Part Part 2 - Financial Sector (Collection of Data) (reporting standard) determination No. 1 of 2024 - Total Benefits Paid for Hospital Treatment and General Treatment

Part 2Total Benefits Paid for Hospital Treatment and General Treatment

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Part 2 Total Benefits Paid for Hospital Treatment and General Treatment

episode/s	Means for a particular type of treatment or place where the treatment was provided:(a) for hospital treatment provided at a hospital, the period between the insured person's admission to the hospital and discharge from that hospital, including leave periods, is one episode; and(b) for:(i) hospital-substitute treatment; and(ii) hospital treatment that is provided, or arranged, with the direct involvement of a hospital, the continuous period between the commencement and cessation of the treatment is one episode, and(c) an episode for which a benefit has been paid is to be counted (unless an incomplete episode).Note: episodes are not reported until the episode is complete.
incomplete episode	If an episode is not completed within a quarter but a benefit has been paid in relation to the treatment because of an interim billing arrangement, the episode is reported as one episode only and only in the quarter in which the episode is completed.
Days - Hospital Treatment	Means day/s on which a policy holder or insured person is a patient of a public or private hospital for hospital treatment.Days must reflect the total days related to each episode, including days when no private health insurance benefits are paid. Where a hospital stay includes leave days, those days are not reported in HRF 601.1.
Days - Hospital-substitute Treatment	While there may be no accommodation benefits involved in hospital-substitute there will be days involved in the care. Either one day only or more than one day.
Benefits Paid Chronic Disease Management Program (CDMP)	Means benefits paid for services covered by Chronic Disease Management Programs.
Benefits Paid General Treatment	Means benefits paid for services covered by general treatment.
Benefits Paid Hospital Benefits	Means benefits paid for services covered by hospital treatment.
Day Hospital Facilities	Means a private hospital that is not licensed or otherwise permitted to provide treatment that includes part of an overnight stay at the hospital.Note: Day hospital facilities are those that were a day hospital facility within the meaning of the National Health Act 1953, and are taken to be private hospitals for the purpose of the Private Health Insurance Act 2007.
Day Only	Means a day on which a policy holder or insured person is accommodated as a patient in a public or private hospital for day treatment.

