Private Health Insurance (Reforms) Amendment Rules 2018
I, Susan Azmi, delegate of the Minister for Health, make the following rules.
Dated 11 October 2018
Susan Azmi
Delegate of the Minister for Health
Contents
1 Name
2 Commencement
3 Authority
4 Schedules
Schedule 1 —Amendments to implement age‑based discounts
Private Health Insurance (Complying Product) Rules 2015
Schedule 2 —Standard information statements and private health information statements
Part 1 —Amendments commencing on 1 January 2019
Private Health Insurance (Complying Product) Rules 2015
Part 2 —Amendments commencing on 1 April 2019
Private Health Insurance (Complying Product) Rules 2015
Part 3 —Amendments commencing on 1 April 2020
Private Health Insurance (Complying Product) Rules 2015
Schedule 3 —Product tiers and related amendments
Part 1 —Amendments commencing on 1 April 2019
Private Health Insurance (Complying Product) Rules 2015
Part 2 —Amendments commencing on 1 April 2020
Private Health Insurance (Complying Product) Rules 2015
Schedule 4 —Second tier administrative reforms
Private Health Insurance (Benefit Requirements) Rules 2011
Private Health Insurance (Health Insurance Business) Rules 2018
Schedule 5 —Removal of coverage of some natural therapies
Private Health Insurance (Health Insurance Business) Rules 2018
Schedule 6 —Information provision
Private Health Insurance (Incentives) Rules 2012 (No. 2)
Private Health Insurance (Lifetime Health Cover) Rules 2017
Schedule 7 —Amendments relating to accredited podiatrists
Private Health Insurance (Complying Product) Rules 2015
Private Health Insurance (Prostheses) Rules 2018 (No. 2)
This instrument is the Private Health Insurance (Reforms) Amendment Rules 2018.
(1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.
Commencement information | ||
Column 1 | Column 2 | Column 3 |
Provisions | Commencement | Date/Details |
1. Sections 1 to 4 and anything in this instrument not elsewhere covered by this table | The day after this instrument is registered. |
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2. Schedule 1 | 1 April 2019 | 1 April 2019 |
3. Part 1 of Schedule 2 | 1 January 2019 | 1 January 2019 |
4. Part 2 of Schedule 2 | 1 April 2019 | 1 April 2019 |
5. Part 3 of Schedule 2 | 1 April 2020 | 1 April 2020 |
6. Part 1 of Schedule 3 | 1 April 2019 | 1 April 2019 |
7. Part 2 of Schedule 3 | 1 April 2020 | 1 April 2020 |
8. Schedule 4 | 1 January 2019 | 1 January 2019 |
9. Schedule 5 | 1 April 2019 | 1 April 2019 |
10. Schedule 6 | 1 April 2019 | 1 April 2019 |
11. Schedule 7 | The day after this instrument is registered. |
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Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.
(2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.
This instrument is made under section 333‑20 of the Private Health Insurance Act 2007.
Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.
Schedule 1—Amendments to implement age‑based discounts
Private Health Insurance (Complying Product) Rules 2015
[1] Rule 4 (note at the end of the rule)
Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, the following terms:
(a) adult;
(b) hospital cover.
[2] Subrule 6(3)
Omit “(e)”, substitute “(ea)”.
[3] Subrule 6(5)
Omit “The following costs are excluded from the calculation of net premium in subrule (4):”, substitute “For the purposes of this rule, disregard:”.
[4] At the end of subrule 6(5)
Insert:
; and (c) any age‑based discount that might apply in relation to the policy (see Part 2A).
[5] After Part 2
Insert:
Note 1: See paragraphs 63‑10 (g) and 66‑5 (3) (ea) of the Act.
Note 2: Nothing in this Part requires a private health insurer to:
make age‑based discounts available under any product; or
if age‑based discounts are available under a product:
– make such discounts available for all ages between 18 and 29 (inclusive); or
– continue to make age‑based discounts available under the product.
Instead, an age‑based discount policy may specify the ranges of ages, between 18 and 29 (inclusive), for which such discounts will be available (see subparagraph 11B (c) (i)).
However, under this Part:
if a person is receiving an age‑based discount, the person is entitled to continue to receive the full discount until the person turns 41 (unless the insurer chooses to discontinue age‑based discounts under the product, or the person transfers to a different insurance policy), and might be entitled to receive a reduced discount for a number of years after turning 41; and
if age‑based discounts are available in relation to particular ages or particular ranges of ages for a particular product, they must be available in relation to those ages or ranges on the same terms and conditions for all insurance policies under that product (see section 63‑5 of the Act).
In this Part:
age‑based discount policy means an insurance policy that provides age‑based discounts.
discount assessment date, in relation to a person who is insured under an age‑based discount policy, means whichever of the following is applicable:
(a) subject to paragraph (c), if the policy provided age‑based discounts at the date the person became insured—that date;
(b) if the policy provided age‑based discounts at a date after the person became insured—the date the person was first eligible for an age‑based discount under the policy;
(c) if:
(i) the person transferred to the policy (the new policy) from another age‑based discount policy (the old policy); and
(ii) at the time of the transfer, the new policy was stated to be a retained age‑based discount policy; and
(iii) the person was not a dependent child under the old policy;
the person’s discount assessment date under the old policy.
eligible person, in relation to an age‑based discount policy, means a person to whom a discount applies in accordance with paragraph 11B (c).
retained age‑based discount policy means an insurance policy:
(a) that is an age‑based discount policy; and
(b) that states that it is a retained age‑based discount policy.
11B. Requirements for age‑based discount policy to be complying health insurance policy
For paragraph 63‑10 (g) of the Act, an insurance policy must not provide for an age‑based discount (the discount) unless:
(a) the policy covers:
(i) hospital treatment; or
(ii) hospital treatment and general treatment; and
(b) the discount will be a reduction in the amount that would otherwise be payable by the person for the policy, equal to the dollar amount calculated in accordance with rule 11C; and
(c) the discount will apply to each person insured under the policy who, on the discount assessment date for the person:
(i) was within one or more ranges of ages, between 18 and 29 (inclusive), that are specified in the policy as eligible for the discount; and
(ii) was not a dependent child under the policy; and
(d) while age‑based discounts are available under the policy, the discount will continue to apply until it is reduced, in accordance with rule 11C, to zero in relation to each such person insured under the policy; and
(e) the policy states whether it is a retained age‑based discount policy.
Note: For paragraph (c), an insurer is not required to provide discounts for all ages between 18 and 29 (inclusive).
11C. Calculation of age‑based discount
Note: This rule deals only with the calculation of the age‑based discount. The premium that is payable in respect of a particular insurance policy is also affected by other provisions of the Act (including Part 2‑3 of the Act, which deals with lifetime health cover) and rules made under the Act (including these Rules).
(1) For paragraph 11B (b), the total age‑based discount that applies under an age‑based discount policy for a particular period is equal to the sum of the applicable discounts to which each eligible person who is insured under the policy is entitled for that period.
(2) An eligible person is entitled to an applicable discount calculated in accordance with the following formula:
where:
applicable percentage, for a particular period, is the greater of:
(a) the person’s percentage for the period, determined in accordance with the table to subrule (3); and
(b) zero.
base rate for hospital cover is the amount of premiums that would be payable for hospital cover under the policy if:
(a) the premiums were not increased under Part 2‑3 of the Act (lifetime health cover); and
(b) there were no discounts of the kind allowed under subsection 66‑5 (2) of the Act (including under this Part of these Rules).
number of adults insured is the number of adults insured under the policy.
(3) For paragraph (a) of the definition of applicable percentage in subrule (2), the table is:
If, for that period, the person is aged: | the person’s percentage for the period is: |
18 or older, but under 41 | the person’s base percentage |
41 | the person’s base percentage minus 2 percentage points |
42 | the person’s base percentage minus 4 percentage points |
43 | the person’s base percentage minus 6 percentage points |
44 | the person’s base percentage minus 8 percentage points |
45 or older | zero |
(4) For subrule (3), a person’s base percentage is equal to:
(a) for an eligible person under the policy—the percentage, as given by the following table, corresponding to the person’s age at the discount assessment date; and
Note: See paragraph 11B (c).
(b) otherwise—zero.
Person’s age at discount assessment date | Percentage |
18 or older, but under 26 | 10% |
26 | 8% |
27 | 6% |
28 | 4% |
29 | 2% |
11D. Circumstances in which a person is entitled to age‑based discount
For paragraph 66‑5 (3) (ea) of the Act, a person is entitled to an age‑based discount for a particular period if:
(a) the person is insured under an age‑based discount policy during that period; and
(b) the person is an eligible person in relation to that policy; and
(c) the person’s applicable discount for that period, as calculated in accordance with subrule 11C (2), is not equal to zero.
Schedule 2—Standard information statements and private health information statements
Part 1—Amendments commencing on 1 January 2019
Private Health Insurance (Complying Product) Rules 2015
[1] Rule 4
Insert:
State, when used in Schedule 1, Schedule 2 or Schedule 3, means a risk equalisation jurisdiction.
Note: The risk equalisation jurisdictions are set out in the Private Health Insurance (Health Benefits Fund Policy) Rules 2015. Under those rules, the area specified in each of the following paragraphs is a risk equalisation jurisdiction:
(a) Australian Capital Territory, Norfolk Island and New South Wales;
(b) Northern Territory;
(c) Queensland;
(d) South Australia;
(e) Tasmania;
(f) Victoria;
(g) Western Australia and the Territory of Christmas Island and the Territory of Cocos (Keeling) Islands.
[2] Rule 4 (note at the end of the rule)
Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, “risk equalisation jurisdiction”.
[3] Part 3
Repeal the Part, substitute:
Part 3 Standard information statements and other information that must be given
Note: This Part deals with:
the information and form for standard information statements, for the purposes of subsection 93‑5 (1) of the Act, and methods by which standard information statements are made available; and
information that must be provided to the Private Health Insurance Ombudsman relating to changes in premiums.
This Part does not limit the information that a private health insurer may give to an insured person.
12. Standard information statements
Note: See rule 20 for a transitional provision relating to this rule that applies until 31 March 2020.
(1) For subsection 93‑5 (1) of the Act, the information to be contained in a standard information statement, and the form, for a product subgroup of a complying health insurance product, are:
(a) the information and form of words set out in Schedule 1; and
(b) if policies that belong to the product subgroup cover hospital treatment—the additional information, and the form of words, set out in Schedule 2; and
(c) if policies that belong to the product subgroup cover general treatment—the additional information, and the form of words, set out in Schedule 3.
(2) However, paragraph (1)(c) does not apply if the only general treatment provided is ambulance cover.
13. Method of making standard information statements available
(1) This rule is made for the purposes of subsection 93‑5 (2) and paragraph 93‑15 (1) (a) of the Act.
(2) If:
(a) the standard information statement is accompanied by information additional to the information and form of words that are required by subrule 12 (1); and
(b) the standard information statement and the additional information are set out in the same document;
the additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).
Example: The document on which a standard information statement is provided might include information about ambulance cover that is additional to the information required by item 10 of the table to clause 2 of Schedule 1. The additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.
14. Information relating to changes to premiums to be provided to Private Health Insurance Ombudsman
(1) This rule is made for the purposes of section 96‑25 of the Act.
(2) This rule applies if the Minister has approved a proposed change to the premiums charged under a complying health insurance product of a private health insurer under subsection 66‑10 (3) of the Act.
(3) The private health insurer must notify the Private Health Insurance Ombudsman of:
(a) the premiums that applied before the approval; and
(b) the premiums that apply after the approval.
(4) The insurer must give this information to the Ombudsman by the earlier of:
(a) the day 14 days after the date of the Minister’s approval for the change; and
(b) 1 April of the year in which the Minister approved the change.
[4] After rule 19
Insert:
Application of rule
(1) This rule applies until 31 March 2020.
Transitional provision
(2) A standard information statement that is in the old form is taken to contain the information, and be in the form, set out in these Rules.
(3) For this rule, a standard information statement is in the old form if it contains the information, and is in the form, set out in these Rules as in force immediately before the commencement of Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018.
Note: Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 January 2019.
[5] Schedules 1, 2, 3 and 4
Repeal the Schedules, substitute:
Schedule 1—Information and form of words for standard information statement—all policies
In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.
2. Information and form of words for standard information statement—all policies
For paragraph 12 (1) (a) of these Rules, the information and form of words are set out in the following table:
Information and form of words for standard information statement—all policies | |
Item | Information and form of words |
1 | Policy name The name of the policy.
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2 | Name of private health insurer The trading or brand name of the private health insurer in the State in which the policy is being made available, together with any associated branding that the insurer elects to include.
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3 | Disclaimer for restricted access insurers If the policy is offered by a restricted access insurer—the following statement: “Membership of this insurer is restricted to” followed by the details.
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4 | Contact details A contact phone number and website address of the private health insurer.
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5 | State/s available in The States in which the product is available, expressed as either: (a) if: (i) the product is offered in all States; and (ii) every feature of the product (including the monthly premium referred to in item 6) is the same in each State; “All States”; or (b) otherwise—the State or States in which the product is available, expressed as whichever of the following is applicable: (i) “NSW & ACT”; (ii) “Northern Territory”; (iii) “Queensland”; (iv) “South Australia”; (v) “Tasmania”; (vi) “Victoria”; (vii) “Western Australia”.
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6 | Monthly premium The total monthly premium payable before any rebate, loading or discount is applied. The following words must be inserted before or following the premium amount: “before any rebate, loading or discount”. Note: This item does not limit the information that a private health insurer may give to an insured person with regard to the premium payable after any rebate, loading and/or discount is applied.
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7 | Corporate products If the policy is part of a corporate product—a statement to that effect, indicating either of the following, with the bracketed text replaced with the appropriate information: (a) “Employees/members of [Company/Organisation]”; (b) “Employees/members of organisations with arrangements with this health insurer”.
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8 | Closed products If the policy is closed so that it is no longer available to anyone except those persons who, at the time of closing, were insured under the policy—the following words: “This policy is closed to new members.”.
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9 | Who is covered The insured groups that may be covered, expressed as whichever of the following is applicable: (b) “2 adults (and no-one else)”; (c) “2 or more people, none of whom is an adult”; (d) “2 or more people, only one of whom is an adult”; (e) “3 or more people, only 2 of whom are adults”; (f) “3 or more people, at least 3 of whom are adults”. Note 1: The insured groups are set out in rule 5 of these Rules. Note 2: This item does not limit the information that a private health insurer may give to an insured person with regard to the name/s of person/s covered by the policy.
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10 | Ambulance cover The following information: (a) whether ambulance cover is included; (b) if so: (i) the waiting period (if any); and (ii) whether the cover is: (A) emergency only; or (B) emergency and non‑emergency; and (iii) any limits on cover (dollar amount or service); and (iv) any call-out fees (if applicable); (c) for each State in which: (i) the product is available; and (ii) ambulance cover is not included; the following information: (iii) whether free ambulance services are available in that State; (iv) if so—whether they are limited to services in that State; (d) if ambulance cover were to be provided by a person other than the private health insurer who prepared the statement—whether the policy would provide a benefit for that cover.
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11 | Date available If, and only if, the policy is not yet available—the date from which the policy will be available.
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12 | Date statement issued or updated The date on which the content of the statement was issued or updated, in the following format, with the bracketed text replaced with the appropriate information: “Date statement [issued/updated]: [dd]/[month in words]/[yyyy]”
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13 | Unique identifier The unique identifier for the standard information statement that is generated by the privatehealth.gov.au system.
