Part 2Total Benefits Paid for Hospital Treatment and General Treatment

Part 2 Total Benefits Paid for Hospital Treatment and General Treatment

The data in this part is to be reported as cumulative totals over the quarter being reported.

5. Report the number of episodes, days and total benefits paid in each hospital category.
6. Report number of and total benefits paid for medical services, prostheses items and CDMP.
7. Report total ineligible hospital benefits. The category Ineligible Benefits is for hospital benefits that are not eligible for Risk Equalisation. They are not reported in any other part of the form.
8. General guidance

(a) Episodes are reported in each category (place where the treatment was provided) in the quarter in which the treatment ceased, this excludes incomplete episodes, see (d). Episodes are to be determined as:

i) 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, as one episode

For:

ii) hospital-substitute treatment, and

iii) 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 as one episode.

(b) Days must reflect the total days related to each episode, including days when no fund benefit is paid.

(c) Leave days from a hospital stay are excluded from reporting days.

(d) Where an episode has not been completed in a quarter (an incomplete episode) but a benefit has been paid in relation to the treatment because of an interim billing arrangement the following applies:

i) the episode should not be reported in the current quarter, the episode is counted as one episode in the quarter in which it is completed.

ii) days and benefits are reported in the quarter they are paid.

It is recognised that this will result in some mismatching of data within quarters.

(e) Days for Day hospital, day only public hospitals, day only private hospitals and day only for hospital-substitute should equal Day only episodes in the respective categories.

(f) Medical benefits should equal the sum of medical benefits reported in Parts 3 and 4, and should equal the total fund benefits reported in Part 11 - Total Hospital Treatment Medical Service Statistics.

(g) Prostheses benefits should equal the sum of prostheses benefits reported in Parts 3 and 4.

(h) Hospital benefits, hospital-substitute benefits and Nursing Home Type Patients benefits reported in this part exclude Medical and Prostheses Benefits.

9. High Cost Claimants Pool (HCCP)

Report HCCP benefits in the state in which the person is resident at the end of the quarter, and associated HCCP data in the same state.

(a) Report the number of insured persons with a HCCP claim in the current quarter.

(b) Report the total (gross) benefit paid for HCCP claimants for the current and the preceding three quarters for the insured persons with a HCCP claim in the current quarter.

(c) Report the net benefit paid for HCCP claimants for the current and the preceding three quarters after Age Based Pooling (ABP) has been applied for the insured persons with a HCCP claim in the current quarter.

(d) Report the net benefit paid above the threshold for HCCP claimants for the current and the preceding three quarters after ABP has been applied. This amount will include any amounts already included in the HCCP.

(e) Report the total benefit to be included in HCCP for the current quarter after ABP has been applied, which is the amount from (d) less any amounts already reported in the HRF 601.1 for inclusion in the HCCP.

(f) Threshold in relation to the high cost claimant’s pool means the designated threshold. The threshold is $50,000.

The amount to be notionally allocated to the HCCP is to be calculated in accordance with the formula m(R-T) - H, where:

(a) m is 82 per cent
(b) R is the total gross benefit for the current and the preceding three quarters less the amount notionally allocated to the ABP in the current and preceding three quarters
(c) T is the designated threshold
(d) H is the sum of the amounts notionally allocated to the HCCP in the preceding three quarters.

Subject to a maximum of 82 per cent of gross benefits being included in Risk Equalisation when summing the ABP and HCCP components.

(Part 2, Private Health Insurance (Risk Equalisation Policy) Rules 2007)

It is not intended that the HCCP calculation will deduct amounts or result in negative amounts, for example as a result of an adjustment, through literal application of the above formula in cases where no benefits have been previously allocated to the HCCP for the claimant.

The amount to be notionally allocated to the HCCP is calculated as:

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where:

C = gross benefits in the quarter for the claimant

m = 82 per cent

p = percent of gross benefits to be allocated to ABP in the quarter, where p is dependent on the age of the claimant

q = current quarter

T = HCCP Threshold = $50,000

Ci(1-p) = the residual after age based pooling (ABP)

C (m-p) = the maximum allowable proportion of gross benefits to be allocated to the HCCP after ABP.

The above formula sums up the residual benefits after ABP for the current and preceding three quarters, takes out the threshold ($50,000), multiplies the result by 82 per cent and from this amount subtracts the sum of benefits that were already included in the HCCP in the preceding three quarters. If this calculation is less than zero (could be as a result of reversal) the formula will return zero and if it is not zero will return the calculated benefit. Further, this calculated benefit undergoes another test to ensure that no more than 82 per cent of the gross benefits are included in Risk Equalisation. The amount to be notionally allocated to the HCCP is taken to be the minimum of the previously calculated benefit or the sum of maximum allowable proportion of gross benefits to be allocated in the HCCP after ABP for the current and the preceding three quarters.

Circular 08/04 of 25 January 2008 provides detailed information to assist health insurers complete the high cost claimants section of the HRF 601.1, with a spreadsheet example attached to the circular.

Parts 3 to 6 Collections by Type of Product and Age Category

The data in these parts is to be reported by age and gender:

• for insured persons in the age cohort that they are in at the end of the quarter; and

• for all other headings as cumulative totals over the quarter being reported.

  10. Part 3 and 4 - “Other HT Benefits” and “Other H-ST Benefits” refers to benefits paid for hospital treatment or hospital-substitute treatment respectively and includes hospital charges such as accommodation and theatre fees. Do not include Medical, Prostheses and Ineligible Benefits under this heading.
  11. Part 3 and 4 - Total benefits for Part 3 are the sum of “Other HT Benefits” + “Medical benefits” + “Prostheses benefits”. Total benefits for Part 4 are the sum of “Other H-ST Benefits” + “Medical benefits” + “Prostheses benefits”. Benefits should be reported:

(a) in the quarter in which they are paid;

(b) against the age of the person as at the date of treatment; and

(c) reversals in benefits should be reported against the age of the person as at the date of treatment if possible, but may be reported against the age of the person as at the time of the reversal.

12. Part 3, 4 and 6 - Services and Episodes are reported under the age at the date of treatment.
13. Part 3 and 4 - Requirements for reporting episodes, days and benefits are the same as reporting requirements in Part 2 (see Part 2 general guidance).
14. All parts - Where an insured person changes age cohort during an episode:

(a) the episode is to be reported in the age cohort that the episode was finalised;

(b) the days and benefits are to be reported for the age cohort in which they were incurred (e.g. a 20 day episode with an accommodation cost of $200 per day, where the insured person turned 50 on day four, is reported as: 1 episode under 50-54, 3 days under 45-49 and 17 days under 50-54, $600 under 45-49 and $3,400 under 50-54). Note that apportionment of benefits by the number of days in each age cohort only relates to the case where the treatment covers more than one age cohort, for example an invoice is received for accommodation for a period where the person had a number of days in one age group and a number of days in another age group. In the case where individual treatments are paid during a single episode where the person moves from one age group to another the benefits paid for those treatments should be reported against the age of the person as at the age of the treatment. (It is not the intent that health insurers should sum all benefits paid over an episode spanning two age groups and then apportion them over the age groups); and

(c) services are reported under the age at the date of treatment.

15. Part 3 and 4 - Medical benefits are reported as benefits paid under all policies only if a Medicare benefit is payable for the service.

16. Part 3 and 4 - Prostheses benefits are reported separately.

17. Part 3 and 4 - Report the fees charged equal to the total amount the patient would have to pay to the provider/s in the absence of any private health insurance, inclusive of hospital, medical and prostheses fees. The amount entered here must exclude the Medicare benefit. The difference between fees charged and benefits paid should be the amount that the patient has to pay (out of pocket payment). If the total fee is not known, e.g. where the provider discounts fee for early payment, enter the invoiced amount. Fees excluding Medicare benefit should be greater than or equal to the sum of other benefits, medical benefits and prostheses benefits.

18. Part 5 - Chronic Disease Management Program (see the section on Guidance for insurers for eligible CDMP benefits for risk equalisation in these reporting instructions for further information on CDMPs).

(a) Programs are reported in the quarter in which the program commenced, in the age category of the participant at the beginning of the program. Programs that run continuously for more than one year are classed as complete at the end of one calendar year after initial commencement. They are reported as a commencing program in the next quarter in which benefits are paid for the program.

i) The commencement date of the program, and thus the first quarter in which the program is deemed to have commenced, should be taken as the date on which benefits were first paid for under the program. The commencement date of the program may be hard to determine due to the different ways benefits can be paid, as well as delays in this information being relayed to health insurers. The first quarter that benefits are paid for a CDMP should be taken as the quarter in which the program commences.

ii) Benefits and fees charged are reported in the quarter in which they are paid in the age category of the participant. Where an insured person changes age cohort during a program, services are reported against the age of the participant at the date benefits were paid for the treatment.

iii) The number of programs does not refer to the particular programs offered by the health insurer, but refers to the number of persons participating in a program.

iv) If a person participates in more than one program, each program they participate in is counted separately.

v) Where an insured person changes age cohort during a program, services are reported against the age of the participant at the date of treatment.

(b) Eligible benefits are reported as the benefit paid for any of the following components of general and/or hospital treatment provided as part of a chronic disease management program:

i) the planning and coordination services described in paragraphs (b) and (c) of the definition of chronic disease management program in the Private Health Insurance (Health Insurance Business) Rules 2013; and

ii) allied health services, as defined in the Private Health Insurance (Health Insurance Business) Rules 2013, which are provided as part of the chronic disease management program.

(c) Ineligible benefits report all benefits paid that are not eligible benefits.

(d) Fees excluding Medicare benefits: as health insurers are precluded from paying benefits for out-of-hospital services for which a Medicare benefit is payable (except in the circumstances outlined in Rule 10 of the Private Health Insurance (Health Insurance Business) Rules 2013 this should be interpreted as “fees” only as no Medicare benefits are payable.

19. Part 6 - General Treatment excluding Hospital-Substitute, CDMP and Hospital-linked Ambulance Treatment

(a) Report the number of persons by age with General Treatment coverage excluding those with Hospital-Substitute, CDMP and Hospital-linked Ambulance Treatment. These persons are those with ancillary or extras cover.

(b) Report the number of General Treatment services, benefits and fees excluding Hospital-Substitute and CDMP.

(c) Services, benefits and fees reported in Part 6 should reconcile with services, benefits and fees reported in Part 9.

i) Services, benefits and fees should include those for ambulance even where these are on behalf of a person with Hospital-linked Ambulance Treatment and the person is not included in this part.

ii) Note that health management programs are reported in each quarter that benefits are paid for the program. The commencement date of the program, and thus the first quarter in which the program is deemed to have commenced, should be taken as the date on which benefits were first paid for under the program. Note that the program would be deemed to be ceased in the case where the participant leaves the program (for example, by choice or other reason such as death). Note that number of programs does not refer to the particular programs offered by the health insurer, but refers to the number of persons participating in a program. If a member participates in more than one program, each program they participate in is counted.

iii) Programs that are similar to, but do not satisfy the criteria for, CDMPs should be reported under Part 9 General Treatment.