<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td style="width:120.6pt; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Age Based Pool (ABP)age based pool</td><td style="width:284.25pt; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">The Age Based Pool (ABP) equalises benefits for the Risk Equalisation Levy. Pooling is based on adding a proportion of applicable benefits, above age 55, in a sliding scale.The amount to be notionally allocated to the ABP in a quarter is to be calculated in accordance with the formula <img src="image.010.png" width="47" height="26" alt="start formula p multiplied by C end formula">, where:(a) p is the percentage of the eligible benefit paid having regard to the age cohort, as specified in the ABP table, into which the insured person falls on the day or days on which the insured person receives the treatment to which the eligible benefit relates; and(b) C is the gross benefit in the current quarter.Where an insured person receives treatment over a number of days such that the age of the insured person on the day or days on which that person receives the treatment falls within more than one age cohort, the amount to be notionally allocated to the ABP must be allocated proportionately in accordance with the number of days during which the insured person was in each age cohort.(Part 2, Private Health Insurance (Risk Equalisation Policy) Rules 2015)</td></tr><tr><td style="width:120.6pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">ABP table</td><td style="width:284.25pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><table cellspacing="0" cellpadding="0" style="border:0.75pt dashed #000000; border-collapse:collapse"><tbody><tr><td style="width:89.7pt; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">Age cohorts</td><td style="width:126.05pt; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">Age % of eligible benefits included in pool</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">0-54</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">0.0%</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">55-59</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">15.0%</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">60-64</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">42.5%</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">65-69</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">60.0%</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">70-74</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">70.0%</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">75-79</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">76.0%</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">80-84</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; border-bottom:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">78.0%</td></tr><tr><td style="width:89.7pt; border-top:0.75pt dashed #000000; border-right:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">85+</td><td style="width:126.05pt; border-top:0.75pt dashed #000000; border-left:0.75pt dashed #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle">82.0%</td></tr></tbody></table>(Part 2, Private Health Insurance (Risk Equalisation Policy) Rules 2015)</td></tr><tr><td style="width:120.6pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Gross Benefit</td><td style="width:284.25pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Means the total eligible benefits paid by the insurer in respect of an insured person in a quarter.</td></tr><tr><td style="width:120.6pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">High Cost Claimants Pool (HCCP)high cost claimants pool</td><td style="width:284.25pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">The High Cost Claimants Pool (HCCP) deals with benefits not equalised by the age-based pool. Pooling is based on applicable benefits accumulated by claimant for the current and preceding 3 quarters. The percentage of the benefits to be pooled will be 82%.A limit is imposed on total pooling under the ABP pool and HCCP of 82% of gross benefits. When assessing HCCP pooling in each quarter, the cumulative residual after ABP pooling is compared with the threshold at that time.The amount to be notionally allocated to the HCCP is to be calculated in accordance with the formula:<a id="_Hlk139022450"><img src="image.011.png" width="89" height="27" alt="start formula m multiplied by open bracket R minus T close bracket minus H end formula"></a>, where:(a) m is 82%(b) R is the total gross benefit for the current and the preceding 3 quarters less the amount notionally allocated to the ABP in the current and preceding 3 quarters(c) T is the designated threshold(d) H is the sum of the amounts notionally allocated to the HCCP in the preceding 3 quartersSubject to a maximum of 82% of gross benefits being included in Risk Equalisation when summing the ABP and HCCP components.(Part 2, Private Health Insurance (Risk Equalisation Policy) Rules 2015)</td></tr><tr><td style="width:120.6pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">HCCP Claimants</td><td style="width:284.25pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Means the number of insured persons whose total eligible benefits paid by the insurer exceed the threshold after applying ABP.</td></tr><tr><td style="width:120.6pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">HCCP Net Benefits</td><td style="width:284.25pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Means applicable benefits, after age based pooling that exceed the threshold. 82% of net benefits in excess of the threshold are to be pooled.</td></tr><tr><td style="width:120.6pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">HCCP Threshold</td><td style="width:284.25pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Means the designated threshold. The designated threshold is $50,000.</td></tr><tr><td style="width:120.6pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">Risk Equalisation Levy</td><td style="width:284.25pt; border-top:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top">To calculate the amount of levy in respect of a current quarter:(a) an amount calculated is first to be notionally allocated to the age based pool (ABP).(b) if the amount of gross benefit not notionally allocated to the ABP in the current and preceding 3 quarters, is greater than the designated threshold, a second amount is to be notionally allocated to the high cost claimants pool (HCCP).(c) If the <img src="image.012.png" width="248" height="22" alt="start formula open bracket ABP plus HCCP close bracket divided by open bracket Average hospital SEU close bracket end formula"> for a fund is less than the equivalent state calculation then the insurer must pay into the Risk Equalisation Pool the difference per SEU.(d) If the <img src="image.012.png" width="248" height="22" alt="start formula open bracket ABP plus HCCP close bracket divided by open bracket Average hospital SEU close bracket end formula"> for a fund is more than the equivalent state calculation then the insurer will receive the difference per SEU from the Risk Equalisation Pool.(Part 2, Private Health Insurance (Risk Equalisation Policy) Rules 2015)</td></tr></tbody></table>

Fees excluding Medicare benefit	The fees excluding Medicare benefit must exclude the Medicare benefit component of the total fee charged. The difference between fees charged and total benefits paid should be the amount that the patient has to pay (gap). In some cases the fund paying the benefits will be unaware of a discount offered by the provider, for example for early payment. Fees excluding Medicare benefit should be, in cases where the discounted fee is unknown, the invoiced amount less the Medicare benefit.Fees excluding Medicare benefit should be greater or equal to the sum of benefits, medical benefits and medical devices or human tissue products benefits.Note: The total fee charged is the total amount the patient and Medicare would have to pay to the provider in the absence of any private health insurance.
Eligible Benefits	Means a benefit paid by an insurer for any of the following:planning and coordination services for CDMP;allied health services which are provided as part of a CDMP;hospital-substitute treatment; andhospital treatment.(Part 1, Private Health Insurance (Risk Equalisation Policy) Rules 2015)
Ineligible Benefits	Includes other benefits paid by an insurer that are not eligible.
Fees Charged	Is the known or invoiced fee charged by the provider for general treatment.
Benefits	In parts 3 and 4 means benefits paid for hospital treatment or hospital-substitute treatment. It does not include Medical, medical devices or human tissue products and Ineligible benefits.
Total Benefits	Means benefits plus Medical and medical devices or human tissue products benefits. It does not include Ineligible benefits.