Misterton Street, FORTITUDE VALLEY QLD 4006 |\n| 174. | Pacific Private Hospital | 119-123 Nerang Street, SOUTHPORT QLD 4215 |\n| 175. | Parkwynd Private Hospital | 137 East Terrace, ADELAIDE SA 5000 |\n| 176. | Pendlebury Clinic Private Hospital | Suite 3, 52 Pendlebury Road, CARDIFF NSW 2285 |\n| 177. | Peninsula Private Hospital (Frankston) | Cnr Cranbourne & McClelland Drive, FRANKSTON VIC 3199 |\n| 178. | Peninsula Private Hospital (Kippa-Ring) | Cnr George and Florence Streets, KIPPA-RING QLD 4020 |\n| 179. | Perfect Vision Eye Surgery | Suite 3, 25 –29 Hunter Street, HORNSBY NSW 2077 |\n| 180. | Perth Clinic | 29 Havelock St, WEST PERTH WA 6005 |\n| 181. | Pindara Day Procedure Centre | 13 Carrara Street, BENOWA QLD 4217 |\n| 182. | Pindara Gold Coast Private Hospital | Allchurch Avenue, BENOWA QLD 4217 |\n| 183. | Pine Rivers Private Hospital | Dixon Street, STRATHPINE QLD 4500 |\n| 184. | Pioneer Valley Private Hospital | 57 Norris Road, NORTH MACKAY QLD 4740 |\n| 185. | Poplars Private Hospital | 66 Norfolk Road, EPPING NSW 2121 |\n| 186. | Port Macquarie Private Hospital | Lake Road, PORT MACQUARIE NSW 2444 |\n| 187. | Prince of Wales Private Hospital | Levels 5-7, Ambulatory Care Services Centre Building, Prince of Wales Campus, Barker Street, RANDWICK NSW 2031 |\n| 188. | QFG Day Theatres | 4th Floor St Andrew's Place 33 North Street SPRING HILL QLD 4000 |\n| 189. | Randwick Day Surgery | 2 Eurimble Avenue, RANDWICK NSW 2031 |\n| 190. | Ringwood Private Hospital | 36 Mount Dandenong Road, EAST RINGWOOD VIC 3134 |\n| 191. | Rivercity Private Hospital | 401 Milton Road, AUCHENFLOWER QLD 4066 |\n| 192. | Roderick Street Day Surgery | 23 Roderick Street, IPSWICH QLD 4305 |\n| 193. | Rosebud SurgiCentre | 1537 Point Nepean Road, ROSEBUD WEST VIC 3940 |\n| 194. | Saint Frances Xavier Cabrini Hospital (Malvern) | 181-183 Wattletree Road, MALVERN VIC 3144 |\n| 195. | Saint Frances Xavier Cabrini Hospital (Prahran) | 646 High Street, PRAHRAN EAST VIC 3181 |\n| 196. | Shellharbour Private Hospital | Captain Cook Drive BARRACK HEIGHTS NSW 2528 |\n| 197. | Shepparton Private Hospital | Fitzgerald Street, SHEPPARTON VIC 3630 |\n| 198. | Short Street Day Surgery | 2 Short Street, SOUTHPORT QLD 4215 |\n| 199. | Solander Day Surgery | 182 Grafton St, CAIRNS QLD 4870 |\n| 200. | South Coast Digestive Diseases Centre | 86 Ashmore Road, BUNDALL QLD 4217 |\n| 201. | South Pacific Private Hospital | 18 Beach Street, CURL CURL NSW 2096 |\n| 202. | South Perth Endoscopy | 20 Fortune Street, SOUTH PERTH WA 6151 |\n| 203. | South Perth Hospital | 76 South Terrace, COMO WA 6152 |\n| 204. | South Western Day Surgery Centre | 20-22 Bigge Street, LIVERPOOL NSW 2170 |\n| 205. | Southern Highlands Private Hospital | 99 Bowral Street, BOWRAL NSW 2576 |\n| 206. | Southern Respiratory & Sleep Disorder Centre | Level 2, The Sutherland Hospital, The Kingsway, CARINGBAH NSW 2229 |\n| 207. | Spendelove House Private Hospital | 24 Spendelove Avenue, SOUTHPORT QLD 4215 |\n| 208. | Sportsmed.SA Hospital | 32 Payneham Road, STEPNEY SA 5069 |\n| 209. | St Andrew’s Ipswich Private Hospital | Cnr Roderick and Pring Streets, IPSWICH QLD 4305 |\n| 210. | St