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Schedule 2—Additional information, and form of words, for standard information statement—hospital treatment
In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.
2. Additional information and form of words—hospital treatment
For paragraph 12 (1) (b) of these Rules, the additional information and form of words are set out in the following table:
Additional information and form of words—hospital treatment | |
Item | Additional information and form of words |
1 | Information relating to policies that are available only with a general treatment policy If the policy is available only with a policy that covers general treatment—whichever of the following is applicable: (a) if the policy may be purchased with any policy that covers general treatment offered by the insurer—the statement “must be purchased with a general treatment policy”; (b) if there is a set range of policies that cover general treatment with which the policy may be combined—the statement “must be purchased with certain general treatment policies”.
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2 | Whether the policy exempts holders from the Medicare Levy Surcharge Whichever of the following is applicable: (a) “This policy exempts you from the Medicare Levy Surcharge”; (b) “This policy does not exempt you from the Medicare Levy Surcharge”.
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3 | What’s included and what’s not included in the policy An indication of: (a) treatments that are covered by the policy, consisting of the words: “This policy includes cover for” followed by the relevant treatments; and (b) treatments that are not covered by the policy, consisting of the words: “This policy does not include cover for” followed by the relevant treatments.
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4 | Restrictions A list of all restrictions (if any) that apply.
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5 | Waiting periods for new and upgrading members The waiting periods that apply under the policy before a policy holder can claim, expressed either: (a) in the following format, with the bracketed text replaced with the appropriate figures: (i) “[the number of months (up to 2)] months for palliative care, rehabilitation and psychiatric treatments”; (ii) “[the number of months (up to 12)] months for pre‑existing conditions”; (iii) if, and only if, the policy covers pregnancy and birth (obstetrics)—“[the number of months (up to 12)] months for pregnancy and birth (obstetrics)”; (iv) “[the number of months (up to 2)] months for all other treatments”; or (b) if shown in a table—for all treatments covered by the policy, the appropriate figure for the relevant waiting period. Note 1: This item does not limit the information that a private health insurer may provide with regard to an individual’s policy. Note 2: The obstetrics waiting period of up to 12 months does not apply to treatment for neonatal care.
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6 | Excess Whichever of the following is appropriate: (a) if there is no excess—the words “No excess”; (b) if there is an excess: (i) whichever of the following is appropriate, with the bracketed text replaced with the appropriate figure, and where the dollar amount for excess per admission is the excess for an overnight admission, if this is different from the excess for day surgery: (A) “You will have to pay an excess of $[number] per admission.”; (B) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per year.”; (C) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per year.”; (D) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per person per year.”; (E) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per person and $[number] per policy per year.”; (F) “You will have to pay an excess of $[number] per admission. This is limited to a maximum of $[number] per person and $[number] per policy per year.”; (G) “You will have to pay an excess on admission. This is limited to a maximum of $[number] per policy per year.”; and (ii) if applicable—“Excess payments do not apply to hospital admissions for accidents, of child dependants, or for day surgery”, with any of “accidents”, “child dependants” and “day surgery” that do not apply deleted, but with the order of those terms otherwise unchanged.
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7 | Extra cost per day (co‑payments) If there are no co-payments—the statement “No co-payments”.
If there are co-payments: (a) the statement “Every time you go to hospital you will have to pay”, followed by (with the bracketed text replaced with the appropriate figures): (i) either: (A) the statement “$[number] per day for overnight admissions”; or (B) the statements: “$[number] per day for a shared room for overnight admissions”; and if the policy covers accommodation in a private room—“$[number] per day for a private room for overnight admissions”; and (ii) as applicable, either: (A) the statement “$[number] for day surgery (no overnight stay)”; or (B) the statement “No co-payment for day surgery (no overnight stay)”; and (iii) the statement “– up to $[number] per hospital stay”, placed, if applicable, and if the insurer so chooses, directly after the statements referred to in subparagraph (i); and (b) if applicable—the statement “The maximum co‑payment is $[number] per year” (with the bracketed text replaced with the appropriate figures).
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8 | Note on out of pocket costs/doctors’ fees The following statement: “Under this policy, you may have to pay out-of-pocket costs above what you get from Medicare or your private health insurer. Before you go to hospital, you should ask your doctors, hospital and health insurer about any out-of-pocket costs that may apply to you.”.
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9 | Note on information relating to contracts between hospitals and insurers The following statement: “The benefits paid for hospital treatment will depend on the type of cover you purchase and whether your fund has an agreement in place with the hospital in which you are treated. See ‘Agreement Hospitals’ on privatehealth.gov.au for which hospitals have arrangements with your insurer.”.
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10 | Other features A statement that indicates any other features of the policy that the insurer wishes to draw attention to. The statement must consist of at most 100 words. Example: Benefits for travel or accommodation, or aged‑based or other discounts. Note: This statement (if included) is in addition to the statement (if included) that is referred to in item 9 of Schedule 3.
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Schedule 3—Additional information, and form of words, for standard information statement—general treatment
Note: The information and form of words set out in this Schedule are not required if the only general treatment covered by the policy is ambulance cover.
In this Schedule, a reference to a policy is a reference to a policy that forms part of the relevant product subgroup.
2. Additional information and form of words—general treatment
For paragraph 12 (1) (c) of these Rules, the additional information and form of words are set out in the following table:
Additional information and form of words—general treatment | |
Item | Additional information and form of words |
1 | Information relating to policies that are available only with a hospital policy If the policy is available only with a policy that covers hospital treatment—whichever of the following is applicable: (a) if the policy may be purchased with any policy that covers hospital treatment offered by the insurer—the statement “must be purchased with a hospital policy”; (b) if there is a set range of policies that cover hospital treatment with which the policy may be combined—the statement “must be purchased with certain hospital policies”.
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2 | Preferred service provider arrangements Whichever of the following is appropriate: (a) if the private health insurer has preferred service provider arrangements—either: (i) a brief outline of the appropriate arrangements; or (ii) the following statement, with the bracketed text replaced with the appropriate text: “By using [insert name of insurer]’s ‘preferred providers’ you may have lower out of pocket costs on [insert services or use “many allied health”] treatments and have access to more ‘no gap’ treatments. A list of ‘preferred providers’ is available from [insert name of insurer].”; (b) otherwise—the following statement, with the bracketed text replaced with the appropriate text: “[Insert name of insurer] does not operate a preferred provider scheme.”.
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3 | Treatments covered by the policy A complete list of treatments that are covered by the policy, expressed in terms of the following: (a) general dental; (b) major dental; (c) endodontic; (d) orthodontic; (e) optical; (f) non PBS pharmaceuticals; (g) physiotherapy; (h) chiropractic; (i) podiatry; (j) psychology; (k) acupuncture; (l) remedial massage; (m) hearing aids; (n) blood glucose monitors; (o) for any treatment that cannot be classified as any of the above—the name of the treatment. Note: Insurers may cover additional treatments, for example, exercise physiology and occupational therapy.
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4 | Treatments not covered by the policy A list of treatments that are not covered by the policy, expressed in terms of the treatments listed in item 3.
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5 | Waiting period (months) For each treatment that is covered by the policy—whichever of the following is applicable, with the bracketed text replaced with the appropriate text: (a) if there is a waiting period—“[Number] months”; (b) if there is no waiting period for the treatment—“None”. Note: If an insured person has already served all applicable waiting periods, this item does not limit the information that a private health insurer may provide with regard to the individual’s policy.
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6 | Benefit limits (per 12 months) For each treatment that is covered by the policy—if there is no annual limit on the benefits that can be paid, the statement “No annual limit”.
Otherwise—the following statements, as applicable, with the bracketed text replaced with the appropriate figures or text: (a) either: (i) any of the following statements: (A) “$[number] per person”; (B) “$[number] per treatment”; (C) “$[number] per policy”; or (ii) any combination of the statements set out in subparagraph (a) (i), linked by the words “up to”; (b) if there is a limit on claims per specified number of years—whichever of the following is applicable: (i) “[number] appliance(s) every [specified number] years”; (ii) “[number] service(s) every [specified number] years”; (c) in the case of combined limits: (i) for the treatment against which the combined limit is listed— “(combined limit for [list treatments listed in item 3 in relation to which limit is combined])”; and (ii) for the other treatments in relation to which the limit is combined—“(combined limit – see [treatment against which the combined limit is listed])”; (d) in the case of limits for individually grouped treatments—whichever of the following statements is applicable: (i) “$[number] per person (combined limit for [whichever of general dental, major dental, endodontic & orthodontic is applicable])”; (ii) “$[number] lifetime limit for [whichever of general dental, major dental, endodontic & orthodontic is applicable]”; (e) if a sub-limit applies on any treatment—the statement “Sub‑limits apply” (in bold font); (f) if: (i) there is a limit on general dental; but (ii) there is no limit on preventative dental; the statement “(no limit on preventative dental)”; (g) if none of paragraphs (a) to (f) apply—a brief outline of the applicable limits. Note 1: If an insured person has used a portion of lifetime limits, this item does not limit the information that a private health insurer may provide with regard to the individual’s usage of lifetime limit amounts. Note 2: This item does not limit the information that a private health insurer may give to an insured person. For example, if limits apply to the policy other than those listed in this item, private health insurers may provide information about those other benefit limits to insured persons.
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7 | Examples of maximum benefits—general dental, major dental, endodontic and orthodontic For each treatment listed in paragraphs (a) to (d) of item 3 (whether or not covered by the policy): (a) the following treatments, broken down into the following dental item numbers: (i) for general dental: (A) “Periodic oral examination”—012; and (B) “Scale & clean”—114; and (C) “Fluoride treatment”—121; and (D) if covered under general dental—“Surgical tooth extraction”—322; (ii) for major dental treatment: (A) if covered under major dental—“Surgical tooth extraction”—322; and (B) “Full crown veneered”—615; (iii) for endodontic treatment—“Filling of one root canal”—417; (iv) for orthodontic treatment—“Braces for upper and lower teeth, including removal plus fitting of retainer”—881; and (b) if the dental item number is covered by the policy—an example of the maximum benefit that is payable when an insured person visits a practitioner who is not a preferred service provider, expressed using whichever of the following is applicable: (i) “$[number]”, with the bracketed text replaced by the appropriate figure, if: (A) the benefit is a dollar figure; or (B) the insurer pays a benefit that is a percentage of the charge up to a dollar limit that is specified for the item separately from an annual limit; (ii) if the only benefit limit for the item is an annual limit— “[number]% of charge”, with the bracketed text replaced by the appropriate figure; and (c) if the dental item number is not covered by the policy—the statement “n/a”.
For paragraph (b) of this item: (d) if: (i) the dental item number is provided by orthodontists and general dentists; and (ii) different benefits are offered for orthodontists and general dentists; the lower of: (iii) the benefit for the orthodontist; and (iv) the benefit for the general dentist; must be used; and (e) if examples are given for initial and subsequent visits, examples must be for individual sessions.
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8 | Examples of maximum benefits—other For each treatment covered by the policy, other than the treatments covered by item 7—examples of the maximum benefits that are payable when an insured person visits a practitioner who is not a preferred service provider, expressed using whichever of subparagraphs (b)(i) and (ii) of item 7 is applicable.
For this item: (a) if examples are given for initial and subsequent visits, examples must be for individual sessions; and (b) if: (i) optical treatment is covered; and (ii) benefits for frames and lenses are paid separately; the example must be expressed as the sum of the benefit for each component. Note 1: If treatments are listed for the purposes of paragraph (o) of item 3, examples of maximum benefits for those treatments must be given. Note 2: This item does not limit the information that a private health insurer may give to an insured person. Note 3: The insurer may provide information about the benefits that apply if treatment is through a preferred provider.
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9 | