{"id":"F2025L01101","name":"Private Health Insurance (Risk Equalisation Administration) Rules 2025","slug":"private-health-insurance-risk-equalisation-administration-rules-2025","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":106841,"registerId":"commonwealth-F2025L01101-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Private Health Insurance (Risk Equalisat","sectionType":"part","heading":"Private Health Insurance (Risk Equalisation Administration) Rules 2025","content":"# Private Health Insurance (Risk Equalisation Administration) Rules 2025\n\nI, Suzanne Smith, a delegate of the Australian Prudential Regulation Authority:\n\n1.  under subsection 333-25(1) of the Private Health Insurance Act 2007 (the Act), for the purposes of section 318-15 and subsection of the 33(3) of the Acts Interpretation Act 1901, REVOKE Private Health Insurance (Risk Equalisation Administration Rules) 2015 made on 26 June 2015; and\n\n1.  under subsection 333-25(1) of the Act, for the purposes of section 318-15, MAKE these Rules.\n\nThis instrument commences on 30 September 2025.\n\nDated: 11 September 2025\n\nSuzanne Smith\n\nMember","sortOrder":0},{"sectionNumber":"Part 1","sectionType":"part","heading":"Preliminary","content":"## Part 1 – Preliminary","sortOrder":1},{"sectionNumber":"1. Name of Rules","sectionType":"division","heading":"1. Name of Rules","content":"### 1. Name of Rules\n\nThese Rules are the Private Health Insurance (Risk Equalisation Administration) Rules 2025.","sortOrder":2},{"sectionNumber":"2. Commencement","sectionType":"division","heading":"2. Commencement","content":"### 2. Commencement\n\nThese Rules commence on 30 September 2025.","sortOrder":3},{"sectionNumber":"3. Interpretation","sectionType":"division","heading":"3. Interpretation","content":"### 3. Interpretation\n\nNote: Terms used in these Rules have the same meaning as in the Act – see section 13 of the Legislation Act 2003. These terms include:\n\nAPRA\n\ncomplying health insurance policy\n\ncover\n\nhealth benefits fund\n\nofficer\n\npolicy holder\n\nprivate health insurer\n\nrisk equalisation jurisdiction\n\n1.  In these Rules:\n\nAct means the Private Health Insurance Act 2007.\n\nadult is as defined in the Act.\n\nBusiness Rules means the Private Health Insurance (Health Insurance Business) Rules 2018 made under the Act.\n\nchronic disease management program or CDMP:\n\n1.  has the same meaning as in the Business Rules; and\n2.  for hospital treatment, includes a program similar to a chronic disease management program as referred to in the definition of ‘eligible benefit’ in the Risk Equalisation Policy Rules.\n\nfund means a health benefits fund.\n\ngeneral treatment is as defined in the Act.\n\nhospital cover is as defined in the Act.\n\nhospital substitute treatment is as defined in the Act.\n\nhospital treatment is as defined in the Act.\n\nmedicare benefit is as defined in the Act.\n\ninsured person, in relation to a policy, means a person covered by the policy.\n\ninsurer means a private health insurer.\n\npolicy means a complying health insurance policy.\n\nquarter means a period of 3 months ending on 31 March, 30 June, 30 September or 31 December in a year.\n\nquarterly return means a return required under the Financial Sector (Collection of Data) Act 2001 relating to risk equalisation information.\n\nRisk Equalisation Policy Rules means the Private Health Insurance (Risk Equalisation Policy) Rules 2025 made under the Act.\n\n1.  In these Rules, a category of policy is to be identified as follows:\n    1.  for a policy under which only one person is insured – as ‘single’;\n    2.  for a policy under which 2 adults are insured (and no‑one else) – as ‘couple’;\n    3.  for a policy under which 2 or more people are insured, none of whom is an adult – as ‘2 + persons, no adults’;\n    4.  a policy under which 2 or more people are insured, only one of whom is an adult – as ‘single parent’;\n    5.  a policy under which 3 or more people are insured, only 2 of whom are adults – as ‘family’.\n2.  In these Rules, the following terms relevant to the high cost claimants pool have the same meaning as in the Risk Equalisation Policy Rules:\n\nage based pool (ABP)\n\ndesignated threshold\n\nhigh cost claimants pool (HCCP)\n\ngross benefit.","sortOrder":4},{"sectionNumber":"Part 2","sectionType":"part","heading":"Requirement for records to be kept","content":"## Part 1 – Preliminary\n\n### 1. Name of Rules\n\nThese Rules are the Private Health Insurance (Risk Equalisation Administration) Rules 2025.\n\n### 2. Commencement\n\nThese Rules commence on 30 September 2025.\n\n### 3. Interpretation\n\nNote: Terms used in these Rules have the same meaning as in the Act – see section 13 of the Legislation Act 2003. These terms include:\n\nAPRA\n\ncomplying health insurance policy\n\ncover\n\nhealth benefits fund\n\nofficer\n\npolicy holder\n\nprivate health insurer\n\nrisk equalisation jurisdiction\n\n1.  In these Rules:\n\nAct means the Private Health Insurance Act 2007.\n\nadult is as defined in the Act.\n\nBusiness Rules means the Private Health Insurance (Health Insurance Business) Rules 2018 made under the Act.\n\nchronic disease management program or CDMP:\n\n1.  has the same meaning as in the Business Rules; and\n2.  for hospital treatment, includes a program similar to a chronic disease management program as referred to in the definition of ‘eligible benefit’ in the Risk Equalisation Policy Rules.\n\nfund means a health benefits fund.\n\ngeneral treatment is as defined in the Act.\n\nhospital cover is as defined in the Act.\n\nhospital substitute treatment is as defined in the Act.\n\nhospital treatment is as defined in the Act.\n\nmedicare benefit is as defined in the Act.\n\ninsured person, in relation to a policy, means a person covered by the policy.\n\ninsurer means a private health insurer.\n\npolicy means a complying health insurance policy.\n\nquarter means a period of 3 months ending on 31 March, 30 June, 30 September or 31 December in a year.\n\nquarterly return means a return required under the Financial Sector (Collection of Data) Act 2001 relating to risk equalisation information.\n\nRisk Equalisation Policy Rules means the Private Health Insurance (Risk Equalisation Policy) Rules 2025 made under the Act.\n\n1.  In these Rules, a category of policy is to be identified as follows:\n    1.  for a policy under which only one person is insured – as ‘single’;\n    2.  for a policy under which 2 adults are insured (and no‑one else) – as ‘couple’;\n    3.  for a policy under which 2 or more people are insured, none of whom is an adult – as ‘2 + persons, no adults’;\n    4.  a policy under which 2 or more people are insured, only one of whom is an adult – as ‘single parent’;\n    5.  a policy under which 3 or more people are insured, only 2 of whom are adults – as ‘family’.\n2.  In these Rules, the following terms relevant to the high cost claimants pool have the same meaning as in the Risk Equalisation Policy Rules:\n\nage based pool (ABP)\n\ndesignated threshold\n\nhigh cost claimants pool (HCCP)\n\ngross benefit.\n\n## Part 2 – Requirement for records to be kept\n\n### 4. General records\n\nFor each fund conducted by an insurer, the insurer must keep records that contain the following details about each policy of the fund:\n\n1.  the name, date of birth, age and principal place of residence of each person covered by the policy; and\n2.  which of the following the policy covers:\n    1.  hospital treatment;\n    2.  hospital-substitute treatment;\n    3.  chronic disease management programs;\n    4.  ambulance service;\n    5.  other general treatment; and\n3.  whether the policy includes any excesses or co‑payments payable; and\n4.  the category of policy by reference to the number of adults and dependents covered; and\n\nNote: Subrule 3 (2) deals with the identification of ‘categories of policies’.\n\n1.  for each benefit that is paid to or on behalf of an insured person:\n    1.  the name of the insured person to whom the benefit relates; and\n    2.  the medical or health speciality for which the benefit was paid; and\n    3.  whether the benefit was paid for:\n        1.  hospital treatment; or\n        2.  hospital-substitute treatment; or\n        3.  chronic disease management program treatment; or\n        4.  ambulance services; or\n        5.  other general treatment; and\n    4.  if the treatment was provided in accordance with a chronic disease management program, the type of disease for which the program was provided and whether the treatment was provided as hospital treatment or general treatment; and\n    5.  the gross benefits paid; and\n    6.  the date of treatment; and\n    7.  the date of payment.\n\n### 5. High cost claimants pool records\n\n1.  This rule applies if the insurer includes in a quarterly return a gross benefit for the high cost claimants pool.\n2.  In addition to the information to be kept in accordance with rule 4, the insurer must keep a record that contains the following information in respect of the insured person to whom the gross benefit relates:\n    1.  the name and age of the person; and\n    2.  the dates of the treatment; and\n    3.  the gross benefits paid; and\n    4.  the dates of payment; and\n    5.  the amount of gross benefit included in the age based pool; and\n    6.  the amount of gross benefit included in the high cost claimants pool; and\n    7.  the amount of gross benefits paid for any of the preceding 3 quarters (after 1 April 2007).","sortOrder":5},{"sectionNumber":"4. General records","sectionType":"division","heading":"4. General records","content":"### 4. General records\n\nFor each fund conducted by an insurer, the insurer must keep records that contain the following details about each policy of the fund:\n\n1.  the name, date of birth, age and principal place of residence of each person covered by the policy; and\n2.  which of the following the policy covers:\n    1.  hospital treatment;\n    2.  hospital-substitute treatment;\n    3.  chronic disease management programs;\n    4.  ambulance service;\n    5.  other general treatment; and\n3.  whether the policy includes any excesses or co‑payments payable; and\n4.  the category of policy by reference to the number of adults and dependents covered; and\n\nNote: Subrule 3 (2) deals with the identification of ‘categories of policies’.\n\n1.  for each benefit that is paid to or on behalf of an insured person:\n    1.  the name of the insured person to whom the benefit relates; and\n    2.  the medical or health speciality for which the benefit was paid; and\n    3.  whether the benefit was paid for:\n        1.  hospital treatment; or\n        2.  hospital-substitute treatment; or\n        3.  chronic disease management program treatment; or\n        4.  ambulance services; or\n        5.  other general treatment; and\n    4.  if the treatment was provided in accordance with a chronic disease management program, the type of disease for which the program was provided and whether the treatment was provided as hospital treatment or general treatment; and\n    5.  the gross benefits paid; and\n    6.  the date of treatment; and\n    7.  the date of payment.","sortOrder":6},{"sectionNumber":"5. High cost claimants pool records","sectionType":"division","heading":"5. High cost claimants pool records","content":"### 5. High cost claimants pool records\n\n1.  This rule applies if the insurer includes in a quarterly return a gross benefit for the high cost claimants pool.\n2.  In addition to the information to be kept in accordance with rule 4, the insurer must keep a record that contains the following information in respect of the insured person to whom the gross benefit relates:\n    1.  the name and age of the person; and\n    2.  the dates of the treatment; and\n    3.  the gross benefits paid; and\n    4.  the dates of payment; and\n    5.  the amount of gross benefit included in the age based pool; and\n    6.  the amount of gross benefit included in the high cost claimants pool; and\n    7.  the amount of gross benefits paid for any of the preceding 3 quarters (after 1 April 2007).","sortOrder":7}],"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"},"flash_summary":{"complexity_score":4,"scope_assessment":{"changed":false,"description":"The instrument revokes the 2015 Rules and re‑enacts record-keeping obligations for insurers and funds (see instrument preamble and rules 4–5). There is no express expansion of the classes of persons or types of records beyond the detailed items set out here; the practical scope depends on the Act and the referenced Business Rules and Risk Equalisation Policy Rules."},"complexity_factors":["Cross-references to the Private Health Insurance Act 2007, the Business Rules (Private Health Insurance (Health Insurance Business) Rules 2018) and the Risk Equalisation Policy Rules 2025 (rule 3) require reading multiple instruments to understand full obligations.","Detailed, itemised data elements insurers must record for each policy and each benefit (rule 4) create operational and IT compliance work.","High Cost Claimants Pool-specific requirements (rule 5) include per-person split of gross benefits between pools and a 3-quarter lookback, increasing record-keeping and reconciliation complexity (rule 5(2)(5)-(7)).","Repeated and duplicated text within the instrument (multiple copies of Part 1 and rules) may cause interpretive uncertainty and administrative friction.","Requirement to retain identifiable personal and payment data (rule 4 and rule 5) raises data governance, privacy and storage-cost considerations.","Commencement and revocation mechanics (instrument preamble) mean insurers must transition from the 2015 Rules by 30 September 2025, creating potential implementation timelines and transitional workload."],"plain_english_summary":"These Rules require private health insurers to keep detailed records about each complying policy, benefits paid and high‑cost claimants for risk‑equalisation reporting (see rules 4–5). They apply to insurers and health benefits funds and commence on 30 September 2025. APRA’s delegate made the Rules; insurers bear the compliance costs and must supply data used to calculate transfers under the risk‑equalisation policy."},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"This appears to be a straightforward re-enactment/update of the 2015 Rules with the same scope. The instrument maintains its original purpose of setting administrative record-keeping requirements for risk equalisation. No significant expansion beyond the original intent is evident."},"complexity_factors":["Extensive cross-referencing to other instruments (Private Health Insurance Act 2007, Business Rules 2018, Risk Equalisation Policy Rules 2025, Financial Sector (Collection of Data) Act 2001)","Nested definitions (e.g., 'chronic disease management program' references Business Rules AND Risk Equalisation Policy Rules)","Multiple policy categories with specific numerical thresholds (single, couple, 2+ persons no adults, single parent, family)","Conditional record-keeping requirements (Rule 5 only applies if insurer includes gross benefit in high cost claimants pool)","Historical lookback requirement (preceding 3 quarters after 1 April 2007)","Dual commencement mechanisms (revocation of 2015 rules and making of 2025 rules under subsection 333-25(1))"],"plain_english_summary":"Private health insurers must keep detailed records of policies, members and every benefit payment — including extra data for very high-cost claims — so APRA can verify Australia’s risk equalisation transfers. \n\nThe rule ensures money is fairly redistributed from funds with younger, healthier members to those with older or sicker members, supporting affordability and stability of private health insurance."}},"importantCases":[],"_links":{"self":"/api/acts/private-health-insurance-risk-equalisation-administration-rules-2025","history":"/api/acts/private-health-insurance-risk-equalisation-administration-rules-2025/history","analysis":"/api/acts/private-health-insurance-risk-equalisation-administration-rules-2025/analysis","conflicts":"/api/acts/private-health-insurance-risk-equalisation-administration-rules-2025/conflicts","importantCases":"/api/acts/private-health-insurance-risk-equalisation-administration-rules-2025/important-cases","documents":"/api/acts/private-health-insurance-risk-equalisation-administration-rules-2025/documents"}}