Contents

Part 1 Preliminary

1. Name of Rules

2. Commencement

3. Definitions

Part 2 Minimum benefit requirements

4. Psychiatric care, rehabilitation and palliative care

5. Other hospital treatments

Schedule 1―Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania

Schedule 2―Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia

Schedule 3―Same-day accommodation: hospitals in all States/Territories

Schedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories

Schedule 5―Second-tier default benefits

Schedule 6―Outreach services

1. Name of Rules

These Rules are the Private Health Insurance (Benefit Requirements) Rules 2007 (No. 02).

2. Commencement and Revocation

(1) These Rules commence on 1 July 2007.

(2) These rules revoke the Private Health Insurance (Benefit Requirements) Rules 2007, as amended.

3. Definitions

In these Rules:

Act means the Private Health Insurance Act 2007.

ACT means the Australian Capital Territory.

certified Type B procedure means a Type B procedure certified in accordance with clause 10 of Schedule 1.

certified overnight Type C procedure means a Type C procedure certified in accordance with clause 11 of Schedule 1.

certified Type C procedure means a Type C procedure certified in accordance with clause 7 of Schedule 3.

continuous period of hospitalisation, for the purpose of counting days of hospital treatment, includes any two periods during which a patient was, or is, receiving hospital treatment as a patient at a hospital, whether or not the same hospital, where the periods are separated from each other by a period of not more than 7 days during which the patient was not receiving hospital treatment as a patient at any hospital.

diagnostic imaging services table means the table prescribed under subsection 4AA (1) of the Health Insurance Act 1973.

fee in the MBS means the Schedule fee as defined in subsection 8 (1A) of the Health Insurance Act 1973.

general medical services table means the table prescribed under subsection 4 (1) of the Health Insurance Act 1973.

insurer means a private health insurer.

item has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.

MBS comprises the:

(a) general medical services table;

(b) diagnostic imaging services table; and

(c) pathology services table.

NSW means the State of New South Wales.

nursing-home type patient has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.

Note: Item 19 of Schedule 2 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 also deals with nursing-home type patients.

outreach service means a service referred to in subsection 16 (1) of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007, unless subsection 16 (2) of that Act applies to the particular service.

pathology services table means the table prescribed under subsection 4A (1) of the Health Insurance Act 1973.

policy means a complying health insurance policy.

private hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a private hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

professional service has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.

public hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a public hospital.

Note: Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

Type A procedure means:

(a) a procedure specified in clauses 3 to 9 of Schedule 1; or

(b) a certified Type B procedure; or

(c) a certified overnight Type C procedure.

Type B procedure means:

(a) a procedure specified in clauses 3 to 7 of Schedule 3 other than a certified Type B procedure; or

(b) a certified Type C procedure.

Type C procedure means a procedure specified in clause 8 of Schedule 3 other than a certified Type C procedure.

Part 2 Minimum benefit requirements

4. Psychiatric care, rehabilitation and palliative care

(1) For item 1 in the table in subsection 72-1 (2) of the Act, the minimum benefit for hospital treatment specified in that item is the amount set out, or worked out using the method for working out the minimum benefit for that treatment, in Schedules 1, 2, 3, 5 or 6 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.

Note: Item 1 in the table in subsection 72-1 (2) of the Act requires that each policy that covers hospital treatment must cover any part of hospital treatment that is psychiatric care, rehabilitation or palliative care if the treatment is provided in a hospital and no medicare benefit is payable for that part of the treatment.

(2) Despite subrule (1), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person's policy in respect of that treatment.

5. Other hospital treatments

(1) For item 5 in the table in subsection 72-1 (2) of the Act, for a policy that covers any type of hospital treatment provided in a hospital, other than treatment referred to in rule 4, the minimum benefit for that treatment is the amount set out, or worked out using the method for working out the minimum benefit, for that treatment in Schedules 1, 2, 3, 4, 5, or 6 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.

(2) Despite subrule (1), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person's policy in respect of that treatment.

Schedule 1―Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania

Part 1―General

1. Circumstances

For rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is:

(a) provided to a patient who is not a nursing-home type patient; and

(b) provided to a patient:

(i) at a private hospital; or

(ii) as shared ward accommodation at a public hospital in Victoria or Tasmania; and

Note: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

(c) provided for the purpose of permitting the provision to the patient of hospital treatment that is:

(i) a Type A procedure; and

(ii) for a period that includes part of an overnight stay.

Note: A Type A procedure is defined to include a certified Type B procedure and a certified overnight Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.

2. Minimum benefit

(1) The minimum benefit for hospital treatment provided in the circumstances specified in this Schedule is the amount set out in the tables in this Schedule for that hospital treatment.

(2) When counting the days referred to in the tables in this Schedule to determine the minimum benefit in respect of any particular patient, days forming part of a continuous period of hospitalisation are to be counted.

Table 1―Accommodation at private hospitals in all States/Territories

Table 2― Victoria: shared ward accommodation at a public hospital

Table 3―Tasmania: shared ward accommodation at a public hospital

Category 1 – attendances

A1:

1 2 3 4 13 19 20 23 24 25 33 35 36 37 38 40 43 44 47 48 50 51 601 602

A2:

52 53 54 57 58 59 60 65 81 83 84 86 87 89 90 91 92 93 95 96 97 98 697 698

A3:

104 105 106 107 108 109

A4:

110 116 119 122 128 131

A5:

160 161 162 163 164

A6:

170 171 172

A7:

173 193 195 197 199

A8:

291 293 296 297 299 300 302 304 306 308 310 312 314 316 318 319 320 322 324 326 328 330 332 334 336 338 342 344 346 348 350 352 353 355 356 357 358 364 366 367 369 370

A9:

10801 10802 10803 10804 10805 10806 10807 10808 10809 10816

A12:

385 386 387 388

A13:

410 411 412 413 414 415 416 417

A14:

700 702 704 708 706 710 712 714 716 717 718 719

A15:

721 723 725 727 729 731 734 736 738 740 742 744 759 762 765 768 771 773 775 778 779 820 822 823 825 826 828 855 857 858

A16:

444 445 446 447 448 449

A17:

900 903

A18:

2497 2501 2503 2504 2506 2507 2509 2517 2518 2521 2522 2525 2526 2546 2547 2552 2553 2558 2559

A19:

2598 2600 2603 2606 2610 2613 2616 2620 2622 2624 2630 2631 2633 2635 2664 2666 2668 2673 2675 2677

A20:

2710 2712 2713 2721 2723 2725 2727

A21:

501 503 507 511 515 519 520 530 532 534 536

A22:

5000 5003 5007 5010 5020 5023 5026 5028 5040 5043 5046 5049 5060 5063 5064 5067

A23:

5200 5203 5207 5208 5220 5223 5227 5228 5240 5243 5247 5248 5260 5263 5265 5267

A24

2801 2806 2814 2824 2832 2840 2946 2949 2954 2958 2972 2974 3005 3010 3014 3018 3023 3028 3032 3040 3044 3051 3055 3062

A25:

5906 5908 5910 5912

A26:

6007 6009 6011 6013 6015

A27:

4001

M2:

10993 10994 10995 10996 10997 10998 10999

M5

10988 10989

Category 2 – diagnostic procedures & investigations

D1:

11000 11003 11006 11009 11012 11015 11018 11024 11027 11200 11203 11204 11205 11210 11211 11212 11215 11218 11221 11222 11224 11225 11235 11237 11240 11241 11242 11243 11300 11306 11309 11312 11315 11318 11321 11324 11327 11332 11333 11336 11339 11500 11503 11506 11509 11512 11602 11604 11605 11610 11611 11612 11614 11615 11700 11701 11702 11708 11709 11710 11711 11712 11713 11715 11718 11721 11722 11724 11727 11800 11810 11820 11830 11833 11900 11903 11906 11909 11912 11915 11917 11919 11921 12000 12003 12012 12015 12018 12021 12200 12201 12306 12309 12312 12315 12318 12321

D2:

12500 12503 12506 12509 12512 12515 12518 12521 12524 12527 12530 12533

Category 3 – therapeutic procedures

T1:

13104 13200 13203 13206 13209 13221 12323 13290 13312 13709 13760 13839 13842 13939 13942 13945 14050 14053 14100 14106 14109 14112 14115 14118 14124 14200 14203 14206 14209 14215 14221 14227 14245

T2:

