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1 Private Health Insurance (Benefit Requirements) Rules 2011 As amended Made under item 3A of the table in section of the Private Health Insurance Act This compilation was prepared on 21 June 2012 taking into account amendments up to the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 4). Prepared by the Department of Health and Ageing, Canberra 1
2 Contents Contents Part 1 Preliminary 3 1. Name of Rules 3 2. Commencement and Revocation 3 3. Definitions 3 4. Psychiatric care, rehabilitation and palliative care 5 5. Other hospital treatments 5 6. Benefit not to exceed hospital fees or charges 5 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 6 Schedule 2 Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia 17 Schedule 3 Same-day accommodation: hospitals in all States/Territories 18 Schedule 4 Nursing-home type patient accommodation: hospitals in all States/Territories 31 Schedule 5 Second-tier default benefits 34 Notes 50 2
3 Part 1 Preliminary Part 1 Preliminary 1. Name of Rules These Rules are the Private Health Insurance (Benefit Requirements) Rules Commencement and Revocation (1) These Rules commence on 1 November 2011, or if registered after 1 November 2011, the day after registration. (2) These Rules revoke the Private Health Insurance (Benefit Requirements) Rules Definitions In these Rules: Act means the Private Health Insurance Act 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 fee in the MBS means the Schedule fee as defined in subsection 8 (1A) of the Health Insurance Act general medical services table means the table prescribed under subsection 4 (1) of the Health Insurance Act insurer means a private health insurer. item has the same meaning as in subsection 3 (1) of the Health Insurance Act MBS comprises the: (a) general medical services table; (b) diagnostic imaging services table; and (c) pathology services table. 3
4 Part 1 Preliminary 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. NSW means the State of New South Wales. nursing-home type patient has the meaning given by Schedule 4 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. participating midwife has the same meaning as in subsection 3(1) of the Health Insurance Act pathology services table means the table prescribed under subsection 4A (1) of the Health Insurance Act policy means a complying health insurance policy. private hospital means a hospital in respect of which there is in force a statement under subsection (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 public hospital means a hospital in respect of which there is in force a statement under subsection (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. 4
5 Part 2 Minimum benefit requirements 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 or 5 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 or 5 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment. (2) Despite subsection (1), if a policy covers a type of hospital treatment, other than treatment referred to in rule 4, and the insurer for that policy has a negotiated agreement with the hospital in which the treatment is provided, the minimum benefit for that treatment is the amount specified for the treatment in the negotiated agreement. (3) Despite subrules (1) and (2), 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. 6. Benefit not to exceed hospital fees or charges (1) In respect of treatment referred to in rule 4 and in rule 5 other than hospital treatment for a nursing-home type patient (as set out in Schedule 4), the amount of benefit payable by the insurer in respect of hospital treatment for a person will not exceed the fees or charges incurred in respect of that hospital treatment. (2) In respect of treatment referred to in rule 5 of this Part, the amount of benefit payable by the insurer in respect of hospital treatment for a nursinghome type patient (as set out in Schedule 4) will not exceed an amount equal to the fees or charges incurred in respect of that hospital treatment less the amount of the patient contribution in relation to the patient for each day on which the patient was a patient in the hospital. 5
6 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 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: (c) The definition of hospital treatment in section 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 (1) (c) of the Act. 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: 2. Minimum benefit 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. (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 Class of patient Advanced surgical patient - first 14 days $384 - over 14 days $266 Minimum benefit payable per night 6
7 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Surgical patient or obstetric patient - first 14 days $356 - over 14 days $266 Psychiatric patient - first 42 days $ days $309 - over 65 days $266 Rehabilitation patient - first 49 days $ days $309 - over 65 days $266 Other patients - first 14 days $309 - over 14 days $266 Table 2 Victoria: shared ward accommodation at a public hospital Class of patient Advanced surgical patient - first 14 days $384 - over 14 days $266 Surgical patient or obstetric patient - first 14 days $356 - over 14 days $266 Psychiatric patient - first 42 days $ days $309 - over 65 days $266 Rehabilitation patient - first 49 days $ days $309 - over 65 days $266 Other patients - first 14 days $309 - over 14 days $266 Minimum benefit payable per night 7
8 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Table 3 Tasmania: shared ward accommodation at a public hospital Class of patient Minimum benefit payable per night Advanced surgical patient - first 14 days $384 - over 14 days $266 Surgical patient or obstetric patient - first 14 days $356 - over 14 days $266 Psychiatric patient - first 42 days $ days $309 - over 65 days $266 Rehabilitation patient - first 49 days $ days $309 - over 65 days $266 Other patients - first 14 days $309 - over 14 days $266 8
9 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Part 2 Type A procedures 3. Interpretation A Type A procedure is a procedure specified in this Part provided to a patient in one of the categories of patients in clauses 4 to Advanced surgical patient (1) In this Schedule, advanced surgical patient has the meaning given by this clause. (2) A patient is taken to be an advanced surgical patient upon admission to a hospital: (a) from and including the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3) is rendered to the patient at that hospital, unless the particular advanced surgical procedure to be rendered is recognised as requiring a longer pre-operative period; or (b) if a longer pre-operative period than that referred to in paragraph (a) is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or (c) if the advanced surgery is rendered to a patient during an admission, from the day the advanced surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before). Note: The effect of the reference in subclause (2) (a) to a professional service, being a service for which a medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply. (3) The item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS greater than $837.05:
10 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania
11 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Obstetric patient (1) In this Schedule, obstetric patient has the meaning given by this clause. (2) A patient shall be taken to be an obstetric patient during an admission to a hospital from and including: (a) whichever is the earlier of: (i) the day on which the patient commences labour leading to delivery in that hospital; or (ii) the day on which a professional service with the item number 16406, 16515, 16518, 16519, (excluding caesarean), 16525, or is rendered to the patient in that hospital; or (b) if the circumstances in paragraph (a) do not apply, the day before a professional service with the item number and (including caesarean) is rendered to the patient at that hospital, unless the particular obstetric procedure to be rendered is recognised as requiring a longer pre-operative period; or (c) the day on which a professional service with the item number or is rendered to a patient by a participating midwife. (3) In this clause, the item numbers specified are the item numbers in the general medical services table. 6. Surgical patient (1) In this Schedule, surgical patient has the meaning given by this clause. (2) A patient shall be taken to be a surgical patient upon admission to a hospital from and including: 11
12 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania (a) (b) (c) Note: the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3), is rendered to the patient at that hospital, unless the particular surgical procedure to be rendered is recognised as requiring a longer preoperative period; or if a longer pre-operative period is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or if the surgery is rendered to a patient during an admission, from the day the surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before). The effect of the reference in subclause (2) (a) to a professional service, being the service for which a medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply. (3) The item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS within the range of $ to $837.05:
13 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania
14 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania
15 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Psychiatric patient In this Schedule, a psychiatric patient is a patient in a hospital who is admitted for the purposes of undertaking a specific psychiatric treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient s disease, injury or condition. Note: 8. Rehabilitation patient If a patient is receiving psychiatric treatment that is not under a specific psychiatric treatment program, the patient is taken to be in the category of 'other patient'. In this Schedule, a rehabilitation patient is a patient in a hospital who is admitted for the purposes of undertaking a specific rehabilitation treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient s disease, injury or condition. Note: 9. Other patient If a patient is receiving rehabilitation treatment that is not under a specific rehabilitation treatment program, the patient is taken to be in the category of 'other patient'. (1) In this Schedule, other patient is deemed to be a patient at a hospital who is receiving any treatment that involves part of an overnight stay, but who is not: (a) an advanced surgical patient; (b) a surgical patient; (c) an obstetric patient; (d) a psychiatric patient; or (e) a rehabilitation patient. Note: A patient receiving hospital treatment that is palliative care as described in item 1 of the table in subsection 72-1 (2) of the Act is deemed to be in the category of 'other patient'. 15
16 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Part 3 Certified Type B procedures and certified overnight Type C procedures 10. Certified Type B procedures (1) Minimum benefits for overnight accommodation are payable for patients receiving a Type B procedure only if certification under subclause (2) is provided. (2) Certification must be provided as follows: (a) the practitioner providing the Type B procedure; or (b) a professional employed by a hospital who is involved in the provision of the procedure provided by that hospital, must certify in writing that: (c) because of the medical condition of the patient specified in the certificate; or (d) because of the special circumstances specified in the certificate, it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay. 11. Certified overnight Type C procedures (1) Minimum benefits for overnight accommodation are payable for patients receiving a certified Type C procedure only if: (a) certification has first been provided for the Type C procedure in accordance with clause 7 of Schedule 3; and (b) certification under subclause (2) is also provided. (2) Certification must be provided as follows the practitioner providing the certified Type C procedure must certify in writing that: (a) because of the medical condition of the patient specified in the certificate; or (b) because of the special circumstances specified in the certificate, it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay. 16
17 Schedule 2 Overnight accommodation: shared accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, Southern Australia and Western Australia Schedule 2 Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia 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 provided: (a) to a patient who is not a nursing-home type patient; and (b) as shared ward accommodation at a public hospital in the ACT, NSW, Northern Territory, Queensland, South Australia or Western Australia; and Note: (c) The definition of hospital treatment in section 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 (1) (c) of the Act. 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: 2. Minimum benefit 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. The minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in the table in this Schedule for that hospital treatment. Table State/Territory Minimum benefit payable per night ACT $318 NSW $318 Northern Territory $318 Queensland $324 South Australia $318 Western Australia $318 17
18 Schedule 3 Same day accommodation: hospitals in all States/Territories Schedule 3 Same-day accommodation: hospitals in all States/Territories 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 provided for the purpose of permitting the provision to the patient of hospital treatment that: (a) is a Type B procedure; and (b) is provided to a patient at a hospital; and (c) does not include part of an overnight stay at a hospital. Note 1: Note 2: 2. Minimum benefit A Type B procedure includes a certified Type C procedure see the definitions of those terms in rule 3 of Part 1 of these Rules. The definition of hospital treatment in section 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 (1) (c) of the Act. (1) The minimum benefit for hospital treatment provided in the circumstances specified in this Schedule is the amount set out in Table 1 or 2 in this clause for that hospital treatment. (2) The references to Bands in the tables are references as follows: (a) Band 1 means Band 1 treatment; (b) Band 2 means Band 2 treatment; (c) Band 3 means Band 3 treatment; (d) Band 4 means Band 4 treatment, Table 1 as those bands are described in Part 2 of this Schedule. Public hospitals Band 1 Band 2 Band 3 Band 4 NSW $230 $257 $283 $318 ACT $230 $257 $283 $318 Northern Territory $230 $262 $305 $318 Queensland $ $264 $291 $324 South Australia $230 $262 $290 $318 Tasmania $223 $265 $308 $356 Victoria $225 $266 $310 $356 Western Australia $260 $260 $260 $260 18
19 Schedule 3 Same day accommodation: hospitals in all States/Territories Table 2 Private hospitals $199 $251 $305 $356 19
20 Schedule 3 Same day accommodation: hospitals in all States/Territories Part 2 Type B procedures 3. Interpretation A Type B procedure is a procedure specified as a Band 1, 2, 3 and 4 as described in this Part. Note: 4. Band 1 These procedures normally require hospital treatment that does not include part of an overnight stay. (1) Hospital treatment that involves a professional service of the type identified by the MBS item number specified in this subclause is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule: (a) category 3 therapeutic procedures, being the items below in the general medical services table: T1: Miscellaneous Therapeutic Procedures: T8: Surgical Operations: (b) ; and category 5 diagnostic imaging services, being the items below in the diagnostic imaging services table: I1: Ultrasound: ; and (2) Other hospital treatment requiring day admission to a hospital that is not Band 2, 3 or 4 treatment is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule. 5. Non-band specific Type B day procedures (1) Hospital treatment that involves a professional service of the type identified by the MBS item number specified in this clause is a non-band specific Type B day procedure
21 Schedule 3 Same day accommodation: hospitals in all States/Territories (2) A non-band specific Type B day procedure is Band 2, 3 or 4 treatment depending on anaesthetic type and, where applicable, theatre time as specified in clause 6 of this Schedule. (3) If a non-band specific Type B day procedure does not involve anaesthetic or theatre times, the minimum benefit is the benefit for Band 1 treatment. 6. Other bands In this Schedule: Band 2 treatment means procedures, other than those that are Band 1 treatment, carried out under local anaesthetic with no sedation. 21
22 Schedule 3 Same day accommodation: hospitals in all States/Territories Band 3 treatment means procedures, other than those that are Band 1 treatment, carried out under: (a) general anaesthesia; or (b) regional anaesthesia; or (c) intravenous sedation, where the theatre time, being the actual time in theatre, is less than one hour. Band 4 treatment means procedures, other than those that are Band 1 treatment, carried out under: (a) general anaesthesia; or (b) regional anaesthesia; or (c) intravenous sedation, where the theatre time, being the actual time in theatre, is one hour or more. 7. Certified Type C procedure Note: Type C procedures are procedures that do not normally require hospital treatment. (1) Benefits for day-only accommodation are payable for patients receiving a Type C procedure only if certification under subclause (2) is provided. (2) Certification must be provided as follows, the medical practitioner providing the professional service must certify in writing that: (a) because of the medical condition of the patient specified in the certificate; or (b) because of the special circumstances specified in the certificate, it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that does not include part of an overnight stay. Part 3 Type C procedures 8. Interpretation A Type C procedure is a procedure specified in this clause by reference to MBS items. Note: These procedures normally do not require hospital treatment. Items in the general medical services table The following items are items in the general medical services table. Category 1 Attendances A1:
23 Schedule 3 Same day accommodation: hospitals in all States/Territories A2: A3: A4: A28: A5: A6: A7: A8: A9: A12: A13:
24 Schedule 3 Same day accommodation: hospitals in all States/Territories A15: A17: A18: A19: A20: A21: A22: A23: A24: A25: A26:
25 Schedule 3 Same day accommodation: hospitals in all States/Territories A27: 4001 M3: M5: Category 2 Diagnostic procedures & investigations D1: D2: Category 3 Therapeutic procedures T1:
26 Schedule 3 Same day accommodation: hospitals in all States/Territories T2: T3: T4: T6: T7: T8: T11:
27 Schedule 3 Same day accommodation: hospitals in all States/Territories Category 4 Oral and maxillofacial O1: O3: O7: O9: O10: Items in the diagnostic imaging services table The following items are items in the diagnostic imaging services table. Category 5 Diagnostic Imaging Services I1: , I2:
28 Schedule 3 Same day accommodation: hospitals in all States/Territories I3: , I4: I5: Category 6 Pathology services The following items are items in the pathology services table. P1: