Document ID: chunk:federal_register_of_legislation:F2024L00144:reg:65:p18
Version: federal_register_of_legislation:F2024L00144
Segment Type: reg
Provision Reference: reg 65 (pt 18/38)
Character Range: 87481–91275

employment of staff can be risk equalised. These costs are the salaries plus on-costs (or overheads).

The fields under the column 'benefits paid' should be reported by taking the total cost of employing staff in the quarter and dividing it by the number of services provided in that quarter. For example, a health insurer employs two full time staff at a cost of $30,000 for the quarter. During the quarter 240 planning services and 960 coordination services were delivered. Therefore, the insurer attributes, for example, $65 for each planning service and $15 for each coordination service.

If staff were engaged in other activities, the employment costs should be apportioned according to the actual time spent providing planning and coordination services.

For auditing purposes, health insurers should also be able to demonstrate the costs of employing staff to provide planning and coordination services, and the proportion of time staff spent providing those services.

In this scenario, no fees would be charged as there should be no liability on the health insurer to pay fees or charges for the program. Accordingly, in the fields under the column 'fees excluding Medicare benefit' report the same values as the benefits paid. These fields are used as validation checks that the benefit paid is not greater than the fees. Reporting the fees as zero would create an error.

Risk Equalisation Guidelines

Quarterly Return

Part  Heading                                                                                 Comment

2.    Total Chronic Disease Management Programs (CDMP)                                        Number – the total number of chronic disease management programs is the number of individual members who commenced programs during the quarter.

                                                                                              Benefits paid – the total benefits paid is the sum of all benefits paid for CDMPs in the quarter.

                                                                                                   Note: health management programs are not included (these are to be included in Part 6 and 9).

5.    Chronic Disease Management Program by age category                                      Details are to be completed separately for males and females.

                                                                                              Insured persons – the number of insured persons who hold policies that cover CDMPs, in the age cohort they are in at the end of the quarter.

                                                                                              Programs – the number of insured persons commencing CDMPs during the quarter. If one person commenced two CDMPs during the quarter, this should be reported as two.

                                                                                              Eligible benefits – eligible benefits are defined in Rule 5 of the Private Health Insurance (Risk Equalisation Policy) Rules 2015.

                                                                                              Ineligible benefits – all other benefits paid for CDMPs in the quarter not included in Rule 5 of the Private Health Insurance (Risk Equalisation Policy) Rules 2015.

                                                                                                   Note: health management programs are not included (these are to be included in Part 6 and 9).

                                                                                              Total benefits – sum of eligible plus ineligible benefits paid for CDMPs in the quarter.

                                                                                              Fees excluding Medicare