{"id":"F2015L01021","name":"Private Health Insurance (Complying Product) Rules 2015","slug":"private-health-insurance-complying-product-rules-2015","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":128936,"registerId":"commonwealth-F2015L01021-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Part 1","sectionType":"part","heading":"Preliminary","content":"## Part 1 Preliminary","sortOrder":0},{"sectionNumber":"1","sectionType":"section","heading":"Name of Rules","content":"#### 1 Name of Rules\n\nThese Rules are the Private Health Insurance (Complying Product) Rules 2015.","sortOrder":1},{"sectionNumber":"3A","sectionType":"section","heading":"Authority","content":"#### 3A Authority\n\nThese Rules are made under the Private Health Insurance Act 2007.","sortOrder":2},{"sectionNumber":"4","sectionType":"section","heading":"Definitions","content":"#### 4 Definitions\n\nIn these Rules:\n\nAct means the Private Health Insurance Act 2007.\n\naddiction medicine specialist means a specialist (within the meaning of the Health Insurance Act 1973) in relation to addiction medicine.\n\nbasic policy means an insurance policy that:\n\n(a) covers hospital treatment; and\n\n(b) covers at least the treatments in all of the clinical categories indicated for a basic policy in Schedule 4; and\n\n(c) is not a gold, silver or bronze policy.\n\nbronze policy means an insurance policy that:\n\n(a) covers hospital treatment; and\n\n(b) covers at least the treatments in all of the clinical categories indicated for a bronze policy in Schedule 4; and\n\n(c) is not a gold or silver policy.\n\ncertified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.\n\ncertified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.\n\nclinical category, for hospital treatment, means a clinical category that is set out in Schedule 5.\n\nconsultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\nconsultant psychiatrist means a specialist (within the meaning of the Health Insurance Act 1973) in relation to psychiatry.\n\ngeneral medical services table has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\ngold policy means an insurance policy that:\n\n(a) covers hospital treatment; and\n\n(b) covers the treatments in all of the clinical categories indicated for a gold policy in Schedule 4.\n\nimplantable cardiac event recorder includes a component of an implantable cardiac event recorder.\n\ninsulin infusion pump includes a component of an insulin infusion pump.\n\ninsurer means a private health insurer.\n\nMBS item means an item that is in, or which from time to time a determination under section 3C of the Health Insurance Act 1973 deems to be in, any of the following:\n\n(a) the general medical services table, made under section 4 of the Health Insurance Act 1973, as in force from time to time;\n\n(b) the diagnostic imaging services table, made under section 4AA of that Act, as in force from time to time;\n\n(c) the pathology services table, made under section 4A of that Act, as in force from time to time.\n\nNational Disability Insurance Scheme has the same meaning as in section 9 of the National Disability Insurance Scheme Act 2013.\n\nNational Disability Insurance Scheme launch has the same meaning as in section 9 of the National Disability Insurance Scheme Act 2013.\n\nNational Law means:\n\n(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or\n\n(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 that corresponds to the Health Practitioner Regulation National Law.\n\nNote: The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions that was made on 26 March 2008 provides for the enactment of the State and Territory legislation mentioned in this definition.\n\nparticipant has the same meaning as in section 9 of the National Disability Insurance Scheme Act 2013.\n\nperiod of pre‑upgrade hospital cover has the meaning given by subrule 9A(5).\n\nperson with a disability means a participant in the National Disability Insurance Scheme or the National Disability Insurance Scheme launch.\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\nproduct tier means:\n\n(a) for a gold policy—“gold”; and\n\n(b) for a silver policy—“silver”; and\n\n(c) for a bronze policy—“bronze”; and\n\n(d) for a basic policy—“basic”.\n\nprofessional attendance has the same meaning as in clause 1.2.3 of the general medical services table.\n\nprofessional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\npsychiatric treatment means hospital treatment, or hospital‑substitute treatment, that is psychiatric care.\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\nregistered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.\n\nNote: The registration requirements for a registered podiatric surgeon for the purpose of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules as made from time to time.\n\nsilver policy means an insurance policy that:\n\n(a) covers hospital treatment; and\n\n(b) covers at least the treatments in all of the clinical categories indicated for a silver policy in Schedule 4; and\n\n(c) is not a gold policy.\n\nspecialist psychiatric treatment means psychiatric treatment provided to a person who is:\n\n(a) an admitted patient of a hospital; and\n\n(b) under the care of an addiction medicine specialist or consult psychiatrist.\n\n> State, when used in Schedule 1, Schedule 2 or Schedule 3, means a risk equalisation jurisdiction.\n\nNote: The risk equalisation jurisdictions are set out in the Private Health Insurance (Health Benefits Fund Policy) Rules 2015. Under those rules, the area specified in each of the following paragraphs is a risk equalisation jurisdiction:\n\n> Note: (a) Australian Capital Territory, Norfolk Island and New South Wales;\n\n> Note: (b) Northern Territory;\n\n> Note: (c) Queensland;\n\n> Note: (d) South Australia;\n\n> Note: (e) Tasmania;\n\n> Note: (f) Victoria;\n\n> Note: (g) Western Australia and the Territory of Christmas Island and the Territory of Cocos (Keeling) Islands.\n\nupgrade, in relation to psychiatric treatment, has the meaning given by subrules 9A(2) and (3).\n\n> Note: Unless the contrary intention appears, terms used in these Rules have the same meaning as in the Act― see section 13 of the Legislative Instruments Act 2003. These terms include: \n> adult \n> applicable benefits arrangement \n> complying health insurance policy \n> complying health insurance product \n> cover \n> dependent non‑student \n> dependent person \n> dependent person with a disability \n> dependent student \n> general treatment \n> hospital cover \n> hospital‑substitute treatment \n> hospital treatment \n> medical practitioner \n> medicare benefit \n> policy holder \n> private health information statement \n> private health insurer \n> product \n> product subgroup \n> risk equalisation jurisdiction \n> rules \\[of an insurer\\] \n> transfer \n> waiting period","sortOrder":3},{"sectionNumber":"Part 2","sectionType":"part","heading":"General","content":"## Part 2 General","sortOrder":4},{"sectionNumber":"5","sectionType":"section","heading":"Insured groups","content":"#### 5 Insured groups\n\n(1) In this rule a non‑classified dependent person is a person under the age of 25, that is not a dependent student or dependent non‑student by the rules of the insurer.\n\n(2) For the purposes of paragraph 63‑5 (2A) (b) of the Act, the following insured groups are specified:\n\n (a) only one person;\n (b) only two adults;\n (c) two or more dependent people and no adults;\n (d) only one adult and at least one non‑classified dependent person under the age of 25, dependent child or dependent student;\n (e) only one adult and any number of non‑classified dependent people under the age of 25, dependent children or dependent students and at least one dependent non‑student;\n (f) only one adult and any number of non‑classified dependent people under the age of 25, dependent children or dependent students and at least one conditional dependent non‑student;\n (g) only one adult and at least one dependent person with a disability and any number of non‑classified dependent people under the age of 25, dependent children, dependent students, dependent non‑students or conditional dependent non‑students;\n (h) only two adults, and at least one non‑classified dependent person under the age of 25, dependent child or dependent student;\n (i) only two adults and any number of non‑classified dependent people under the age of 25, dependent children or dependent students and at least one dependent non‑student;\n (j) only two adults and any number of non‑classified dependent people under the age of 25, dependent children or dependent students and at least one conditional dependent non‑student;\n (k) only two adults and at least one dependent person with a disability and any number of non‑classified dependent people under the age of 25, dependent children, dependent students, dependent non‑students or conditional dependent non‑students.\n\n(3) If an insurer does not have insured groups in paragraphs 2(e), 2(f), 2(i) or 2(j) for a product, then insured groups in paragraphs 2(d) and 2(h) can include dependent non‑students or conditional dependent non‑students.\n\n(4) In this rule a conditional dependent non‑student is required to have their own policy covering general treatment with the same insurer that is covering them for hospital treatment.","sortOrder":5},{"sectionNumber":"5A","sectionType":"section","heading":"Psychiatric treatment—limitations","content":"#### 5A Psychiatric treatment—limitations\n\nFor the purposes of paragraph 63‑10(g) of the Act, an insurance policy must not reduce a benefit for psychiatric treatment provided to a person if the reduction is because of:\n\n(a) the number of psychiatric treatments, for which there is or has been an entitlement to a benefit under any policy, provided to the person during a period; or\n\n(b) the number of a particular kind of such psychiatric treatments provided to the person during a period.","sortOrder":6},{"sectionNumber":"6","sectionType":"section","heading":"Maximum percentage of discount","content":"#### 6 Maximum percentage of discount\n\n(1) For subparagraph 66‑5 (1) (c) (ii) of the Act, the maximum percentage discount allowed is 12% per annum.\n\n(2) The discount for a policy is the difference between the full premium and the net premium.\n\n(3) The full premium for a policy is the premium that would be received by the private health insurer for a policy in the same product subgroup without any reduction due to the circumstances set out in paragraphs 66‑5 (3) (a) to (ea) of the Act.\n\n(4) The net premium is the full premium less the cost, or the cost foregone, of any of the following:\n\n(a) incentive payment;\n\n(b) promotional payment;\n\n(c) rebate; and\n\n(d) any other inducement whatsoever,\n\nmade available by the insurer to another person, including to an insured person, in respect of the payment of the premium for the policy, including to induce a person to purchase or maintain a policy.\n\n(5) For the purposes of this rule, disregard:\n\n(a) a brokerage fee or commission paid in respect of the policy; and\n\n(b) the cost of any discount, product, service, waiver or other thing (promotion) offered to a person at the time the person first purchases a policy from the insurer if:\n\n(i) the cost of the promotion does not exceed 12% of the full premium, for a year, for the policy purchased; and\n\n(ii) the promotion is provided in the first year after the person purchases the policy; and\n\n(c) any age‑based discount that might apply in relation to the policy (see Part 2A).","sortOrder":7},{"sectionNumber":"7","sectionType":"section","heading":"Benefits authorised to be provided under a policy","content":"#### 7 Benefits authorised to be provided under a policy\n\n(1) In this rule, specified benefit means a benefit specified in subrule (3).\n\n(2) If a person was entitled to a specified benefit under an applicable benefits arrangement or a table of ancillary health benefits in force at the commencement of the Act, the provision of the same specified benefit under the person's policy is authorised for the purposes of paragraph 69‑1 (1) (b) of the Act as long as the person's policy continues to cover the same specified treatments and provide the same specified benefits.\n\nNote: Section 10 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of existing applicable benefits arrangements and tables of ancillary benefits at the commencement of the Act.\n\n(3) The specified benefits for this rule are:\n\n(a) benefits paid in connection with the birth of a baby;\n\n(b) funeral benefits;\n\n(c) disability benefits.\n\n(4) In this rule, ancillary health benefit means ancillary health benefits within the meaning of section 67 the National Health Act 1953 as in force immediately before the commencement of the Act.","sortOrder":8},{"sectionNumber":"8","sectionType":"section","heading":"Complying products―coverage requirements","content":"#### 8 Complying products―coverage requirements\n\n(1) For subsection 69‑1 (2) of the Act, a policy of a kind specified in the following table must also cover any treatment as specified in the table.\n\n```html\n

Coverage requirements

Item

Kind of policy

Treatments the policy must cover

1

A policy that includes cover for hospital‑substitute treatment.

Hospital treatment for the same types of treatment covered by the policy for hospital‑substitute treatment.

2

A policy under which a person is covered, wholly or partly, for hospital treatment where:

(a) the treatment includes the provision of a kind of medical device or human tissue product that is listed in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules, made under the Act, as in force from time to time; and

(b) either:

(i) a medicare benefit is payable in respect of the professional service associated with the provision of the medical device or human tissue product; or

(ii) the provision of the medical device or human tissue product is associated with podiatric treatment by a registered podiatric surgeon; or

(iii) for a medical device or human tissue product that is an insulin infusion pump:

(A) the insulin infusion pump is provided during a professional service for which a medicare benefit is payable; and

(B) the professional service is a professional attendance by a consultant physician in the practice of his or her specialty; and

(C) the professional service is provided as a certified Type C procedure or certified overnight Type C procedure; and

(D) the insulin infusion pump is provided for the purpose of administering insulin.

The provision of the medical device or human tissue product.

3

A policy under which a person is covered, wholly or partly, for hospital‑substitute treatment where:

(a) the treatment includes the provision of a medical device or human tissue product of a kind listed in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules, made under the Act, as in force from time to time; and

(b) a medicare benefit is payable in respect of the professional service associated with the provision of the medical device or human tissue product.

The provision of the medical device or human tissue product.

