Part Part 1 - Financial Sector (Collection of Data) (reporting standard) determination No. 1 of 2024 - Policies and insured persons

Part 1Policies and insured persons

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Part 1 Policies and insured persons

adult	Means a person who is not a dependent child.(Schedule 1, Private Health Insurance Act 2007)
cover	(1) An insurance policy covers a treatment if, under the policy, the health insurer undertakes liability in respect of some or all loss arising out of a liability to pay fees or charges relating to the provision of goods or a service that is or includes that treatment.(2) An insurance policy also covers a treatment if the insurer provides an insured person, or arranges for an insured person to be provided with, goods or a service that is or includes that treatment.(3) If an insurance policy covers a treatment in the way described in subsection (2), this Part applies as if the provision of the goods or service were a benefit provided under the policy.(Division 69, Private Health Insurance Act 2007)
Coverage requirementscoverage requirements	(1) An insurance policy meets the coverage requirements in Division 69 if:(a) the only treatments the policy covers are:(i) specified treatments that are hospital treatment; or(ii) specified treatments that are hospital treatment and specified treatments that are general treatment; or(iii) specified treatments that are general treatment but none that are hospital-substitute treatment; and(b) if the policy provides a benefit for anything else—the provision of the benefit is authorised by the Private Health Insurance (Complying Product) Rules.(2) Despite paragraph (1)(a), the policy must also cover any treatment that a policy of its kind is required by the Private Health Insurance (Complying Product) Rules to cover.(3) Despite paragraph (1)(a), the policy must not cover any treatment that a policy of its kind is not allowed under the Private Health Insurance (Complying Product) Rules to cover.(Division 69, Private Health Insurance Act 2007)
dependent child	Means a person(a) who is:(i) aged under 18: or(ii) a dependent child under the rules of the insurer that insures the person; and(b) who is not aged 25 or over; and(c) who does not have a partner.(Schedule 1, Private Health Insurance Act 2007)
holder(of an insurance policy)	Means a person who is insured under the policy and who is not a dependent child.(Schedule 1, Private Health Insurance Act 2007)
Insured personsinsured persons	All persons covered by health insurance policies.

2 + persons, no adults	A policy under which 2 or more people are insured, none of whom is an adult.
3 + adults	A policy under which 3 or more people are insured, at least 3 of whom are adults.
couple	A policy under which 2 adults are insured (and no-one else).
family	A policy under which 3 or more people are insured, only 2 of whom are adults.
single	A policy under which only one person is insured.
single parent	A policy under which 2 or more people are insured, only one of whom is an adult.

Excess & Co-payments	Means an amount of money a policy holder agrees to pay before private health insurance benefits are payable. A co-payment could apply every time a person insured under the policy goes to hospital in a year, or an excess may be capped at a total amount for the year. The terms “Excess” and “Co-payments” are sometimes referred to as “Front-end Deductibles” and are similar in meaning.For taxation purposes those taxpayers who would be subject to the Medicare Levy Surcharge are exempted if they have a hospital treatment policy with an excess no greater than $500 for a policy covering a single person or an excess no greater than $1,000 for a policy covering more than one person.
Excess & Co-payments	Excess & Co-payments Policies- includes all policy holders who contribute to hospital treatment policies under which an agreed, excess, amount is paid by the policy holder for hospital treatment and/or general treatment services, reducing the benefit otherwise payable in exchange for lower premium costs.Note: these can be combined with exclusionary policies.Excess (also referred to as front-end deductible)An excess is an amount of money a policy holder agrees to pay for a hospital stay before health fund benefits are payable. For example, if a policy has an excess of $200, the insured person will be required to pay the first $200 of the hospital costs if they go to hospital as a private patient. An excess could apply every time the insured person goes to hospital in a year, or it may be capped at a total amount that will be paid in each year.Co-paymentWith a co-payment, a policy holder agrees to pay an agreed amount each time a service is provided. For example, a policy may have a co-payment clause that requires payment for the first $50 for each day’s hospital accommodation. If the policy has such a co-payment and they were in hospital for 5 days, they would have to pay $250, equal to $50 multiplied by 5.The total amount of co-payment that can be paid in a year is often limited to a set maximum amount.
Exclusionary Policies	Means where the private health insurance policy features an exclusion for a particular condition covered by Medicare and there is no coverage at all for medical treatment as a private patient in a public or private hospital or any other setting for that condition. Exclusionary tables exclude payment of benefits for a particular condition in all settings. (This does not refer to the case where the policy only covers the medical services to a limited extent, only in certain settings or only after a certain time.)(This does not refer to the case where the service referred to is not covered by Medicare. For example cosmetic surgery.)
No Excess & No Co-payments	Means all policies other than Excess & Co-payments Policies. The sum of Excess & Co-payments and No Excess & No Co-payments policies will reflect the total hospital treatment policies.
Non-Exclusionary Policies	Means the policy does not have any exclusions (see Exclusionary Policies). The sum of exclusionary and non-exclusionary policies will reflect the total hospital treatment policies. NB: Where a product only relates to select hospitals but covers all treatment in those hospitals the policies should be included in the non-exclusionary category.Errors to avoid:The majority of errors that come to APRA’s attention for exclusionary policy holders are where treatment is excluded in some, but not all, settings where the product can be utilised but the policy holders are counted as exclusionary. For example, if treatment is excluded in a private hospital but not excluded in a public hospital the member with that product should not be counted as an exclusionary policy holder.

