{"id":"F2025L00896","name":"Private Health Insurance (Health Benefits Fund Policy) Rules 2025","slug":"private-health-insurance-health-benefits-fund-policy-rules-2025","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":442908,"registerId":"F2025L00896-fast-fetch-1775957820083","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Private Health Insurance (Health Benefits Fund Policy) Rules 2025","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n![Commonwealth Coat of Arms of Australia](image.001.jpeg)\n\n \n\nPrivate Health Insurance (Health Benefits Fund Policy) Rules 2025\n\nI, Paul McBride, delegate of the Minister for Health and Ageing, make the following rules.\n\nDated, 30 July 2025 \n\n \n\n \n\nPaul McBride \n\nAssistant Secretary   Private Health Strategy Branch   Health Systems Strategy Division    Strategy and First Nations Group   Department of Health, Disability and Ageing\n\n \n\n \n\n \n\n \n\nContents\n\nPart 1  Preliminary............................................1\n\n1  Name...................................................1\n\n2  Commencement............................................1\n\n3  Authority................................................1\n\n4  Definitions...............................................1\n\n5  Schedules................................................1\n\nPart 2  Meaning of health-related business..............................2\n\n6  Overseas treatment...........................................2\n\n7  Agency business............................................2\n\nPart 3  Risk equalisation jurisdictions.................................3\n\n8  Areas that are risk equalisation jurisdictions............................3\n\nPart 4  Operation of health-related businesses through health benefits funds..........3\n\n9  Insurance for overseas students or specified temporary visa holders..............3\n\nSchedule 1—Repeals 5\n\nPrivate Health Insurance (Health Benefits Fund Policy) Rules 2015 5\n\n \n\nPart 1  Preliminary\n\n1  Name\n\nThis instrument is the Private Health Insurance (Health Benefits Fund Policy) Rules 2025.\n\n2  Commencement\n\n1.     Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n\n \n\n- Commencement information\n- Column 1 Column 2 Column 3\n- Provisions Commencement Date/Details\n- 1. The whole of this instrument The day after this instrument is registered\n\n\nNote:  This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n1.     Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.\n\n\n3  Authority\n\nThis instrument is made under the Private Health Insurance Act 2007.\n\n4  Definitions\n\nNote: A number of expressions used in this instrument are defined in the Act, including the following:\n\n(a) general treatment;\n\n(b) health benefits fund;\n\n(c) hospital treatment;\n\n(d) medicare benefit;\n\n(e) policy holder;\n\n(f) private health insurer.\n\nIn this instrument:\n\nAct means the Private Health Insurance Act 2007.\n\n5  Schedules\n\nEach instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.\n\nPart 2  Meaning of health-related business\n\n6  Overseas treatment\n\n (1) For the purposes of paragraph 131-15 (1) (d) of the Act, the business described in subrule (2) is specified.\n\n (2) A business of undertaking of liability, by way of insurance, for the provision to a person outside Australia of treatment that is intended to manage a disease, injury or condition, but only when:\n\n1.     the disease, injury or condition is chronic and permanent; and\n2.     the liability is confined to treatment that would be required routinely, whether or not the person had remained in Australia; and\n3.     the amount of the liability incurred by the insurer for any particular treatment does not exceed the amount of the liability that would be incurred by the insurer for that treatment if it were provided to the person in Australia; and\n4.     the liability does not extend to any treatment administered to a person more than 60 days after the person last departed from Australia.\n\n\n7  Agency business\n\n1.     For the purposes of paragraph 131-15 (1) (d) of the Act, a business of the offering of goods, services or benefits by a private health insurer under an agency arrangement is specified.\n2.     In this rule agency arrangement means a written arrangement between a person (the agent) and another person (the principal) under which:\n  1.     the agent is permitted to act on behalf of the principal to create legal relations between the principal and a third person in transactions to provide goods, services or benefits; and\n  2.     the principal assumes liability for the transaction to the third person, including for the provision of the goods, services or benefits; and\n  3.     