2. Minimum Level of Benefit

(1) The minimum level of benefit payable by a RHBO in respect of an episode of hospital treatment (excluding in situations of emergency) in a facility that does not have a HPPA (or a similar arrangement) with the RHBO, is that set by this clause 2, being the second tier default benefit, and not the minimum level of benefit set by Schedules 1, 2, 3, or 7 of the Determination made under paragraph (1) (bj) of Schedule 1 of the Act.

Note 1: Schedule 1 sets the minimum level of benefit payable for overnight shared ward accommodation in private hospitals in all States and Territories and overnight shared ward accommodation in recognised hospitals in Victoria and Tasmania.

Schedule 2 sets the minimum level of benefit payable for overnight shared ward accommodation in recognised hospitals in the Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia and Western Australia.

Schedule 3 sets the minimum level of benefit payable for same day accommodation in hospitals and day hospital facilities in all States and Territories.

Schedule 7 sets the minimum level of benefit payable for outreach services provided by, or on behalf of, specified hospitals and day hospital facilities.

Note 2: In situations of emergency paragraph (1)(bi) of Schedule 1 of the Act applies.

(2) This Schedule does not apply to episodes of hospital treatment referred to in Schedules 4 and 6 of the Determination made under paragraph (1)(bj) of Schedule 1 to the Act, and the Determination made under subsections 73AAG(6) and (7) of the Act.

Note: RHBOs must continue to pay benefits for:

• nursing-home type patients as prescribed in Schedule 4 of the Determination made under paragraph (1)(bj) of Schedule 1 of the Act;
• no gap prostheses and gap permitted prostheses determined under subsections 73AAG(6) and (7) of the Act; and
• care plans and case conferencing in accordance with Schedule 6 of the Determination made under paragraph (1) (bj) of Schedule 1 of the Act.

(3)(a) Subject to subclauses (6), and (7), the minimum level of benefit payable by a RHBO in respect of an episode of hospital treatment between 1 September of a particular year (“the first year”) and 31 August of the next year will be no less than 85% of the average charge for the equivalent episode of hospital treatment under that RHBO’s HPPAs (or similar arrangements) that were in force on 1 August of the first year with:

(i) all comparable private hospitals in the State in which the facility is located (if treatment was provided in a facility that was a private hospital); or

(ii) all private day hospital facilities in the State in which the facility is located (if the treatment was provided in a facility that was a private day hospital facility).