Document ID: chunk:federal_register_of_legislation:F2024L00144:reg:65:p9
Version: federal_register_of_legislation:F2024L00144
Segment Type: reg
Provision Reference: reg 65 (pt 9/38)
Character Range: 64349–67030

the number of days in each age cohort only relates to the case where the treatment covers more than one age cohort, for example an invoice is received for accommodation for a period where the person had a number of days in one age group and a number of days in another age group. In the case where individual treatments are paid during a single episode where the person moves from one age group to another the benefits paid for those treatments should be reported against the age of the person as at the age of the treatment. (It is not the intent that health insurers should sum all benefits paid over an episode spanning two age groups and then apportion them over the age groups); and

       (c)          services are reported under the age at the date of treatment.

    15.         Part 3 and 4 - Medical benefits are reported as benefits paid under all policies only if a Medicare benefit is payable for the service.

    16.         Part 3 and 4 - Medical devices or human tissue products benefits are reported separately.

    17.         Part 3 and 4 - Report the fees charged equal to the total amount the patient would have to pay to the provider/s in the absence of any private health insurance, inclusive of hospital, medical and medical devices or human tissue products  fees. The amount entered here must exclude the Medicare benefit. The difference between fees charged and benefits paid should be the amount that the patient has to pay (out of pocket payment). If the total fee is not known, e.g. where the provider discounts fee for early payment, enter the invoiced amount. Fees excluding Medicare benefit should be greater than or equal to the sum of other benefits, medical benefits and medical devices or human tissue products benefits.

    18.         Part 5 - Chronic Disease Management Program (see the section on Guidance for insurers for eligible CDMP benefits for risk equalisation in these reporting instructions for further information on CDMPs).

       (a)          Programs are reported in the quarter in which the program commenced, in the age category of the participant at the beginning of the program. Programs that run continuously for more than one year are classed as complete at the end of one calendar year after initial commencement. They are reported as a commencing program in the next quarter in which benefits are paid for the program.

           i)              The commencement date of the program, and thus the first quarter in which the program is deemed to have commenced, should be taken as the date on which benefits were first paid for under the program. The commencement date of the program may be hard to determine due to