Document ID: chunk:federal_register_of_legislation:F2024L00144:reg:65:p27
Version: federal_register_of_legislation:F2024L00144
Segment Type: reg
Provision Reference: reg 65 (pt 27/38)
Character Range: 117426–120944

human tissue products in the circumstances specified.

Ineligible benefits                                      See page 31

Risk Equalisation

Age Based Pool (ABP)             The Age Based Pool (ABP) equalises benefits for the Risk Equalisation Levy. Pooling is based on adding a proportion of applicable benefits, above age 55, in a sliding scale.

age based pool                   The amount to be notionally allocated to the ABP in a quarter is to be calculated in accordance with the formula , where:

                                    (a)        p is the percentage of the eligible benefit paid having regard to the age cohort, as specified in the ABP table, into which the insured person falls on the day or days on which the insured person receives the treatment to which the eligible benefit relates; and
                                    (b)       C is the gross benefit in the current quarter.

                                 Where an insured person receives treatment over a number of days such that the age of the insured person on the day or days on which that person receives the treatment falls within more than one age cohort, the amount to be notionally allocated to the ABP must be allocated proportionately in accordance with the number of days during which the insured person was in each age cohort.

                                 (Part 2, Private Health Insurance (Risk Equalisation Policy) Rules 2015)

ABP table                        Age cohorts  Age % of eligible benefits included in pool

                                 0-54         0.0%

                                 55-59        15.0%

                                 60-64        42.5%

                                 65-69        60.0%

                                 70-74        70.0%

                                 75-79        76.0%

                                 80-84        78.0%

                                 85+          82.0%

                                 (Part 2, Private Health Insurance (Risk Equalisation Policy) Rules 2015)

Gross Benefit                    Means the total eligible benefits paid by the insurer in respect of an insured person in a quarter.

High Cost Claimants Pool (HCCP)  The High Cost Claimants Pool (HCCP) deals with benefits not equalised by the age-based pool. Pooling is based on applicable benefits accumulated by claimant for the current and preceding 3 quarters. The percentage of the benefits to be pooled will be 82%.

high cost claimants pool         A limit is imposed on total pooling under the ABP pool and HCCP of 82% of gross benefits. When assessing HCCP pooling in each quarter, the cumulative residual after ABP pooling is compared with the threshold at that time.

                                 The amount to be notionally allocated to the HCCP is to be calculated in accordance with the formula:

                                 , where:

                                    (a)        m is 82%
                                    (b)       R is the total gross benefit for the current and the preceding 3 quarters less the amount notionally allocated to the ABP in the current and preceding 3 quarters
                                    (c)        T is the designated threshold
                                    (d)       H is the sum of the amounts notionally allocated to the HCCP in the preceding 3 quarters

                                 Subject to a maximum of 82% of gross benefits being included in Risk Equalisation when