the agent assumes no liability in respect of the transaction, other than to perform its obligations under the arrangement for and on behalf of the principal.\n\n\nNote: An example of the specified business is a private health insurer offering travel insurance policies under an arrangement with an overseas travel insurance company where the principal assumes the insurable risks under the policy and responsibility for the provision of benefits under the policy, and the private health insurer takes on no such liability, except to duly perform its obligations under the contract or agreement between it and the overseas travel insurance company which establishes the agency arrangement.\n\n \n\nPart 3  Risk equalisation jurisdictions\n\n8  Areas that are risk equalisation jurisdictions\n\n1.     For subsection 131-20(1) of the Act, each of the following areas are a risk equalisation jurisdiction:\n  1.     the area comprising the Australian Capital Territory, Norfolk Island and New South Wales;\n  2.     the Northern Territory;\n  3.     Queensland;\n  4.     South Australia;\n  5.     Tasmania;\n  6.      Victoria;\n  7.     the area comprising Western Australia, the Territory of Christmas Island and the Territory of Cocos (Keeling) Islands.\n\n\nPart 4  Operation of health-related businesses through health benefits funds\n\n9  Insurance for overseas students or specified temporary visa holders\n\n1.     This section applies if a private health insurer has a health benefits fund in respect of its health insurance business and some or all of its health-related businesses.\n2.     For section 131-25 of the Act, requirements are specified in subrule (3) relating to how the insurer must conduct that health-related business.\n3.    The private health insurer must not:\n  1.     take or fail to take any action; or\n  2.    in making a decision, have regard to or fail to have regard to any matter;\n\n\nthat would result in the insurer improperly discriminating between people who are, or wish to be, insured under an overseas student health insurance contract or specified temporary visa holder health insurance contract of the insurer.\n\n1.     In this rule, improper discrimination is discrimination that relates to:\n  1.     the suffering by a person from a chronic disease, illness or other medical condition or from a disease, illness or medical condition of a particular kind; or\n  2.     the gender, race, sexual orientation or religious belief of a person; or\n  3.     the age of a person; or\n  4.     where a person lives; or\n  5.     any other characteristic of a person (including but not just matters such as occupation or leisure pursuits) that is likely to result in an increased need for hospital treatment or general treatment; or\n  6.      the frequency with which a person needs hospital treatment or general treatment; or\n  7.     the amount or extent of the benefits to which a person becomes entitled during a period under an overseas student health insurance contract or a specified temporary visa holder health insurance contract, as the case may be, except to the extent allowed by the written agreement, made between the private health insurer and the Commonwealth, referred to in the definition of overseas student health insurance contract and specified temporary visa holder health insurance contract in the Private Health Insurance (Health Insurance Business) Rules 2018.\n\n\n \n\n1.    In this rule, the following terms have the same meaning as in the Private Health Insurance (Health Insurance Business) Rules 2018:\n\n\n1.     overseas student;\n2.    overseas student health insurance contract;\n3.     specified temporary visa holder;  \n4.    specified temporary visa holder health insurance contract.\n\n\n \n\n \n\nSchedule 1—Repeals\n\nPrivate Health Insurance (Health Benefits Fund Policy) Rules 2015\n\n1  The whole of the instrument\n\n \n\nRepeal the instrument.\n","sortOrder":0}],"analysis":{"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"},"kimi_summary":{"content_quality":"ok","complexity_score":3,"scope_assessment":{"changed":false,"description":"This is a direct replacement of the 2015 Rules with the same scope and purpose. The instrument maintains the same four-part structure covering health-related business definitions, risk equalisation jurisdictions, and conduct requirements for overseas student insurance. No expansion beyond original intent is evident."},"complexity_factors":["Short instrument (approximately 9 substantive rules across 4 Parts)","Minimal defined terms (only 3 explicit definitions in the instrument itself: 'Act', 'agency arrangement', and 'improper discrimination')","Heavy reliance on external definitions from the Private Health Insurance Act 2007 and the Private Health Insurance (Health Insurance Business) Rules 2018","Simple conditional structure in Rule 6 (four cumulative conditions for overseas treatment)","No nested exceptions or complex cross-referencing beyond basic references to the Act and 2018 Rules","Straightforward repeal of previous instrument in Schedule 1"],"plain_english_summary":"These Rules replace the 2015 version and set how private health insurers may run certain health-related businesses through health benefits funds — allowing limited overseas treatment cover, agency arrangements where the insurer bears no financial risk, and defining risk‑equalisation territories — while banning improper discrimination against overseas students and temporary visa holders. It affects private insurers, international students/visa holders, and people seeking short-term overseas care, ensuring compliant products and protections."},"flash_summary":{"complexity_score":4,"scope_assessment":{"changed":true,"description":"This instrument repeals the 2015 Rules and restates which activities qualify as health‑related business, explicitly specifying limited overseas treatment cover, defining agency arrangements that allocate liability to a principal, listing risk‑equalisation jurisdictions, and adding an explicit non‑discrimination requirement for overseas student and specified temporary visa holder insurance contracts. Entities previously operating under the 2015 Rules must update contracts, underwriting and compliance processes to align with the new specifications."},"complexity_factors":["Cross-references to the Private Health Insurance Act 2007 and the Private Health Insurance (Health Insurance Business) Rules 2018 create dependency on external instruments (see s 3; rule 9 cross-reference).","Overseas treatment rule sets multiple cumulative conditions (chronic/permanent; routine treatment; cost equivalence to Australian care; 60-day post-departure limit) requiring factual and actuarial assessment (rule 6(2)(1)-(4)).","Agency business requires specific contractual allocation of legal liability to the principal and limited agent liability, shifting commercial and compliance risk into agency agreements (rule 7(2)).","Non-discrimination prohibition for overseas student and specified temporary visa holder contracts enumerates many protected bases but allows exceptions where a written Commonwealth agreement permits it, creating a narrow compliance carve‑out to be checked against each contract (rule 9(3); referenced definition).","Mapping of risk equalisation jurisdictions into seven area groupings affects financial equalisation processes and regulator calculations (rule 8(1)).","The instrument wholly repeals the 2015 Rules, so prior compliance approaches must be reviewed and operationally replaced (Schedule 1).","Practical compliance costs: insurers must amend policy wordings, vendor/agent contracts and underwriting practices to reflect liability caps, agency liability allocation and anti-discrimination duties (rules 6, 7, 9).","Interpretive ambiguity: the requirement that liability not exceed the amount that 'would be incurred...in Australia' invites actuarial comparison methods and potential disputes over valuation (rule 6(2)(3)).","Interaction across regulatory layers (Act, 2018 Rules, these Rules) increases legal review needs and regulator oversight to ensure consistent application (s 3; rule 4 note)."],"plain_english_summary":"**Private Health Insurance (Health Benefits Fund Policy) Rules 2025** replace the 2015 Rules and set out what counts as health‑related business for private health insurers: limited overseas treatment cover for chronic, permanent conditions (cost‑equivalent to Australian care and capped to 60 days after departure); agency arrangements where a principal assumes liability; a mapped list of risk‑equalisation jurisdictions; and a prohibition on improper discrimination in overseas student and specified temporary visa holder policies.\n\nThese provisions affect private health insurers operating health benefits funds, their agents, and eligible overseas students/temporary visa holders by clarifying insurer liabilities, contractual obligations, who bears costs, and compliance duties."}},"importantCases":[],"_links":{"self":"/api/acts/private-health-insurance-health-benefits-fund-policy-rules-2025","history":"/api/acts/private-health-insurance-health-benefits-fund-policy-rules-2025/history","analysis":"/api/acts/private-health-insurance-health-benefits-fund-policy-rules-2025/analysis","conflicts":"/api/acts/private-health-insurance-health-benefits-fund-policy-rules-2025/conflicts","importantCases":"/api/acts/private-health-insurance-health-benefits-fund-policy-rules-2025/important-cases","documents":"/api/acts/private-health-insurance-health-benefits-fund-policy-rules-2025/documents"}}