Andrew’s Toowoomba Hospital | 280 North Street, TOOWOOMBA QLD 4350 |\n| 211. | St George Private Hospital | 1 South Street, KOGARAH NSW 2217 |\n| 212. | St Helens Private Hospital | 186 Macquarie Street, HOBART TAS 7000 |\n| 213. | St John of God Health Care (Ballarat) | 101 Drummond Street North, BALLARAT VIC 3350 |\n| 214. | St John of God Health Care (Burwood) | 13 Grantham Street, BURWOOD NSW 2135 |\n| 215. | St John of God Health Care (Warrnambool) | 136 Botanic Road, WARRNAMBOOL VIC 3280 |\n| 216. | St John of God Health Care Berwick | Gibb Street, BERWICK VIC 3806 |\n| 217. | St John of God Health Care Nepean Rehabilitation Hospital | 255 Cranbourne Road, FRANKSTON VIC 3199 |\n| 218. | St John of God Hospital Bendigo | Lily Street, BENDIGO VIC 3552 |\n| 219. | St John of God Hospital Bunbury | Cnr Robertson Drive & Bussell Highway, BUNBURY WA 6230 |\n| 220. | St John of God Hospital Geelong | 80 Myers Street, GEELONG VIC 3220 |\n| 221. | St John of God Hospital Geraldton | 12 Hermitage Street, GERALDTON WA 6530 |\n| 222. | St John of God Hospital Murdoch | 100 Murdoch Drive, MURDOCH WA 6150 |\n| 223. | St John of God Hospital (Richmond) | 177 Grose Vale Road, NORTH RICHMOND NSW 2754 |\n| 224. | St John of God Hospital, Subiaco | 12 Salvado Road, SUBIACO WA 6008 |\n| 225. | St John of God Pinelodge Clinic | 1480 Heatherton Road, DANDENONG VIC 3175 |\n| 226. | St Kilda Day Hospital | 26A Dickens Street, ELWOOD VIC 3184 |\n| 227. | St Luke’s Hospital | 18 Roslyn Street, POTTS POINT NSW 2011 |\n| 228. | St Vincent’s & Mercy Private Hospital, Mercy Campus | 159 Grey Street, MELBOURNE EAST VIC 3002 |\n| 229. | St Vincent’s Hospital (Toowoomba) | Scott Street, TOOWOOMBA QLD 4350 |\n| 230. | St Vincent’s Private Hospital (Bathurst) | Gorman’s Hill Road, BATHURST NSW 2795 |\n| 231. | St Vincent’s Private Hospital (Fitzroy) | 59 Victoria Parade, FITZROY VIC 3065 |\n| 232. | Stirling District Hospital | 20 Milan Terrace, STIRLING SA 5152 |\n| 233. | Stonnington Day Surgery | Level 1, 253 Wattletree Road, MALVERN VIC 3144 |\n| 234. | Strathfield Private Hospital | 3 Everton Road, STRATHFIELD NSW 2135 |\n| 235. | Sunnybank Private Hospital | 245 McCullough Street, SUNNYBANK QLD 4109 |\n| 236. | Sunshine Coast Day Surgery | Cnr Memorial and Second Avenues Maroochydore QLD 4558 |\n| 237. | Sydney Adventist Private Hospital | 185 Fox Valley Road, WAHROONGA NSW 2076 |\n| 238. | Sydney Day Surgery | 213-219 Darlinghurst Road, DARLINGHURST NSW 2010 |\n| 239. | Sydney Haematology and Oncology Clinics | Unit 13/49 Palmerston Road, HORNSBY NSW 2077 |\n| 240. | Sydney IVF – Liverpool | 173-175 Bigge Street, LIVERPOOL NSW 2170 |\n| 241. | Sydney IVF Day Surgery | Level 4, 321 Kent Street, SYDNEY NSW 2000 |\n| 242. | Sydney Oculoplastic Surgery | 229 Macquarie St, SYDNEY NSW 2000 |\n| 243. | Sydney Retina Clinic & Day Surgery | Level 13, 187 Macquarie Street, SYDNEY NSW 2000 |\n| 244. | Sydney Southwest Private Hospital | 32-40 Bigge Street, LIVERPOOL NSW 2170 |\n| 245. | Tamara Private Hospital | 2-6 Dean Street, TAMWORTH NSW 2340 |\n| 246. | Terrace West Endoscopy Centre | 18 Limestone Street, IPSWICH QLD 4305 |\n| 247. | The Adelaide Clinic | 33 Park Terrace, GILBERTON SA 5081 |\n| 248. | The Albert Road Clinic | 31-33 Albert Road, SOUTH MELBOURNE VIC 3004 |\n| 249. | The Avenue Private Hospital | 40 The Avenue, WINDSOR VIC 3181 |\n| 250. | The Bays Hospital – Mornington | 262-268 Main Street, MORNINGTON VIC 3931 |\n| 251. | The Burnside War Memorial Hospital | 120 Kensington Road, TOORAK GARDENS SA 5065 |\n| 252. | The CAPS Clinic | Strickland Crescent, DEAKIN ACT 2600 |\n| 253. | The Double Bay Day Surgery | 20 Manning Road, DOUBLE BAY NSW 2028 |\n| 254. | The Eye Institute | Level 4, 270 Victoria Avenue, CHATSWOOD NSW 2057 |\n| 255. | The Geelong Clinic | 98 Townsend Road, ST ALBANS PARK VIC 3219 |\n| 256. | The Hills Parenting Centre | 105 Showground Road, CASTLE HILL NSW 2154 |\n| 257. | The Hornsby Sleep Disorder and Diagnostic Centre | 104 Balmoral Street, WAITARA NSW 2077 |\n| 258. | The Marian Centre | 187 Cambridge Street, WEMBLEY WA 6014 |\n| 259. | The Melbourne Clinic | 130 Church Street, RICHMOND VIC 3121 |\n| 260. | The Melbourne Private Hospital | Royal Parade, PARKVILLE VIC 3050 |\n| 261. | The San Day Surgery | 1a Northcote Road, HORNSBY NSW 2077 |\n| 262. | The Sydney Clinic | 22-24 Murray Street, WAVERLEY NSW 2024 |\n| 263. | The Sydney Private Hospital | 63 Victoria Street, ASHFIELD NSW 2131 |\n| 264. | The Victoria Clinic | 324 Malvern Road, PRAHRAN VIC 3181 |\n| 265. | Toowong Private Hospital | 496 Milton Rd, TOOWONG QLD 4066 |\n| 266. | Toronto Private Hospital | Cary Street, TORONTO NSW 2283 |\n| 267. | Townsville Day Surgery | 1 Martinez Avenue, West End, TOWNSVILLE QLD 4810 |\n| 268. | Tweed Day Surgery | 38-44 Boyd Street, TWEED HEADS NSW 2485 |\n| 269. | Vaucluse Private Hospital | 82 Moreland Road, BRUNSWICK VIC 3056 |\n| 270. | Victorian Rehabilitation Centre | 499 Springvale Road, GLEN WAVERLY VIC 3150 |\n| 271. | Vista Laser Eye Clinics NSW | 1 McClaren St, NORTH SYDNEY NSW 2060 |\n| 272. | Waikiki Private Hospital | 221 Willmott Drive, WAIKIKI WA 6169 |\n| 273. | Wandene Private Hospital | 7 Blake Street, KOGARAH NSW 2217 |\n| 274. | Wangaratta Private Hospital | 134-150 Templeton Street, WANGARATTA VIC 3677 |\n| 275. | Warners Bay Private Hospital | Fairfax Road, WARNERS BAY NSW 2282 |\n| 276. | Warringal Private Hospital | 216 Burgundy Street, HEIDELBERG VIC 3084 |\n| 277. | Waverly Private Hospital | 343-357 Blackburn Road, MOUNT WAVERLY VIC 3149 |\n| 278. | Wesley Private Hospital | 91 Milton Street, ASHFIELD NSW 2131 |\n| 279. | West Lakes Day Surgery | 151 Brebner Drive, WEST LAKES SA 5021 |\n| 280. | Western Plains Day Surgery | 62 Windsor Parade, DUBBO NSW 2830 |\n| 281. | Western Private Hospital | Corner Eleanor and Marion Streets, FOOTSCRAY VIC 3011 |\n| 282. | Westmead Rehabilitation Centre | 7 Coleman Street, MERRYLANDS NSW 2160 |\n| | Wolper Jewish Private Hospital | 8 Trelawney Street, WOOLLAHRA NSW 2025 |\n\nSchedule 6―Outreach services\n\n1. Application\n\nThis Schedule ceases to have effect at midnight on 30 June 2008.\n\nNote: Section 16 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with outreach services. That section ceases to have effect on 1 July 2008.\n\n2. Circumstances\n\nFor rules 4 and 5 of Part 2 of these Rules, the circumstance specified for hospital treatment to which this Schedule applies is that the treatment is an outreach service.\n\n3. Minimum benefit\n\nThe minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in Table 1 or 2 of this clause for that hospital treatment.\n\nTable 1\n\n| Public hospital: State/Territory | Minimum benefit payable per day |\n| -------------------------------- | ------------------------------- |\n| NSW | $166 |\n| Victoria | $166 |\n| Queensland | $166 |\n| South Australia | $166 |\n| Western Australia | $166 |\n| Tasmania | $166 |\n| ACT | $166 |\n| Northern Territory | $157 |\n\nTable 2\n\n| Private hospitals | $166 |\n| ----------------- | ---- |","sortOrder":13}],"analysis":{"flash_summary":{"complexity_score":8,"scope_assessment":{"changed":true,"description":"These Rules revoke the prior Benefit Requirements Rules on commencement (rule 2(2)) and replace the minimum‑benefit framework with updated rate tables, new classification ties for Types A/B/C (rule 3; Schedules 1 & 3), a detailed facility list treated as ‘facilities’ for second‑tier defaults (Schedule 5 cl.4 and table), and a second‑tier default calculation for hospitals without negotiated agreements (Schedule 5 cl.3–7). They also modify nursing‑home type patient timing/continuity rules (Schedule 4 cl.2–5) and impose a sunset on outreach provisions (Schedule 6 cl.1)."},"complexity_factors":["Multiple schedules (1–6) with distinct rate tables and differing eligibility circumstances for overnight, same‑day, nursing‑home type and outreach care (Schedules 1–4, 6).","Extensive enumerations mapping thousands of MBS/pathology/diagnostic items into categories used to identify procedures and benefit levels (Schedules 1–3 and item lists).","Second‑tier default benefit mechanism requires insurer‑level averaging of negotiated agreement charges across comparable private hospitals with an 85% floor and detailed inclusions/exclusions (Schedule 5 cl.3–7).","Definition and interaction of Type A/B/C procedures and certified variants cross‑refer to multiple schedule clauses (rule 3; Schedules 1 and 3), creating interdependent classification rules.","Nursing‑home type patient rules establish a 35‑day threshold, 7‑day continuity breaks and rules for acute care interruptions, affecting eligibility timing (Schedule 4 cl.2–5).","State/Territory variations and jurisdictional mappings (e.g. ACT=NSW, NT=SA for Schedule 5 cl.2), plus per‑state rate tables for nursing‑home and outreach benefits (Schedules 4 and 6).","Large, explicit facility list creates administrative maintenance and potential edge cases where facility status affects benefit calculation (Schedule 5 cl.4 and table).","Temporal limitation: outreach services schedule ceases 30 June 2008, adding transitional complexity (Schedule 6 cl.1).","Allowance for insurer rules (co‑payments/excesses) to reduce minimum benefits creates interactions between policy design and statutory minima (rules 4(2), 5(2)).","Revocation of prior Rules on commencement requires mapping old determinations to the new regime (rule 2(2))."],"plain_english_summary":"These Rules set the minimum cash benefits private health insurers must pay for many types of hospital treatment under complying policies. They prescribe fixed nightly/daily rates and counting rules for overnight, same‑day, nursing‑home‑type, psychiatric/rehabilitation/palliative and outreach care, and supply a backup (“second‑tier”) formula for facilities without insurer agreements.\n\nThey affect insurers (who pay), hospitals (who receive set rates or negotiated payments) and insured patients (whose co‑payments/excesses may reduce benefits), and include a listed set of facilities and a sunset for outreach services."},"kimi_summary":{"_metrics":{"model":"kimi-k2.5","source":"moonshot-realtime","completionTokens":3738},"content_quality":"ok","complexity_score":8,"scope_assessment":{"changed":false,"description":"The legislation remains focused on its original purpose of establishing minimum benefit requirements for private health insurance hospital coverage. The inclusion of specific hospital lists, MBS item references, and transitional provisions for outreach services represents implementation detail rather than scope expansion."},"complexity_factors":["Six separate schedules with distinct calculation methods for overnight, same-day, nursing-home type, and second-tier benefits","State/territory-specific rate variations (different tables for Victoria/Tasmania versus other jurisdictions for public hospital benefits)","Multi-tiered patient classification system with benefit reduction triggers at 14, 35, 42, 49, and 65 days of continuous care","Extensive cross-referencing to the Medicare Benefits Schedule (MBS) via hundreds of item numbers to determine procedure types and certification","Mathematical averaging formula for second-tier benefits requiring calculation of 85% of mean negotiated rates across comparable hospital categories","Complex conditional logic including 'despite' clauses, sunset provisions, and 7-day continuity rules for counting hospitalisation periods","Integration with primary legislation (Private Health Insurance Act 2007 and Health Insurance Act 1973) through 25+ defined terms"],"plain_english_summary":"These Rules set nationwide minimum benefit rates private health insurers must pay for hospital treatments—covering overnight, same‑day and long‑stay care, plus a safety‑net for certain hospitals—to guarantee baseline financial support for insured patients.\n\nThey affect private insurers (obligated payors), hospitals (benefit recipients) and insured patients (claimants and gap‑payers), by standardising minimum payments and limiting shortfalls."}},"importantCases":[],"_links":{"self":"/api/acts/private-health-insurance-benefit-requirements-rules-2007-no-4","history":"/api/acts/private-health-insurance-benefit-requirements-rules-2007-no-4/history","analysis":"/api/acts/private-health-insurance-benefit-requirements-rules-2007-no-4/analysis","conflicts":"/api/acts/private-health-insurance-benefit-requirements-rules-2007-no-4/conflicts","importantCases":"/api/acts/private-health-insurance-benefit-requirements-rules-2007-no-4/important-cases","documents":"/api/acts/private-health-insurance-benefit-requirements-rules-2007-no-4/documents"}}