Excess & Co-payments

Means an amount of money a policy holder agrees to pay before private health insurance benefits are payable. A co-payment could apply every time a person insured under the policy goes to hospital in a year, or an excess may be capped at a total amount for the year. The terms “Excess” and “Co-payments” are sometimes referred to as “Front-end Deductibles” and are similar in meaning.For taxation purposes those taxpayers who would be subject to the Medicare Levy Surcharge are exempted if they have a hospital treatment policy with an excess no greater than $500 for a policy covering a single person or an excess no greater than $1,000 for a policy covering more than one person.

Excess & Co-payments

Excess & Co-payments Policies- includes all policy holders who contribute to hospital treatment policies under which an agreed, excess, amount is paid by the policy holder for hospital treatment and/or general treatment services, reducing the benefit otherwise payable in exchange for lower premium costs.Note: these can be combined with exclusionary policies.Excess (also referred to as front-end deductible)An excess is an amount of money a policy holder agrees to pay for a hospital stay before health fund benefits are payable. For example, if a policy has an excess of $200, the insured person will be required to pay the first $200 of the hospital costs if they go to hospital as a private patient. An excess could apply every time the insured person goes to hospital in a year, or it may be capped at a total amount that will be paid in each year.Co-paymentWith a co-payment, a policy holder agrees to pay an agreed amount each time a service is provided. For example, a policy may have a co-payment clause that requires payment for the first $50 for each day’s hospital accommodation. If the policy has such a co-payment and they were in hospital for 5 days, they would have to pay $250, equal to $50 multiplied by 5.The total amount of co-payment that can be paid in a year is often limited to a set maximum amount.

Exclusionary Policies

Means where the private health insurance policy features an exclusion for a particular condition covered by Medicare and there is no coverage at all for medical treatment as a private patient in a public or private hospital or any other setting for that condition. Exclusionary tables exclude payment of benefits for a particular condition in all settings. (This does not refer to the case where the policy only covers the medical services to a limited extent, only in certain settings or only after a certain time.)(This does not refer to the case where the service referred to is not covered by Medicare. For example cosmetic surgery.)

No Excess & No Co-payments

Means all policies other than Excess & Co-payments Policies. The sum of Excess & Co-payments and No Excess & No Co-payments policies will reflect the total hospital treatment policies.

Non-Exclusionary Policies

Means the policy does not have any exclusions (see Exclusionary Policies). The sum of exclusionary and non-exclusionary policies will reflect the total hospital treatment policies. NB: Where a product only relates to select hospitals but covers all treatment in those hospitals the policies should be included in the non-exclusionary category.Errors to avoid:The majority of errors that come to APRA’s attention for exclusionary policy holders are where treatment is excluded in some, but not all, settings where the product can be utilised but the policy holders are counted as exclusionary. For example, if treatment is excluded in a private hospital but not excluded in a public hospital the member with that product should not be counted as an exclusionary policy holder.

