Schedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories
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.
Interpretation
Nursing-home type patient, in relation to a hospital, means a patient who has been provided with hospital treatment whether:
(a) acute care; or
(b) accommodation and nursing care, as an end in itself; or
(c) a mixture of both,
for a continuous period of hospitalisation exceeding 35 days (35-day period), but a patient receiving acute care immediately after the 35-day period does not become a nursing-home type patient unless the period of acute care ends and the patient is then provided with accommodation and nursing care, as an end in itself, as part of a continuous period of hospitalisation.
Note 1: 'Continuous period of hospitalisation' is defined in rule 3 of Part 1 of these Rules.
Note 2: Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.
Note 3: If there is disagreement as to whether a patient is, or is not, a nursing‑home type patient, an insured person, a private health insurer or a health care provider may make a complaint to the Private Health Insurance Ombudsman under Part 6-2 of the Act. The Ombudsman has various powers to deal with complaints, including conducting mediation if the complainant agrees.
Application
(1) Clause 2 of this Schedule applies to a patient who on or after the day on which the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) commence:
(a) returns to hospital for hospital treatment at a hospital not later than 7 days after receiving hospital treatment at that hospital or another hospital; or
(b) is otherwise admitted to a hospital for hospital treatment at the hospital.
(2) If subclause (1) does not apply to a patient, the definition of 'nursing‑home type patient' in these Rules before the commencement of the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) continues to apply to that patient.
Note: Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.
Provision of acute care
If a nursing-home type patient is provided with acute care at the hospital (the first hospital), or at another hospital, the patient:
(a) ceases to be a nursing‑home type patient only for the days on which the acute care is provided; and
(b) again becomes a nursing‑home type patient when the provision of acute care ends and the patient is then provided with accommodation and nursing care as an end in itself, whether at the first hospital or another hospital.
Ceasing and resuming hospital treatment
If a nursing-home type patient, or a person referred to in paragraph 4 (a), leaves hospital but returns to a hospital, whether or not at the same hospital, not more than 7 days later and is provided with hospital treatment at the hospital, the patient is a nursing‑home type patient for each subsequent day that the patient is provided with accommodation and nursing care, as an end in itself, until the patient ceases to be provided with hospital treatment at a hospital for a period of more than 7 days.
Note: If the relevant period of hospitalisation is broken by more than 7 days, clause 2 of this Schedule may again apply to the person.
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
Public hospital: State/Territory
Minimum benefit per night
NSW
$101.65
Northern Territory
$60.72
Queensland
$92.00
South Australia
$97.50
Tasmania
$99.25
Victoria
$99.15
ACT
$93.15
Western Australia
$99.30
Table 2
Private hospitals
$69.75
Schedule 5―Second-tier default benefits
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.
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.
Minimum benefit
(1) Despite anything in Schedules 1, 2 or 3, 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 or 3 the minimum benefit is the amount determined in accordance with Schedules 1, 2 or 3 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: