Document ID: chunk:federal_register_of_legislation:F2024L00144:reg:65:p16
Version: federal_register_of_legislation:F2024L00144
Segment Type: reg
Provision Reference: reg 65 (pt 16/38)
Character Range: 82309–85247

data in this part is to be reported as cumulative totals over the quarter being reported. Report Medical Services Statistics for hospital-substitute treatment where the treatment includes professional services for which a Medicare benefit is payable as outlined in Private Health Insurance (Health Insurance Business) Rules 2018.

    38.         Medical service statistics are collected in this section under the different headings of No Gap agreement, Known Gap agreement and No agreement and for different ranges of amount charged in relation to the MBS fee:

       (a)          amount charged <= MBS Fee

       (b)          amount charged >MBS to 125% MBS Fee

       (c)          amount charged >125% to 150% MBS Fee

       (d)          amount charged >150% to 200% MBS Fee

       (e)          amount charged >200% MBS Fee.

    39.         For the amount charged report the amount accepted in full payment (if known), or the invoice amount.

    40.         Report the amount that Medicare pays for the procedure. The Medicare benefit for in-hospital procedures and hospital-substitute treatment is set at 75 per cent of the schedule fee.

    41.         Report the amount that the fund pays for the service.

    42.         The term Agreement is applicable where the health insurer has an agreement with a provider in regard to no gap or known gap.

    It is also applicable to the situation where a medical service has no gap or known gap as stipulated under the conditions of the fund's policy. For example, where the conditions of the policy state there will be no gap where the provider charges no more than a certain amount, regardless of whether there is a formal agreement with the provider.

Guidance for insurers for eligible CDMP benefits for risk equalisation

    43.         Guidance for insurers completing HRF 601.1 to report eligible benefits for risk equalisation.

    The purpose of this section is to provide guidance to health insurers about when and how to complete the sections of the HRF 601.0 series for benefits paid for chronic disease management programs (CDMPs).

    The Private Health Insurance (Risk Equalisation Policy) Rules 2015 provide that only benefits paid for planning, coordination and allied health service components of CDMPs are eligible for risk equalisation. Programs must also meet the definition of CDMP set out in the Private Health Insurance (Health Insurance Business) Rules 2018.

    The duration of, and diversity of various components of CDMPs mean that health insurers may have varying arrangements for the payment of benefits. Benefits may be paid on a per service basis, on a per program basis (either as a single payment or in instalments) or by directly employing staff to deliver programs.

    When to report on CDMPs

    Information on CDMPs should be reported in the quarter that benefits were paid for the program, regardless of whether the benefits are paid