\n```\n\nNote: The Private Health Insurance (Medical Devices and Human Tissue Products) Rules set out the benefit requirements for medical devices and human tissue products listed in those Rules.\n\n(2) For the avoidance of doubt, a policy of a kind mentioned in the table may also be a policy that covers other types of treatment, unless excluded by rules made for the purpose of subsection 69‑1 (3).","sortOrder":9},{"sectionNumber":"8A","sectionType":"section","heading":"Benefit requirement―nursing‑home type patients","content":"#### 8A Benefit requirement―nursing‑home type patients\n\n(1) For paragraph 72‑1 (1) (b) of the Act, the requirement in subrule (2) is a benefit requirement for a policy that covers hospital treatment.\n\n(2) The requirement is that the amount of benefit payable under the policy in respect of hospital treatment at a hospital for a nursing‑home type patient must not exceed an amount equal to the fees or charges incurred in respect of that hospital treatment less the amount of the patient contribution in relation to the patient for each day on which the patient is a nursing‑home type patient at the hospital.\n\n(3) In this rule:\n\nnursing‑home type patient has the same meaning as in the Private Health Insurance (Benefit Requirements) Rules, made under section 333‑20 of the Act, as in force from time to time.\n\npatient contribution, for each day on which the patient is a nursing‑home type patient at the hospital, means:\n\n(a) in relation to a nursing‑home type patient at a public hospital, the following amount for the State or Territory in which the hospital is located:\n\n (i) Australian Capital Territory ‑ $78.95;\n (ii) New South Wales ‑ $80.95;\n (iii) Northern Territory ‑ $80.95;\n (iv) Queensland ‑ $80.95;\n (v) South Australia ‑ $80.95;\n (vi) Tasmania ‑ $80.94;\n (vii) Victoria ‑ $80.95; and\n (viii) Western Australia ‑ $80.95.\n\n(b) in relation to a nursing‑home type patient at a private hospital, $80.95.","sortOrder":10},{"sectionNumber":"9","sectionType":"section","heading":"Waiting periods―former gold card holders","content":"#### 9 Waiting periods―former gold card holders\n\n(1) The waiting period requirements in subsection 75‑1 (1) of the Act are modified in relation to insured persons referred to in subrule (2) by specifying the conditions set out in that subrule.\n\n(2) A policy that covers a person who:\n\n(a) held a gold card, or was entitled to treatment under a gold card, before applying for the insurance; and\n\n(b) applies for the insurance no longer than 2 months after the person ceased to hold, or be entitled under, the gold card,\n\nmust not apply to the person any waiting period or benefit limitation period for any hospital treatment or general treatment covered by the policy.\n\n(3) In this rule:\n\ngold card has the same meaning as in section 34‑15 of the Act.\n\nbenefit limitation period, in respect of the person's insurance policy, means a period:\n\n(a) starting at the time the person becomes insured under the policy referred to in this rule; and\n\n(b) ending at the time specified in the policy,\n\nduring which the amount of benefit in relation to any period is less than the amount for which the person would be eligible during any other period.","sortOrder":11},{"sectionNumber":"9AA","sectionType":"section","heading":"Terminating products—portability requirements","content":"#### 9AA Terminating products—portability requirements\n\n (1) For paragraph 78‑1 (5A) (c) of the Act, the matters are:\n (a) that the policy forms part of a product, or belongs to a product subgroup, that is being terminated and that will not be available to any person insured under a policy that forms part of the product or that belongs to the product subgroup, as appropriate (a terminating policy); and\n (b) that, as a consequence, the persons insured under the policy are to be transferred to another insurance policy; and\n (c) the date by which the transfer is to take place (the transfer date); and\n (d) that:\n (i) before the transfer date, the persons insured under the policy may transfer to any insurance policy of their choosing; but\n (ii) if they do not do so before the transfer date, they will be transferred, on the transfer date, to a specified insurance policy (the default policy); and\n (e) the matters set out in subrule(2) that relate to the default policy; and\n (f) the other matters set out in subrule (3) that relate to the transfer.\n Matters that relate to the default policy\n (2) For paragraph (1) (e), the matters are:\n (a) the private health information statement for the default policy; and\n (b) details of the premium that would be payable for the default policy, including any increase in the premium under Part 2‑3 of the Act (lifetime health cover), and any discounts that might apply; and\n (c) details of:\n (i) any treatments that are covered under the terminating policy that will not be covered under the default policy; and\n (ii) any differences between the excesses or co‑payments payable under the terminating policy and the default policy.\n Other matters that relate to the transfer\n (3) For paragraph (1) (f), the matters are:\n (a) that if:\n (i) a person transfers from the terminating policy to another policy, or is transferred to the default policy; and\n (ii) there are particular hospital treatments or hospital‑substitute treatments that are covered by both the terminating policy and the policy to which the person transfers or is transferred;\n for each such treatment, to the extent that the person has satisfied the waiting period (if any) under the terminating policy, the person will have satisfied the waiting period (if any) under the other policy; but\n (b) that if:\n (i) a person is transferred from the terminating policy to the default policy; and\n (ii) the person subsequently transfers from the default policy to another insurance policy (the replacement policy);\n then:\n (iii) if there are any treatments that were not covered by the default policy but that are covered by the replacement policy—the person may be subject to a waiting period under the replacement policy in respect of those treatments, even if the treatments were originally covered by the terminating policy; and\n (iv) if the default policy had higher excesses or co‑payments than the replacement policy—those higher excesses or co‑payments might, for a period of time, continue to apply under the replacement policy.","sortOrder":12},{"sectionNumber":"9A","sectionType":"section","heading":"Specialist psychiatric treatment—portability requirements","content":"#### 9A Specialist psychiatric treatment—portability requirements\n\n(1) For the purposes of subsection 78‑1(6) of the Act, subrules (4) to (8) of this rule modify the requirements of section 78‑1 of the Act in relation to:\n\n(a) an insurance policy (the new policy) to which a person transfers from another policy (the old policy), if:\n\n(i) the transfer is an upgrade in relation to psychiatric treatment; and\n\n(ii) the person chooses under rule 9B to have the upgrade treated in accordance with those subrules; and\n\n(b) a benefit (the higher benefit) under the new policy for specialist psychiatric treatment provided to the person.\n\n(2) The transfer is an upgrade, in relation to psychiatric treatment, if the benefit for psychiatric treatment under the new policy is higher than the benefit for psychiatric treatment under the old policy.\n\n(3) For the purposes of subrule (2), disregard any co‑payment or excess that is required to be paid under the old policy or the new policy in respect of psychiatric treatment.\n\nWaiting periods\n\n(4) The new policy must not:\n\n(a) if the length of the person’s period of pre‑upgrade hospital cover was 2 months or longer—apply to the person a waiting period for the higher benefit; or\n\n(b) otherwise—apply to the person a waiting period for the higher benefit that is longer than 2 months reduced by the length of the person’s period of pre‑upgrade hospital cover.\n\n(5) The person’s period of pre‑upgrade hospital cover is the longest period:\n\n(a) that ended immediately before the upgrade; and\n\n(b) at all times during which the person had hospital cover.\n\nRetrospective cover\n\n(6) Subrules (7) and (8) apply if the upgrade occurs:\n\n(a) on or after the day (the admission day) the person became an admitted patient of a hospital in relation to the specialist psychiatric treatment mentioned in paragraph (1)(b); and\n\n(b) on or before the fifth business day to occur on or after the admission day.\n\n(7) The new policy’s coverage of specialist psychiatric treatment must start no later than the admission day.\n\nExample: A person is admitted to hospital for specialist psychiatric treatment. The person’s insurance policy provides minimum benefits for psychiatric treatment. 3 business days later, the person upgrades to a new policy and chooses to have the upgrade treated in accordance with subrules (4) to (8). The higher benefits under the new policy for specialist psychiatric treatment must apply from the day of the admission.\n\n(8) Subrule (7) does not prevent the new policy from applying a waiting period in accordance with subrule (4). The reference in paragraph (5)(a) to the upgrade is taken to be a reference to the start of the new policy’s coverage of specialist psychiatric treatment.","sortOrder":13},{"sectionNumber":"9B","sectionType":"section","heading":"Specialist psychiatric treatment—choice to have upgrade treated in accordance with rule 9A","content":"#### 9B Specialist psychiatric treatment—choice to have upgrade treated in accordance with rule 9A\n\n(1) A person may choose to have an upgrade in relation to psychiatric treatment treated in accordance with subrules 9A(4) to (8) if the person has not previously made such a choice in relation to any such upgrade.\n\n(2) If:\n\n(a) a person transfers to an insurance policy (the new policy), and the transfer is an upgrade in relation to psychiatric treatment; and\n\n(b) a claim is made under the new policy for a benefit for specialist psychiatric treatment provided to the person; and\n\n(c) a benefit of the amount claimed is only payable under the new policy for the treatment if the person chooses to have the upgrade treated in accordance with subrules 9A(4) to (8);\n\nthe making of the claim is sufficient evidence of the person choosing to have the upgrade treated in accordance with those subrules.\n\n(3) For the purposes of paragraph (2)(c) of this rule, disregard any co‑payment or excess that is required to be paid under the new policy in respect of psychiatric treatment.","sortOrder":14},{"sectionNumber":"10","sectionType":"section","heading":"Transfer certificates","content":"#### 10 Transfer certificates\n\nFor section 99‑1 of the Act, the following periods are set out:\n\n(a) for subsection 99‑1 (1), certificate for the insured person―14 days;\n\n(b) for subsection 99‑1 (2), certificate for the new insurer―14 days;\n\n(c) for subsection 99‑1 (3), old insurer to provide a certificate to the new insurer on request―14 days.","sortOrder":15},{"sectionNumber":"11","sectionType":"section","heading":"Performance indicators","content":"#### 11 Performance indicators\n\nFor subsection 188‑1 (1) of the Act, the following performance indicators are set out:\n\n(a) the number and kind of complaints made to the Private Health Insurance Ombudsman about private health insurers;\n\n(b) changes in the number of insured persons in particular age groups;\n\n(c) changes in the number of episodes of hospital treatment and hospital‑substitute treatment, and the average number of episodes of each, for particular age groups;\n\n(d) changes in the nature of the episodes of hospital treatment and hospital‑substitute treatment, for which benefits are paid in particular age groups;\n\n(e) changes in the average amount of benefits paid for an insured person, or an episode of hospital treatment or hospital substitute treatment, in particular age groups.","sortOrder":16},{"sectionNumber":"Part 2A","sectionType":"part","heading":"Age‑based discounts","content":"## Part 2A Age‑based discounts\n\nNote 1: See paragraphs 63‑10 (g) and 66‑5 (3) (ea) of the Act.