New policies/persons	Policies and insured persons joining but not transferring from another fund. This category should include:New policies.Reinstated policies where these policies were not included in the previous quarter’s return because of suspension (note that if a policy is both suspended and reinstated within the quarter to which this return relates they should not be counted as discontinued or reinstated).Hospital Treatment Only or General Treatment Only policies who take additional cover.Insured persons with a General Treatment Only policy transferring to an existing Hospital Treatment policy (an increase in insured persons, not policies).Births, or children covered under one parent’s cover (increase in insured persons not policies).
Transferring from another state	Means policies and insured persons transferring from another state within this fund.
Transferring to another state	Means policies and insured persons transferring to another state.
Transferring from another Fund	Means policies and insured persons transferring from another fund but not joining. This category should include:Policies joining as transfers from another fund.Insured persons transferring from another fund to an existing policy (new insured persons, not new policies).Policies with a Hospital Treatment Only policy with your fund and General Treatment Only policy with another fund who transfer the General Treatment Only policy to your fund (new Hospital and General Treatment policy).
Transferring to another policy	Means policies and insured persons transferring to another policy treatment type. Policy types being “Hospital Treatment Only”, “Hospital Treatment and General Treatment” or “General Treatment Only”.
Transferring from another policy	Means policies and insured persons transferring from another policy treatment type. Policy types being “Hospital Treatment Only”, “Hospital Treatment and General Treatment” or “General Treatment Only”.
Discontinued	Means policies and insured persons leaving. Represents the balancing item for the aggregate fund coverage from one quarter to the next. Included in this category is:Deaths (decrease in insured persons, not necessarily policies).Suspended policies, where they are not included in the coverage count for risk equalisation purposes.Policies with “Hospital and General Treatment” that drop “Hospital Treatment” cover or drop “General Treatment Cover”.
End of quarter	This equals:policies/insured persons at start of quarterplus new policies/insured persons joiningplus transfers from another state, fund or policy typeless transfers to another state or policy typeless discontinued coverage.

New policies/persons

Policies and insured persons joining but not transferring from another fund. This category should include:New policies.Reinstated policies where these policies were not included in the previous quarter’s return because of suspension (note that if a policy is both suspended and reinstated within the quarter to which this return relates they should not be counted as discontinued or reinstated).Hospital Treatment Only or General Treatment Only policies who take additional cover.Insured persons with a General Treatment Only policy transferring to an existing Hospital Treatment policy (an increase in insured persons, not policies).Births, or children covered under one parent’s cover (increase in insured persons not policies).

Transferring from another state

Means policies and insured persons transferring from another state within this fund.

Transferring to another state

Means policies and insured persons transferring to another state.

Transferring from another Fund

Means policies and insured persons transferring from another fund but not joining. This category should include:Policies joining as transfers from another fund.Insured persons transferring from another fund to an existing policy (new insured persons, not new policies).Policies with a Hospital Treatment Only policy with your fund and General Treatment Only policy with another fund who transfer the General Treatment Only policy to your fund (new Hospital and General Treatment policy).

Transferring to another policy

Means policies and insured persons transferring to another policy treatment type. Policy types being “Hospital Treatment Only”, “Hospital Treatment and General Treatment” or “General Treatment Only”.

Transferring from another policy

Means policies and insured persons transferring from another policy treatment type. Policy types being “Hospital Treatment Only”, “Hospital Treatment and General Treatment” or “General Treatment Only”.

Discontinued

Means policies and insured persons leaving. Represents the balancing item for the aggregate fund coverage from one quarter to the next. Included in this category is:Deaths (decrease in insured persons, not necessarily policies).Suspended policies, where they are not included in the coverage count for risk equalisation purposes.Policies with “Hospital and General Treatment” that drop “Hospital Treatment” cover or drop “General Treatment Cover”.

End of quarter

This equals:policies/insured persons at start of quarterplus new policies/insured persons joiningplus transfers from another state, fund or policy typeless transfers to another state or policy typeless discontinued coverage.

