Document ID: chunk:federal_register_of_legislation:F2025C00117:body:0:p28
Version: federal_register_of_legislation:F2025C00117
Segment Type: other
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Character Range: 79119–82037

to an episode of hospital treatment for an insured person who was an admitted patient at the hospital or booked for hospital treatment at the hospital (as opposed to merely being on the hospital's waiting list) before the day that the hospital ceased to be a second‑tier eligible hospital is the minimum benefit that would have applied if the hospital continued to be a second‑tier eligible hospital 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 at a second‑tier eligible hospital for which the admission date was 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 as in force on 1 August of the first year, with all private hospitals:
            (a) that:
                (i) if the second‑tier eligible hospital is on the list published on the Department's website under subclause 1A(5)—were comparable on 1 August of the first year with the second‑tier eligible hospital; and
                (ii) otherwise—are in the same category as the second‑tier eligible hospital in the list published on the Department's website under subclause 1A(5) as at 1 August of the first year; and
            (b) that are in the same State as the second‑tier eligible hospital.

          Note: See clause 4 for a transitional arrangement for admissions to second‑tier eligible hospitals between 1 January 2019 and 31 August 2019.

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

                   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 second‑tier eligible hospital 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