15000 15003 15006 15009 15012 15100 15103 15106 15109 15112 15115 15211 15214 15215 15218 15221 15224 15227 15230 15233 15236 15239 15242 15245 15248 15251 15254 15257 15260 15263 15266 15269 15272 15500 15503 15506 15509 15512 15515 15518 15521 15524 15527 15530 15533 15550 15553 15556 15559 15562

T3:

16003 16006 16009 16012 16015 16018

T4:

16400 16500 16514 16600

T6:

17610 17615 17620 17625 17640 17645 17650 17655 17680 17690

T7:

18213 18350 18351 18352 18354 18356 18358 18360 18362 18364 18366 18368 18370 18371 18372 18373

T8:

30003 30006 30026 30032 30038 30061 30062 30064 30071 30097 30185 30186 30192 30195 30196 30202 30203 30205 30207 30213 30214 30216 30219 30628 31200 31205 31210 31215 31220 32072 32115 32132 32135 32142 32500 32501 35502 35503 35554 35608 35614 35620 36800 37041 37218 37300 37303 37415 38800 39115 40862 41500 41659 41662 41698 41704 41755 41828 41846 42587 42614 42615 42617 42620 42644 42650 42667 42668 42676 42677 42744 42782 42783 42785 42786 42788 42789 42791 42792 42794 42797 42806 42807 42808 42809 42811 45021 45025 45026 45546 45799 45801 45805 45807 45829 45847 45851 47471 47735 47904 47912 47916 47924 50124 50125

Category 4 – oral and maxillofacial

O1:

51700 51703

O3:

52034 52036 52039 52055 52056 52133

O7:

53000 53004 53052

O9:

53458

O10:

53600

Items in the diagnostic imaging services table

The following items are items in the diagnostic imaging services table.

Category 5

I1:

55028 55029 55030 55031 55032 55033 55036 55037 55038 55039 55044 55045 55048 55049 55054 55070 55073 55076 55079, 55113 55114 55115 55116 55117 55238 55244 55246 55248 55252 55274 55276 55278 55280 55282 55284 55292 55294 55296 55700 55703 55704 55705 55706 55707 55708 55709 55712 55715 55718 55721 55723 55725 55729 55731 55733 55736 55739 55812 55814 55816 55818 55820 55822 55824 55826 55828 55830 55832 55834 55836 55838 55840 55842 55844 55846 55852 55854

I2:

56001 56007 56010 56013 56016 56022 56028 56030 56036 56041 56047 56050 56053 56056 56062 56068 56070 56076 56101 56107 56141 56147 56220 56221 56223 56224 56225 56226 56227 56228 56229 56230 56231 56232 56233 56234 56235 56236 56237 56238 56239 56240 56259 56301 56307 56341 56347 56401 56407 56409 56412 56441 56447 56449 56501 56507 56541 56547 56552 56554 56619 56625 56659 56665 56801 56807 56841 56847 57001 57007 57041 57047 57201 57247 57341 57345 57350 57355

I3:

57506 57509 57512 57515 57518 57521 57524 57527 57700 57703 57706 57709 57712 57715 57721 57901 57902 57903 57906 57909 57912 57915 57918 57921 57924 57927 57930 57933 57939 57942 57945 57960, 57963 57966 57969 58100 58103 58106 58108 58109 58112 58115 58300 58306 58500 58503 58506 58509 58521 58524 58527 58700 58706 58715 58718 58721 58900 58903 58909 58912 58915 58916 58921 58924 58927 58933 58936 59103 59300 59303 59306 59309 59312 59314 59318 59503 59700 59703 59712 59715 59718 59724 59733 59736 59739 59751 59754 59760 59763 60100 60500 60503 60918 60927

I4:

61302 61303 61306 61307 61310 61313 61314 61316 61317 61320 61328 61340 61348 61352 61353 61356 61360 61361 61364 61368 61372 61373 61376 61381 61383 61384 61386 61387 61389 61390 61393 61397 61401 61402 61405 61409 61413 61417 61421 61425 61426 61429 61430 61433 61434 61437 61438 61441 61442 61445 61446 61449 61450 61453 61454 61457 61458 61462 61465 61469 61473 61480 61484 61485 61495 61499 61505

Magnetic resonance imaging

I5:

63001 63004 63007 63010 63040 63043 63046 63049 63052 63055 63058 63061 63064

63067 63070 63073 63101 63111 63114 63125 63128 63131 63151 63154 63161 63164 63167 63170 63173 63176 63179 63182 63185 63201 63204 63219 63222 63225 63228 63231 63234 63237 63240 63243 63271 63274 63277 63280 63301 63304 63307 63322 63325 63328 63331 63334 63337 63340 63361 63385 63388 63391 63401 63404 63416 63425 63428 63440 63443 63446 63461 63470 63473 63491 63494 63497

Items in the pathology services table

The following items are items in the pathology services table.

P1:

65060 65066 65070 65072 65075 65078 65081 65084 65087 65090 65093 65096 65099 65102 65105 65108 65111 65114 65117 65120 65123 65126 65129 65132 65133 65134 65135 65136 65137 65139 65140 65142 65144 65147 65150 65153 65156 65159 65162 65165 65171

P2:

66500 66503 66506 66509 66512 66515 66518 66519 66536 66539 66542 66545 66548 66551 66554 66557 66560 66563 66566 66569 66572 66575 66578 66581

66584 66587 66590 66593 66596 66599 66602 66605 66608 66623 66626 66629 66632 66635 66638 66641 66644 66647 66650 66653 66655 66656 66659 66662 66665 66667 66669 66670 66671 66672 66673 66674 66677 66680 66683 66686 66695 66698 66701 66704 66707 66710 66711 66712 66713 66716 66719 66722 66725 66728 66731 66734 66737 66743 66749 66750 66751 66752 66755 66758 66761 66764 66767 66770 66773 66776 66779 66782 66785 66788 66791 66800 66803 66806 66809 66812 66815 66818

P3:

69300 69303 69306 69309 69312 69318 69321 69324 69327 69330 69333 69336 69339 69345 69354 69357 69360 69363 69364 69365 69367 69384 69387 69390 69393 69396 69399 69402 69405 69408 69411 69413 69442 69443 69445 69471 69472 69474 69475 69478 69481 69484

P4:

71057 71058 71059 71060 71062 71064 71066 71068 71069 71071 71072 71073 71074 71075 71077 71079 71081 71083 71085 71087 71089 71091 71093 71095 71097 71099 71101 71103 71106 71109 71113 71115 71117 71119 71121 71123 71125 71127 71129 71131 71133 71134 71135 71137 71139 71141 71143 71145 71146 71147 71149 71151 71153 71155 71157 71159 71163 71164

P5:

72813 72816 72817 72818 72823, 72824, 72825, 72826, 72830, 72836, 72844, 72846, 72847 72848 72851 72852 72855 72856 72857

P6:

73043 73045 73047 73049 73051 73053 73055 73057 73059 73060 73061

P7:

73287 73289 73300 73305 73308 73311 73314 73317 73320

P8:

73521 73523 73525 73527 73529

P9:

73801 73802 73803 73804 73805 73806 73807 73808 73809 73810 73811

P10:

73901 73903 73905 73907 73909 73910 73912 73913 73915

P11:

73921

Category 8 – services provided by nurses, allied and dental health professionals

The following items are items in the general medical services table.

M6:

80000 80005 80010 80015 80020

M7:

80100 80105 80110 80115 80120 80125 80130 80135 80140 80145 80150 80155 80160 80165 80170

M8:

81000 81005 81010.

M9

81100 81105 81110 81115 81120 81125

Schedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories

1. Circumstances

(1) For rule 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided:

(a) to a nursing-home type patient; and

(b) at a hospital.

Note: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

2. Minimum benefit

The minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in Table 1 or 2 of this Schedule for that hospital treatment.

Table 1

Table 2

Schedule 5―Second-tier default benefits

1. Interpretation

(1) In this Schedule:

facility means a private hospital specified in clause 4 of this Schedule.

negotiated agreement means an agreement entered into between a hospital and an insurer, that includes provisions to the effect that, except to the extent (if any) provided in the agreement, the hospital agrees to accept payment by the insurer in satisfaction of any amount that would, apart from the agreement, be owed to the hospital, in relation to an episode of hospital treatment, by an insured person under a policy.

(2) In this Schedule, except in subclause (4) of this clause, the ACT is taken to be part of NSW and the Northern Territory is taken to be part of the State of South Australia.

(3) In this Schedule, private hospitals are comparable if they fall within the same category from the following list:

(a) private hospitals which provide psychiatric care for at least 50% of the episodes of hospital treatment;

(b) private hospitals which provide rehabilitation care for at least 50% of the episodes of hospital treatment;

(c) private hospitals which do not fall into categories (a) or (b), with up to and including 50 licensed beds;

(d) private hospitals which do not fall into categories (a) or (b) with more than 50 licensed beds and up to and including 100 licensed beds;

(e) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit;

(f) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, with either (or both) an accident and emergency unit or a specialised cardiac care unit;

(g) private hospitals which only provide hospital treatment which does not include any part of an overnight stay.

(4) In subclause (3), a reference to licensed beds is a reference to the beds or patients that a private hospital is permitted, under State or Territory legislation in the State or Territory where the private hospital is located.

2. Circumstances

For rules 4 and 5 of Part 2 of these Rules, the circumstances for hospital treatment to which this Schedule applies are that the treatment is provided to a patient who is not a nursing-home type patient and the treatment is provided at a facility.

Note: The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

3. Minimum benefit

(1) Despite anything in Schedules 1, 2, 3 or 6, but subject to subclause (2) of this clause, the minimum benefit for an episode of hospital treatment at a facility that does not have a negotiated agreement with the insurer, is the amount specified in this Schedule (the second tier default benefit).

(2) If the minimum benefit determined in accordance with this Schedule for an episode of hospital treatment is below the amount determined in accordance with Schedules 1, 2, 3 or 6 the minimum benefit is the amount determined in accordance with Schedules 1, 2, 3 or 6 for that episode of hospital treatment.

(3) If a hospital ceases to be a facility for the purposes of this Schedule, the minimum benefit in relation to an episode of hospital treatment for an insured person who was an admitted patient at the facility or booked for hospital treatment at the facility (as opposed to merely being on the facility’s waiting list) before the day that the hospital ceased to be a facility is the minimum benefit that would have applied if the hospital continued to be a facility at the time the treatment was provided.

(4) Subject to subclauses (2) and (8), the minimum benefit payable by an insurer for an episode of hospital treatment between 1 September of a particular year (the first year) and 31 August of the next year is an amount no less than 85% of the average charge for the equivalent episode of hospital treatment, under that insurer's negotiated agreements in force on 1 August of the first year with all such comparable private hospitals in the State in which the facility is located.

(5) The formula for calculating the average charge for the equivalent episode of hospital treatment by an insurer in each State is as follows:

View image in the official source

Where: j = group of equivalent episodes of hospital treatment under the insurer's negotiated agreements;

i = group of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;

n= the number of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;

Rji = charge for episode of hospital treatment type j in the negotiated agreement i

Rj = average charge for episode of hospital treatment type j.

(6) In subclause (4), each episode of hospital treatment must be identified using the patient classification system and payment structure in the majority of the relevant insurer's negotiated agreements in force on 1 August of the first year with all comparable private hospitals in the State in which the facility is located.

(7) In subclause (4), for the purpose of calculating the average charge for the equivalent episode of hospital treatment in a State:

(a) the charge will include the sum of the amount payable by the insurer under that insurer's negotiated agreement and any excess or co‑payment amounts payable by members, in accordance with the insurer's rules; and

Note: Policy holders’ financial obligations under such levels of cover will still apply.

(b) must not include any charges:

(i) referred to in the insurer's negotiated agreements for prostheses; and

(ii) that are minimum benefits for prosthesis as specified for the purpose of item 4 of the table in subsection 72-1 (2) of the Act, and

(iii) referred to in the insurer's negotiated agreements for hospital treatment provided to nursing-home type patients.

(8) Subject to subclause (2), if an insurer has less than 5 negotiated agreements in force on 1 August of the first year with a particular category of comparable private hospitals in a State, then all of that insurer's negotiated agreements with all classes of private hospitals in that State are to be used to calculate the minimum benefit.

4. Facilities

The hospitals specified in the table below are facilities for the purpose of this Schedule.

Table

Schedule 6―Outreach services

1. Application

This Schedule ceases to have effect at midnight on 30 June 2008.

Note: Section 16 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with outreach services. That section ceases to have effect on 1 July 2008.

2. Circumstances

For rules 4 and 5 of Part 2 of these Rules, the circumstance specified for hospital treatment to which this Schedule applies is that the treatment is an outreach service.

3. Minimum benefit

The minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in Table 1 or 2 of this clause for that hospital treatment.

Table 1

Table 2