Subdivision 282‑A—When and how payments can be recovered

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An Act to regulate private health insurance, and for related purposes

Chapter 1—Introduction

Part 1‑1—Introduction

Division 1—Preliminary

1‑1 Short title

This Act may be cited as the Private Health Insurance Act 2007.

1‑5 Commencement

This Act commences on 1 April 2007.

1‑10 Identifying defined terms

(1) Many of the terms in this Act are defined in the Dictionary in Schedule 1.

(2) Most of the terms that are defined in the Dictionary are identified by an asterisk appearing at the start of the term: as in “*health benefits fund”. The footnote with the asterisk contains a signpost to the Dictionary.

(3) An asterisk usually identifies the first occurrence of a term in a section (if not divided into subsections), subsection, definition, table item or diagram. Later occurrences of the term in the same provision are not usually asterisked.

(4) Terms are not asterisked in headings, notes, examples or guides.

(5) If a term is not identified by an asterisk, disregard that fact in deciding whether or not to apply to that term a definition or other interpretation provision.

(6) The following basic terms used throughout the Act are not identified with an asterisk:

Terms that are not identified with an asterisk
Item This term ... is defined in ...
2 Federal Court the Dictionary in Schedule 1
3 insurance section 5‑1
4 Chief Executive Medicare the Dictionary in Schedule 1
5 Private Health Insurance Ombudsman the Dictionary in Schedule 1
6 private health insurer the Dictionary in Schedule 1

1‑15 Extension to Norfolk Island

This Act extends to Norfolk Island.

Division 3—Overview of this Act

3‑1 What this Act is about

This Act is about private health insurance. It:

(a) provides incentives to encourage people to have private health insurance; and

(b) sets out rules governing private health insurance *products.

Note: The Private Health Insurance (Prudential Supervision) Act 2015 sets out the registration process for private health insurers, imposes requirements about how private health insurers conduct health insurance business and deals with other matters in relation to the prudential supervision of private health insurers.

3‑5 Incentives (Chapter 2)

Chapter 2 provides the following incentives:

(a) reductions in premiums for *complying health insurance policies;

Subdivision Subdivision 282 - Private Health Insurance Act 2007 - ‑A—When and how payments can be recovered | Zoe

Requirements that a policy that *covers *hospital treatment must meet
Item There must be a benefit for ... The amount of the benefit must be ...
1 any part of *hospital treatment that is one or more of the following:(a) psychiatric care;(b) rehabilitation;(c) palliative care;if the treatment is provided in a *hospital and no *medicare benefit is payable for that part of the treatment. at least the amount set out, or worked out using the method set out, in the Private Health Insurance (Benefit Requirements) Rules as the minimum benefit, or method for working out the minimum benefit, for that treatment.
2 *hospital treatment *covered under the policy for which a *medicare benefit is payable. (a) if the charge for the treatment is less than the *schedule fee for the treatment—so much of the charge (if any) as exceeds 75% of the schedule fee; and(b) otherwise—at least 25% of the schedule fee for the treatment.
3 if the policy *covers *hospital‑substitute treatment—hospital‑substitute treatment covered under the policy for which a *medicare benefit is payable. (a) if the charge for the treatment is less than the *schedule fee for the treatment—so much of the charge (if any) as exceeds 75% of the schedule fee; and(b) otherwise—at least 25% of the schedule fee for the treatment;but the benefit must not be provided if a medicare benefit of an amount that is at least 85% of the schedule fee is claimed for the treatment (or could be claimed for the treatment but for section 19AD of the Health Insurance Act 1973).
4 (a) *hospital treatment *covered under the policy; and(b) if the policy covers *hospital‑substitute treatment—hospital‑substitute treatment covered under the policy;that is the provision of a *medical device or *human tissue product, of a kind listed in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules, as described in either of the following paragraphs:(c) the medical device or human tissue product is provided in circumstances in which a *medicare benefit is payable, and, if those Rules set out conditions that must be satisfied in relation to the provision of the medical device or human tissue product in those circumstances, those conditions are satisfied;(d) the medical device or human tissue product is provided in other circumstances set out in those Rules, and, if those Rules set out conditions that must be satisfied in relation to the provision of the medical device or human tissue product in those circumstances, those conditions are satisfied. (a) at least the amount set out, or worked out using the method set out, in the Private Health Insurance (Medical Devices and Human Tissue Products) Rules as the minimum benefit, or method for working out the minimum benefit, for the medical device or human tissue product; and(b) if the Private Health Insurance (Medical Devices and Human Tissue Products) Rules set out an amount, or a method for working out an amount, as the maximum benefit, or method for working out the maximum benefit, for the medical device or human tissue product—no more than that amount or the amount worked out using that method.
5 any treatment for which the Private Health Insurance (Benefit Requirements) Rules specify there must be a benefit. at least the amount set out, or worked out using the method set out, in the Private Health Insurance (Benefit Requirements) Rules as the minimum benefit, or method for working out the minimum benefit, for that treatment.

Reviewable decisions
Item Decision Provision under which decision is made
1 To reject an application for registration of a person in respect of a health insurance policy section 23‑20
2 To revoke a person’s registration in respect of a health insurance policy section 23‑35
4 To refuse to make a declaration, or to revoke a declaration, that a facility is a *hospital subsection 121‑5(6)
4A To specify a condition, in relation to a particular facility, to which a declaration that a facility is a *hospital is subject paragraph 121‑7(1)(b)
5 To decide that a *hospital does not satisfy the assessment criteria set out in the Private Health Insurance (Health Insurance Business) Rules section 121‑8A
6 To decide to revoke a *hospital’s inclusion in a class set out in the Private Health Insurance (Health Insurance Business) Rules section 121‑8C
31 To direct a private health insurer not to make a change that it proposes to make to its *rules subsection 169‑10(2)
32 To refuse a request for a longer period for a private health insurer to respond to a request for an explanation subsection 191‑1(3)
33 To refuse to consent to a private health insurer withdrawing or varying an undertaking subsection 197‑1(3)
34 To give a direction to a private health insurer section 200‑1
35 To revoke a private health insurer’s status as a *participating insurer section 206‑1
38 To reject an application to become a *participating insurer section 279‑5
39 On reconsideration of a decision notifying a private health insurer in relation to a claim for payment under Division 279 section 279‑45
41 To affirm an original decision by the Chief Executive Medicare that an amount is recoverable as a debt under paragraph 282‑1(1)(h) in respect of a payment made to an individual section 282‑15
42 To affirm an original decision by the Chief Executive Medicare to set off a debt against an amount otherwise payable to a person or his or her estate section 282‑15
43 Not to waive, or to waive only a part of, an amount of *late payment penalty section 307‑20