\n\nNote 2: Nothing in this Part requires a private health insurer to:\n\n> Note:  make age‑based discounts available under any product; or\n\n> Note:  if age‑based discounts are available under a product:\n\n> Note: – make such discounts available for all ages between 18 and 29 (inclusive); or\n\n> Note: – continue to make age‑based discounts available under the product.\n\nInstead, an age‑based discount policy may specify the ranges of ages, between 18 and 29 (inclusive), for which such discounts will be available (see subparagraph 11B (c) (i)).\n\nHowever, under this Part:\n\n> Note:  if a person is receiving an age‑based discount, the person is entitled to continue to receive the full discount until the person turns 41 (unless the insurer chooses to discontinue age‑based discounts under the product, or the person transfers to a different insurance policy), and might be entitled to receive a reduced discount for a number of years after turning 41; and\n\n> Note:  if age‑based discounts are available in relation to particular ages or particular ranges of ages for a particular product, they must be available in relation to those ages or ranges on the same terms and conditions for all insurance policies under that product (see section 63‑5 of the Act).","sortOrder":17},{"sectionNumber":"11A","sectionType":"section","heading":"Definitions","content":"#### 11A Definitions\n\n In this Part:\n\n> age‑based discount policy means an insurance policy that provides age‑based discounts.\n\n> discount assessment date, in relation to a person who is insured under an age‑based discount policy, means whichever of the following is applicable:\n\n (a) subject to paragraph (c), if the policy provided age‑based discounts at the date the person became insured—that date;\n (b) if the policy provided age‑based discounts at a date after the person became insured—the date the person was first eligible for an age‑based discount under the policy;\n (c) if:\n (i) the person transferred to the policy (the new policy) from another age‑based discount policy (the old policy); and\n (ii) at the time of the transfer, the new policy was stated to be a retained age‑based discount policy; and\n (iii) the person was not a dependent child under the old policy;\n the person’s discount assessment date under the old policy.\n\n> eligible person, in relation to an age‑based discount policy, means a person to whom a discount applies in accordance with paragraph 11B (c).\n\n> retained age‑based discount policy means an insurance policy:\n\n (a) that is an age‑based discount policy; and\n (b) that states that it is a retained age‑based discount policy.","sortOrder":18},{"sectionNumber":"11B","sectionType":"section","heading":"Requirements for age‑based discount policy to be complying health insurance policy","content":"#### 11B Requirements for age‑based discount policy to be complying health insurance policy\n\n For paragraph 63‑10 (g) of the Act, an insurance policy must not provide for an age‑based discount (the discount) unless:\n (a) the policy covers:\n (i) hospital treatment; or\n (ii) hospital treatment and general treatment; and\n (b) the discount will be a reduction in the amount that would otherwise be payable by the person for the policy, equal to the dollar amount calculated in accordance with rule 11C; and\n (c) the discount will apply to each person insured under the policy who, on the discount assessment date for the person:\n (i) was within one or more ranges of ages, between 18 and 29 (inclusive), that are specified in the policy as eligible for the discount; and\n (ii) was not a dependent person under the policy; and\n (d) while age‑based discounts are available under the policy, the discount will continue to apply until it is reduced, in accordance with rule 11C, to zero in relation to each such person insured under the policy; and\n (e) the policy states whether it is a retained age‑based discount policy.\n\n> Note: For paragraph (c), an insurer is not required to provide discounts for all ages between 18 and 29 (inclusive).","sortOrder":19},{"sectionNumber":"11C","sectionType":"section","heading":"Calculation of age‑based discount","content":"#### 11C Calculation of age‑based discount\n\nNote: This rule deals only with the calculation of the age‑based discount. The premium that is payable in respect of a particular insurance policy is also affected by other provisions of the Act (including Part 2‑3 of the Act, which deals with lifetime health cover) and rules made under the Act (including these Rules).\n\n (1) For paragraph 11B (b), the total age‑based discount that applies under an age‑based discount policy for a particular period is equal to the sum of the applicable discounts to which each eligible person who is insured under the policy is entitled for that period.\n (2) An eligible person is entitled to an applicable discount calculated in accordance with the following formula:\n ![Start formula applicable discount equals start fraction base rate for hospital cover times applicable percentage over number of adults insured end fraction end formula](image.002.png)\n where:\n\n> applicable percentage, for a particular period, is the greater of:\n\n (a) the person’s percentage for the period, determined in accordance with the table to subrule (3); and\n (b) zero.\n\n> base rate for hospital cover is the amount of premiums that would be payable for hospital cover under the policy if:\n\n (a) the premiums were not increased under Part 2‑3 of the Act (lifetime health cover); and\n (b) there were no discounts of the kind allowed under subsection 66‑5 (2) of the Act (including under this Part of these Rules).\n\n> number of adults insured is the number of adults insured under the policy.\n\n (3) For paragraph (a) of the definition of applicable percentage in subrule (2), the table is:\n\n| If, for that period, the person is aged: | the person’s percentage for the period is: |\n| ---------------------------------------- | ------------------------------------------------------ |\n| 18 or older, but under 41 | the person’s base percentage |\n| 41 | the person’s base percentage minus 2 percentage points |\n| 42 | the person’s base percentage minus 4 percentage points |\n| 43 | the person’s base percentage minus 6 percentage points |\n| 44 | the person’s base percentage minus 8 percentage points |\n| 45 or older | zero |\n\n (4) For subrule (3), a person’s base percentage is equal to:\n (a) for an eligible person under the policy—the percentage, as given by the following table, corresponding to the person’s age at the discount assessment date; and\n\nNote: See paragraph 11B (c).\n\n (b) otherwise—zero.\n\n| Person’s age at discount assessment date | Percentage |\n| ---------------------------------------- | ---------- |\n| 18 or older, but under 26 | 10% |\n| 26 | 8% |\n| 27 | 6% |\n| 28 | 4% |\n| 29 | 2% |","sortOrder":20},{"sectionNumber":"11D","sectionType":"section","heading":"Circumstances in which a person is entitled to age‑based discount","content":"#### 11D Circumstances in which a person is entitled to age‑based discount\n\n For paragraph 66‑5 (3) (ea) of the Act, a person is entitled to an age‑based discount for a particular period if:\n (a) the person is insured under an age‑based discount policy during that period; and\n (b) the person is an eligible person in relation to that policy; and\n (c) the person’s applicable discount for that period, as calculated in accordance with subrule 11C (2), is not equal to zero.","sortOrder":21},{"sectionNumber":"Part 2B","sectionType":"part","heading":"Requirements relating to product tiers for, and names of, insurance policies","content":"## Part 2B Requirements relating to product tiers for, and names of, insurance policies\n\nNote 1: This Part specifies additional requirements that an insurance policy must meet in order to be a complying health insurance policy, for the purposes of paragraph 63‑10 (g) of the Act.\n\nNote 2: Nothing in this Part affects the operation of Division 72 of the Act (which relates to benefit requirements for policies that cover hospital treatment) or the operation of the Private Health Insurance (Benefit Requirements) Rules for the calculation of minimum benefits where restricted cover is allowed under rule 11G.","sortOrder":22},{"sectionNumber":"11E","sectionType":"section","heading":"Product tiers for insurance policies that cover hospital treatment","content":"#### 11E Product tiers for insurance policies that cover hospital treatment\n\n (1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).\n (2) The policy must be one of the following:\n (a) a gold policy;\n (b) a silver policy;\n (c) a bronze policy;\n (d) a basic policy.","sortOrder":23},{"sectionNumber":"11F","sectionType":"section","heading":"Coverage of treatments for insurance policies that cover hospital treatment","content":"#### 11F Coverage of treatments for insurance policies that cover hospital treatment\n\n Application of rule\n (1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).\n Treatments that must be covered by policy\n (2) The policy must cover:\n (a) all hospital treatments that are within the scope of cover that is identified, in Schedule 5, for each clinical category in relation to which the policy provides cover (see subrules (5) and (6)); and\n (b) all hospital treatments that are not within the scope of cover of such a clinical category, but that are:\n (i) associated treatments for complications (see subrule (7)); or\n (ii) associated unplanned treatments (see subrule (8)).\n (3) However, the policy is not required to cover cosmetic surgery that is not medically necessary.\n Treatments that may be covered by policy\n (4) The policy may also provide either or both of the following:\n (a) accident cover;\n (b) benefits for travel or accommodation relating to a treatment referred to in subrule (2) or paragraph (a).\n Interpretation\n (5) For paragraph (2) (a), the scope of cover of a particular clinical category includes, but is not limited to:\n (a) all hospital treatments involving the provision of an MBS item listed in Schedule 5 against that clinical category; and\n (b) all hospital treatments:\n (i) that are provided in relation to a treatment of a kind referred to in paragraph (2) (a) or (5) (a); and\n (ii) involving the provision of an MBS item listed in:\n (A) the common treatments list in Schedule 6; or\n (B) the support treatments list in Schedule 7.\n (6) Paragraph (5) (b) does not apply in relation to the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”.\n (7) For subparagraph (2) (b) (i), a hospital treatment is an associated treatment for complications if it is:\n (a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and\n (b) provided for a complication that arises during that episode.\n (8) For subparagraph (2) (b) (ii), a hospital treatment is an associated unplanned treatment if it is:\n (a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and\n (b) an unplanned treatment that:\n (i) is provided as part of planned surgery performed during that episode; and\n (ii) is, in the view of the medical practitioner who provides the unplanned treatment, medically necessary and urgent.","sortOrder":24},{"sectionNumber":"11G","sectionType":"section","heading":"Provision of restricted and unrestricted cover","content":"#### 11G Provision of restricted and unrestricted cover\n\n Gold policies\n (1) A gold policy must provide unrestricted cover for all hospital treatments in all clinical categories.\n Silver policies and bronze policies\n (2) A silver policy or a bronze policy:\n (a) must provide restricted cover or unrestricted cover for all hospital treatments in the following clinical categories:\n (i) rehabilitation;\n (ii) hospital psychiatric services;\n (iii) palliative care; and\n (b) must provide unrestricted cover for all hospital treatments in:\n (i) the other clinical categories that a silver policy or a bronze policy, as appropriate, is required to cover; and\n (ii) any other clinical categories that the policy covers.\n Basic policies\n (3) A basic policy must provide restricted cover or unrestricted cover for all hospital treatments in:\n (a) all of the clinical categories that a basic policy is required to cover; and\n (b) any other clinical categories that the policy covers.","sortOrder":25},{"sectionNumber":"11H","sectionType":"section","heading":"Naming of insurance policies that cover hospital treatment","content":"#### 11H Naming of insurance policies that cover hospital treatment\n\n (1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).\n (2) The policy must include a name that contains the policy’s product tier.\n (3) If the policy covers one or more clinical categories additional to those required for a policy of that product tier in Schedule 4, the name may also contain “plus” or “+”.\n (4) The name must not contain:\n (a) the name of any other metal; or\n (b) the name of any gemstone or any semi‑precious stone; or\n (c) unless permitted by subrule (3)—either “plus” or “+”.","sortOrder":26},{"sectionNumber":"11J","sectionType":"section","heading":"Naming of insurance policies that cover general treatment only","content":"#### 11J Naming of insurance policies that cover general treatment only\n\n (1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers general treatment only.\n (2) The policy must include a name that does not contain:\n (a) the name of any metal; or\n (b) the name of any gemstone or any semi‑precious stone; or\n (c) either “plus” or “+”.","sortOrder":27},{"sectionNumber":"Part 3","sectionType":"part","heading":"Private health information statements and other information that must be given","content":"## Part 3 Private health information statements and other information that must be given\n\nNote: This Part deals with:\n\n the information and form for private health information statements, for the purposes of subsection 93‑5 (1) of the Act, and methods by which private health information statements are made available; and\n\n information that must be provided to the Private Health Insurance Ombudsman relating to changes in premiums.\n\nThis Part does not limit the information that a private health insurer may give to an insured person.","sortOrder":28},{"sectionNumber":"12","sectionType":"section","heading":"Private health information statements","content":"#### 12 Private health information statements\n\nNote: See rule 20 for a transitional provision relating to this rule that applies until 31 March 2020.\n\n(1) For subsection 93‑5 (1) of the Act, the information to be contained in a private health information statement, and the form, for a product subgroup of a complying health insurance product, are:\n\n(a) the information and form of words set out in Schedule 1; and\n\n(b) if policies that belong to the product subgroup cover hospital treatment—the additional information, and the form of words, set out in Schedule 2; and\n\n(c) if policies that belong to the product subgroup cover general treatment—the additional information, and the form of words, set out in Schedule 3.\n\n(2) However, paragraph (1)(c) does not apply if the only general treatment provided is ambulance cover.","sortOrder":29},{"sectionNumber":"13","sectionType":"section","heading":"Method of making private health information statements available","content":"#### 13 Method of making private health information statements available\n\n(1) This rule is made for the purposes of subsection 93‑5 (2) and paragraph 93‑15 (1) (a) of the Act.\n\n(2) If:\n\n(a) the private health information statement is accompanied by information additional to the information and form of words that are required by subrule 12 (1); and\n\n(b) the private health information statement and the additional information are set out in the same document;\n\nthe additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).\n\nExample: The document on which a private health information statement is provided might include information about ambulance cover that is additional to the information required by item 10 of the table to clause 2 of Schedule 1\\. The additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.","sortOrder":30},{"sectionNumber":"14","sectionType":"section","heading":"Information relating to changes to premiums to be provided to Private Health Insurance Ombudsman","content":"#### 14 Information relating to changes to premiums to be provided to Private Health Insurance Ombudsman\n\n(1) This rule is made for the purposes of section 96‑25 of the Act.\n\n(2) This rule applies if the Minister has approved a proposed change to the premiums charged under a complying health insurance product of a private health insurer under subsection 66‑10 (3) of the Act.\n\n(3) The private health insurer must notify the Private Health Insurance Ombudsman of:\n\n(a) the premiums that applied before the approval; and\n\n(b) the premiums that apply after the approval.\n\n(4) The insurer must give this information to the Ombudsman before the end of the day that is the later of:\n\n(a) 1 February immediately following the day the Minister approved the change; or\n\n(b) 20 business days after the day the Minister approved the change.","sortOrder":31},{"sectionNumber":"15","sectionType":"section","heading":"Information provided to insured persons","content":"#### 15 Information provided to insured persons\n\n (1) This rule is made for the purposes of section 96‑25 of the Act.\n (2) When giving an insured person a copy of a private health information statement in accordance with section 93‑15 or subsection 93‑20 (1) of the Act, the private health insurer must inform the person of the following:\n (a) the name of each person who is covered by the policy;\n (b) if the product subgroup to which the policy belongs covers hospital treatment—the following statements for each adult who is covered by the policy and to whom a lifetime health cover loading applies, with the bracketed text replaced with the appropriate amounts:\n (i) “Your Lifetime Health Cover Loading is \\[Number\\]%.”;\n (ii) “You have \\[the period of time expressed in years, months, days as appropriate\\] remaining until you have reached 10 continuous years of cover and your loading is removed.”.\n (3) However, the insurer does not need to inform the person of the information referred to in subrule (2) more than once in any 12 month period.\n (4) The information referred to in subrule (2) may be accompanied by either or both of the following:\n (a) information additional to the information and form of words that are required by subrule 12 (1);\n (b) other information about the policy and how it pertains to the person.\n\n> Note: Example for paragraph (4) (b): An insurer may also inform an insured person of:\n\n> Note:  the premium for hospital treatment and for general treatment that applies in relation to each adult insured under the policy, taking account of matters such as loadings, rebates and discounts; and\n\n> Note:  the remaining portion (if any) of the waiting period for any or each treatment covered by the policy.\n\n (5) If the private health information statement and the additional information referred to in subrule (2) and paragraphs (4)(a) and (b) are set out in the same document, the additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).\n\n> Note: Example: The document on which a private health information statement is provided might include information about the monthly premium that is payable by the insured person under the policy that is additional to the information required by item 6 of the table to clause 2 of Schedule 1\\. That additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.","sortOrder":32},{"sectionNumber":"16","sectionType":"section","heading":"Information provided to persons about product subgroups","content":"#### 16 Information provided to persons about product subgroups\n\n For subsection 93‑5 (2) of the Act, if a person asks an insurer for information about a complying health insurance product, the insurer must give the person a copy of the private health information statement for a product subgroup of that product:\n (a) by post; or\n (b) if the person has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the person.\n\n> Note: Example: If requested by an insured person, a private health information statement may be provided in an electronic format, including via a web page.","sortOrder":33},{"sectionNumber":"Part 4","sectionType":"part","heading":"Pilot Projects","content":"## Part 4 Pilot Projects","sortOrder":34},{"sectionNumber":"17","sectionType":"section","heading":"Kinds of pilot projects","content":"#### 17 Kinds of pilot projects\n\nThe kinds of pilot projects specified for subsection 55‑15(2) of the Act are projects that enable an insurer to trial and develop, with a limited group of policy holders, new models of service delivery or health care. The objectives of the pilot project must be for any or all of the following:\n\n(a) to increase the value to consumers of their health insurance products by better meeting their needs;\n\n(b) to prolong health, improve quality of life and reduce expenditure on hospital benefits by preventing and reducing disease and prevent the need for hospitalisation;\n\n(c) to produce products that better reflect advances in medical knowledge and service delivery models.","sortOrder":35},{"sectionNumber":"18","sectionType":"section","heading":"Requirements of pilot projects","content":"#### 18 Requirements of pilot projects\n\nFor the purposes of sub‑section 55‑15(2) of the Act, a pilot project of a kind specified in rule 17 is to be conducted in accordance with all the following requirements:\n\n(a) an insurer must not charge a person to participate in the project;\n\n(b) participation in a pilot project must be voluntary;\n\n(c) a pilot project may be conducted for a maximum of four years;\n\n(d) an insurer may only limit participation in a pilot project on the basis of where a person lives;\n\n(e) an insurer must develop a written plan for a pilot project, including a timeline and evaluation process;\n\n(f) written notice of the details of the project, including a copy of the written plan referred to in (e), must be provided to the Department at least 28 days before the pilot project commences.","sortOrder":36},{"sectionNumber":"Part 5","sectionType":"part","heading":"Transitional provisions","content":"## Part 5 Transitional provisions","sortOrder":37},{"sectionNumber":"19","sectionType":"section","heading":"Transitional provisions relating to the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018","content":"#### 19 Transitional provisions relating to the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018\n\nDefinitions\n\n(1) In this rule:\n\namending rules means the Private Health Insurance (Complying Product) Amendment (Psychiatric Care) Rules 2018.\n\nApplication of subrule 9A(4)\n\n(2) Subrule 9A(4), as inserted by the amending rules, applies to a waiting period that ends on or after 1 April 2018, whether the upgrade occurred before, on or after 1 April 2018.\n\nApplication of subrules 9A(6) to (8)\n\n(3) Subrules 9A(6) to (8), as inserted by the amending rules, apply to an upgrade that occurs on or after 1 April 2018.\n\n(4) If a person:\n\n(a) became an admitted patient of a hospital in relation to specialist psychiatric treatment before 1 April 2018; and\n\n(b) is still an admitted patient in relation to the treatment on 1 April 2018;\n\nthe reference in paragraph 9A(6)(a), as inserted by the amending rules, to the day the person became an admitted patient of a hospital in relation to the treatment is taken to be a reference to 1 April 2018.\n\n(5) If subrule 9A(7), as inserted by the amending rules, would, apart from this subrule, require an insurance policy’s coverage of specialist psychiatric treatment to start before 1 April 2018, subrule 9A(7) is taken to require the coverage to start no later than 1 April 2018.","sortOrder":38},{"sectionNumber":"2","sectionType":"section","heading":"Information and form of words for private health information statement—all policies","content":"#### 2 Information and form of words for private health information statement—all policies\n\nFor paragraph 12 (1) (a) of these Rules, the information and form of words are set out in the following table:\n\n```html\n

Information and form of words for private health information statement—all policies

Item

Information and form of words

1

Policy name

The name of the policy.

Note: See rules 11H and 11J for rules governing the naming of policies that cover hospital treatment and the naming of policies that cover general treatment.

2

Name of private health insurer

The trading or brand name of the private health insurer in the State in which the policy is being made available, together with any associated branding that the insurer elects to include.

3

Disclaimer for restricted access insurers

If the policy is offered by a restricted access insurer—the following statement:

“Membership of this insurer is restricted to”

followed by the details.

4

Contact details

A contact phone number and website address of the private health insurer.

5

State/s available in

The States in which the product is available, expressed as either:

(a) if:

(i) the product is offered in all States; and

(ii) every feature of the product (including the monthly premium referred to in
item 6) is the same in each State;

“All States”; or

(b) otherwise—the State or States in which the product is available, expressed as
whichever of the following is applicable:

(i) “NSW & ACT”;

(ii) “Northern Territory”;

(iii) “Queensland”;

(iv) “South Australia”;

(v) “Tasmania”;

(vi) “Victoria”;

(vii) “Western Australia”.

6

Monthly premium

The total monthly premium payable before any rebate, loading or discount is applied.

The following words must be inserted before or following the premium amount: “before any rebate, loading or discount”.

Note: This item does not limit the information that a private health insurer may give to an insured person with regard to the premium payable after any rebate, loading and/or discount is applied.

7

Corporate products

If the policy is part of a corporate product—a statement to that effect, indicating either of the following, with the bracketed text replaced with the appropriate information:

(a) “Employees/members of [Company/Organisation]”;

(b) “Employees/members of organisations with arrangements with this health insurer”.

8

Closed products

If the policy is closed so that it is no longer available to anyone except those persons who, at the time of closing, were insured under the policy—the following words:

“This policy is closed to new members.”.

9

Who is covered

The insured groups that may be covered, expressed as whichever of the following is applicable:

(a) “only one person”;

(b) “2 adults (and no‑one else)”;

(c) “2 or more people, none of whom is an adult”;

(d) “2 or more people, only one of whom is an adult”;

(e) “3 or more people, only 2 of whom are adults”;

(f) “3 or more people, at least 3 of whom are adults”.

Note 1: The insured groups are set out in rule 5 of these Rules.

Note 2: This item does not limit the information that a private health insurer may give to an insured person with regard to the name/s of person/s covered by the policy.

10

Ambulance cover

The following information:

(a) whether ambulance cover is included;

(b) if so:

(i) the waiting period (if any); and

(ii) whether the cover is:

(A) emergency only; or

(B) emergency and non‑emergency; and

(iii) any limits on cover (dollar amount or service); and

(iv) any call‑out fees (if applicable);

(c) for each State in which:

(i) the product is available; and

(ii) ambulance cover is not included;

the following information:

(iii) whether free ambulance services are available in that State;

(iv) if so—whether they are limited to services in that State;

(d) if ambulance cover were to be provided by a person other than the private health
insurer who prepared the statement—whether the policy would provide a benefit for
that cover.

11

Date available

If, and only if, the policy is not yet available—the date from which the policy will be available.

12

Date statement issued or updated

The date on which the content of the statement was issued or updated, in the following format, with the bracketed text replaced with the appropriate information:

“Date statement [issued/updated]: [dd]/[month in words]/[yyyy]”

13

Unique identifier

The unique identifier for the private health information statement that is generated by the privatehealth.gov.au system.

\n```","sortOrder":40}],"analysis":{"flash_summary":{"complexity_score":9,"scope_assessment":{"changed":true,"description":"Yes. The Rules have expanded beyond a minimal technical implementation of the Act into a comprehensive operational framework that standardises product tiers, imposes detailed naming and disclosure requirements, prescribes exact clinical category mappings to MBS item numbers, creates a specific age‑based discount regime, and adds consumer protections around psychiatric treatment upgrades and portability. Compared with a narrow original purpose of defining what makes a product \"complying\", this version layers many additional prescriptive consumer‑facing and insurer‑facing obligations (examples: Part 2A age‑based discounts; Part 2B product tiers/naming and restricted/unrestricted cover rules; detailed private health information statement templates in Schedules 1–3; specialist psychiatric portability in rules 9A–9B; and the extensive clinical category/MBS mapping in Schedule 5). Those additions increase regulatory detail, administrative burden on insurers, and reliance on external lists, thereby broadening the instrument's practical scope and implementation requirements."},"complexity_factors":["Extensive definitions section with many specialised terms and cross‑references to other Acts and Rules (rule 4 referencing the Private Health Insurance Act 2007, Health Insurance Act 1973, National Disability Insurance Scheme Act 2013, National Law, and other instrument lists).","Large number of schedules containing precise templates and data: Schedules 1–3 (private health information statement wording and multiple items), Schedule 4 (product tier matrix), Schedule 5 (detailed clinical categories mapped to hundreds of MBS item numbers), Schedule 6 and Schedule 7 (common and support MBS lists) — together hundreds of listed MBS items and tables.","Multiple conditional and nested rules: e.g. age‑based discount calculation with a formula and multi‑step percentage reductions depending on age and discount assessment date (rules 11B–11C).","Portability and waiting‑period rules with timing conditions and retrospective cover window for psychiatric upgrades, including choice mechanics for insured persons (rules 9A, 9B, 9AA).","Cross‑instrument dependencies and references to external changing lists (MBS tables, Prostheses Rules, Medical Devices and Human Tissue Products Rules), creating ongoing interpretive complexity (rule 8 and numerous schedule notes).","Detailed consumer disclosure mandates with prescribed wording and formatting requirements across multiple items (Schedules 1–3) — increases compliance detail and potential for minor drafting errors to cause non‑compliance.","Nested exceptions and permutations for product naming and restricted vs unrestricted cover across product tiers (rules 11F–11J and rule 11G).","Transitional provisions and amendment history affecting scope and timing (rule 19 referencing 2018 psychiatric amendment), adding temporal conditionals to application of rules.","Multiple timelines and administrative time limits (e.g. transfer certificate periods, Ombudsman notification deadlines, pilot project notice periods) requiring precise operational processes (rules 10, 14, 18)."],"plain_english_summary":"**What these Rules do (short version)**\n\n- They set out in detail what a \"complying\" private health insurance product must look like for the Private Health Insurance Act 2007 to treat it as meeting legal requirements. (A \"complying\" product is one that counts for things like Medicare Levy Surcharge exemptions and lifetime health cover.)\n\n- The Rules specify: definitions, required minimum hospital and ancillary coverage by product tier (gold / silver / bronze / basic), how waiting‑periods and portability work (including special rules for psychiatric care), maximum allowable premium discounts, templates and mandatory content for consumer information statements, naming rules for products, age‑based discount mechanics, reporting and notice requirements, and limited rules for insurer pilot projects. (See rules 4, 11E–11J, 9A–9B, 6, 12–16, 11A–11D, 17–18.)\n\n**Who is affected**\n\n- Private health insurers: they must design, label and document their products to meet the coverage, naming, discount, information and procedural rules in this instrument (rules 11F–11J, 11B, 12). Insurers also must notify the Ombudsman of approved premium changes (rule 14) and follow transfer/portability procedures (rules 9A, 9AA, 10).\n\n- Policy holders and prospective buyers: the Rules control what treatments must be covered under each product tier, the wording of the private health information statement shown to consumers, waiting period and portability protections (including retrospective application in certain psychiatric upgrades), and how age‑based discounts operate (rules 11F, Schedules 1–3, rules 9A–9B, 11B–11C).\n\n- Health care providers and hospitals are indirectly affected because the Rules mandate cover for specified clinical categories and list many MBS item numbers that determine what insurers must (or may) reimburse (Schedule 5 and Schedules 6–7).\n\n**Why it matters (mechanics, not politics)**\n\n- Product structure and minimum benefits: the Rules convert high‑level statutory requirements into operational categories and concrete benefit obligations. They define what \"gold/silver/bronze/basic\" mean in terms of clinical categories that must be covered and whether cover may be restricted (rules 11E–11G; Schedule 4; Schedule 5). That constrains insurers’ product design and what consumers can reasonably expect for each tier.\n\n- Transparency and consumer choice: the Rules prescribe a standard private health information statement with exact wording and content items (Schedule 1, plus Schedules 2 and 3 for hospital and general treatment). Insurers must present premiums \"before any rebate, loading or discount\" and include waiting periods, excesses, co‑payments and other key facts (rule 12; Schedule 1 item 6; Schedule 2 items 5–8). This reduces information asymmetry between insurers and consumers but increases compliance work for insurers.\n\n- Pricing and discounts: the Rules cap the maximum percentage discount at 12% p.a. and set a definition of full vs net premium and what inducements must be included when calculating the discount (rule 6). They also create a detailed regime for voluntary age‑based discounts with a step‑down schedule after age 41 and rules about retention of earlier discounts (Part 2A, rules 11A–11D). These mechanics shape insurers’ pricing incentives and how they market to younger customers.\n\n- Portability and waiting periods: the Rules narrow ambiguity about transfer of waiting‑period credit and give special protections for psychiatric treatment upgrades (rules 9A–9B), and former gold card holders (rule 9). They also require transfer certificates within specified time frames (rule 10). Those provisions affect consumer mobility between funds and the moment benefits become payable when switching products.\n\n- Provider‑level detail: by mapping clinical categories to explicit MBS item numbers and support/common treatment lists (Schedules 5–7), the Rules tie insurer obligations to the Medicare Benefits Schedule (MBS) and other external lists (e.g. prostheses, medical devices rules). That creates precise, technical dependence on external instruments (see rule 8 and Schedules 5–7).\n\n**Who pays, who decides, and what behaviour changes**\n\n- Who pays: insured persons ultimately pay via premiums, excesses and co‑payments; insurers pay claims according to the benefits the Rules require. Where the Rules require additional cover or restrict discounting, that affects insurer cost structures and therefore likely premium pricing (see rules 6, 11F, 11G).\n\n- Who decides: Parliament set the Act; these Rules (made under the Private Health Insurance Act 2007 — rule 3A) bind insurers. Insurers still decide product specifics within the boundaries set (e.g. whether to offer age‑based discounts, what extra clinical categories to include, whether to offer preferred‑provider schemes), but must follow naming, coverage, disclosure and procedural prescriptions (rules 11B, 11H–11J, 12–16).\n\n- Behaviour changes expected:\n - Insurers must structure products to satisfy the tiered coverage matrices and labelling rules, which constrains product naming and permitted cover restrictions (rules 11E–11J, Schedule 4).\n - Insurers must prepare and publish standardised private health information statements and keep them updated (rule 12, Schedule 1–3), increasing administrative compliance and reducing variance in how product features are disclosed.\n - Insurers face limits on discounting practices (rule 6) and formal rules for age‑based discounts (Part 2A), shaping promotional strategies and customer acquisition tactics.\n - Consumers gain more predictable portability and waiting‑period outcomes—particularly for psychiatric care upgrades and former gold card holders—reducing risk when switching products (rules 9, 9A–9B, 9AA).\n\n**Official rationale and trade‑offs (brief testing of stated purposes against costs and incentives)**\n\n- The Rules claim to standardise products and improve transparency so consumers can compare and insurers can compete on comparable terms (see Schedules 1–3 and Part 2B). Mechanically, standardisation increases comparability but raises compliance costs: insurers must maintain template statements, map product features to the clinical category/MBS lists and ensure naming conforms (rules 12, 11H–11J; Schedules 1–3, 5–7).\n\n- The product‑tier and minimum coverage rules reduce product heterogeneity and protect consumers from misleading metal/tier names; the trade‑off is reduced product design flexibility for insurers and potential limits to niche offers unless structured as additional categories or restricted cover where permitted (rules 11E–11G, Schedule 4). Insurers can still offer extras but only within permitted forms and disclosure requirements.\n\n- Age‑based discounts are designed to encourage younger people to join private cover (Part 2A). The Rules prescribe how long discounts may be retained and how they step down after age 41 (rules 11A–11C). That makes the subsidy predictable but may reduce insurers’ ability to run bespoke youth promotions beyond the capped mechanics and could create cross‑subsidy implications in pricing.\n\n- The detailed mapping to MBS item numbers and external rules (prostheses, medical device lists) ties insurer obligations to healthcare provider billing practice and to other legislative instruments. That precision reduces ambiguity but creates dependence and potential administrative churn whenever the MBS or those external lists change (rule 8, Schedules 5–7; cross references to Health Insurance Act and other Rules).\n\n**Implementation and compliance risks**\n\n- High administrative burden for insurers to keep private health information statements and product documentation current, and to map products to the many clinical categories and MBS items. (Schedules 1–3; Schedules 5–7.)\n\n- Operational risk where the Rules rely on external lists (MBS, prostheses, medical device rules): updates to those instruments can trigger complex product adjustments.\n\n- Some conditional rules (e.g. psychiatric upgrade retrospective cover windows, interaction between terminating/default policies and portability of waiting periods) create timing and recordkeeping requirements that, if misapplied, could produce consumer disputes (rules 9A–9B, 9AA, 10).\n\n**Key sections to look up quickly**\n\n- Definitions and scope: rule 4.\n- Product tiers and minimum coverage: rules 11E–11G and Schedule 4 (clinical categories in Schedule 5).\n- Private health information statement content and templates: rule 12 and Schedules 1–3.\n- Maximum discount rules: rule 6; age‑based discounts: Part 2A (rules 11A–11D, 11C formula).\n- Portability, transfer and waiting‑period special rules: rules 9, 9A–9B, 9AA, 10.\n- Pilot project rules: 17–18.\n\n"},"kimi_summary":{"_metrics":{"completionTokens":939},"content_quality":"ok","complexity_score":8,"scope_assessment":{"changed":true,"description":"The legislation has expanded significantly from its original 2015 form. Major additions include: Part 2A (age-based discounts, 2017), Part 2B (product tier system, 2019), and substantial amendments to psychiatric treatment portability rules (2018). The 2019 reforms introducing the Gold/Silver/Bronze/Basic tier system represented a fundamental restructuring of how hospital cover is categorised and marketed, going well beyond the original rules' focus on disclosure and basic compliance requirements."},"complexity_factors":["Extensive cross-referencing between multiple legislative instruments (Private Health Insurance Act 2007, Health Insurance Act 1973, National Disability Insurance Scheme Act 2013)","47+ defined terms in the interpretation section, many incorporating definitions from other Acts","Nested conditional logic throughout — for example, Rule 9A's psychiatric upgrade provisions have multiple layers of \"if/then\" conditions with time-based calculations","Three detailed schedules (Schedules 1-3) specifying exact wording for consumer disclosures, with HTML table formatting in the legislative text","Schedule 5 contains a 38-row table mapping clinical categories to hundreds of specific MBS item numbers","Multiple formula-based calculations for age-based discounts (Rule 11C) with percentage tables and conditional reductions","Complex portability rules (Rule 9AA) for terminating products with cascading conditions about waiting periods and excesses","Transitional provisions (Rule 19) with date-specific application rules for amendments","Product tier system creates a matrix of coverage requirements with \"restricted\" vs \"unrestricted\" variations"],"plain_english_summary":"These rules define what private health insurance must include to qualify as a \"complying product\" in Australia, by imposing minimum coverage standards, pricing and discount limits, and strict disclosure and naming requirements (the Gold/Silver/Bronze/Basic framework). They reshape how policies are structured and compared, affecting insurers, buyers and regulators by increasing transparency and ensuring baseline protections."},"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"}},"importantCases":[],"_links":{"self":"/api/acts/private-health-insurance-complying-product-rules-2015","history":"/api/acts/private-health-insurance-complying-product-rules-2015/history","analysis":"/api/acts/private-health-insurance-complying-product-rules-2015/analysis","conflicts":"/api/acts/private-health-insurance-complying-product-rules-2015/conflicts","importantCases":"/api/acts/private-health-insurance-complying-product-rules-2015/important-cases","documents":"/api/acts/private-health-insurance-complying-product-rules-2015/documents"}}