Chronic Disease Management Program (CDMP)	See Page 33
Hospital treatmenthospital treatment	Meaning of hospital treatment(1) Hospital treatment is treatment (including the provision of goods and services) that:(a) is intended to manage a disease, injury or condition; and(b) is provided to a person:(i) by a person who is authorised by a hospital to provide the treatment; or(ii) under the management or control of such a person;(c) either:(i) is provided at a hospital; or(ii) is provided, or arranged, with the direct involvement of a hospital.(Division 121, Private Health Insurance Act 2007)Definition for Hospital see page 28
Hospital-substitute Treatmenthospital-substitute treatment	Means general treatment that:(a) substitutes for an episode of hospital treatment; and(b) is any of, or any combination of, nursing, medical, surgical, podiatric surgical, diagnostic, therapeutic, medical device or human tissue product, pharmacological, pathology or other services or goods intended to manage a disease, injury or condition; and(c) is not specified in the Private Health Insurance (Complying Product) Rules as a treatment that is excluded from this definition.(Division 69, Private Health Insurance Act 2007)Note: In the Act the Coverage Requirements do not permit a general treatment policy only to include hospital-substitute treatment. Policies that include hospital-substitute treatment must also include hospital treatment.
General Treatment	See page 37
General Treatment Only Policies	Means policies that cover specified treatments that are general treatment but none that are hospital or hospital-substitute treatment.General Treatment Ambulance Only is included in Total General Treatment Only.
General Treatment Ambulance Only Policies	Means policies that cover ambulance services but does not cover any other hospital or general treatment.A subset of General Treatment Only Policies, covering only ambulance services. Ambulance services associated with the provision of treatment to an insured person are specified as included in General Treatment for the purposes of subsection 121-10 (2) of the Private Health Insurance Act 2007.
Hospital Treatment Only Policies	Means policies that specify only treatments that are hospital treatment.
Hospital and General Treatment Combined	Means policies that specify treatments that are hospital treatment and specify treatments that are general treatment.

Chronic Disease Management Program (CDMP)

See Page 33

Hospital treatmenthospital treatment

Meaning of hospital treatment(1) Hospital treatment is treatment (including the provision of goods and services) that:(a) is intended to manage a disease, injury or condition; and(b) is provided to a person:(i) by a person who is authorised by a hospital to provide the treatment; or(ii) under the management or control of such a person;(c) either:(i) is provided at a hospital; or(ii) is provided, or arranged, with the direct involvement of a hospital.(Division 121, Private Health Insurance Act 2007)Definition for Hospital see page 28

Hospital-substitute Treatmenthospital-substitute treatment

Means general treatment that:(a) substitutes for an episode of hospital treatment; and(b) is any of, or any combination of, nursing, medical, surgical, podiatric surgical, diagnostic, therapeutic, medical device or human tissue product, pharmacological, pathology or other services or goods intended to manage a disease, injury or condition; and(c) is not specified in the Private Health Insurance (Complying Product) Rules as a treatment that is excluded from this definition.(Division 69, Private Health Insurance Act 2007)Note: In the Act the Coverage Requirements do not permit a general treatment policy only to include hospital-substitute treatment. Policies that include hospital-substitute treatment must also include hospital treatment.

General Treatment

See page 37

General Treatment Only Policies

Means policies that cover specified treatments that are general treatment but none that are hospital or hospital-substitute treatment.General Treatment Ambulance Only is included in Total General Treatment Only.

General Treatment Ambulance Only Policies

Means policies that cover ambulance services but does not cover any other hospital or general treatment.A subset of General Treatment Only Policies, covering only ambulance services. Ambulance services associated with the provision of treatment to an insured person are specified as included in General Treatment for the purposes of subsection 121-10 (2) of the Private Health Insurance Act 2007.

Hospital Treatment Only Policies

Means policies that specify only treatments that are hospital treatment.

Hospital and General Treatment Combined

Means policies that specify treatments that are hospital treatment and specify treatments that are general treatment.

private health insurance policy	Means an insurance policy that covers hospital treatment or general treatment or both (whether or not it also covers any other treatment or provides a benefit for anything else).(Schedule 1, Private Health Insurance Act 2007)
Single equivalent unit/s (SEU/s)	Single equivalent units (SEUs) are used as a standard measure of the different categories of policies. The Single equivalent units for each category of policy are:(a) Single―1(b) Couple―2(c) 2+ persons no adults―1(d) Single parent―1(e) Family―2(f) 3+ adults―2(the Preliminary section, Private Health Insurance (Risk Equalisation Policy) Rules 2015)SEUs are calculated as: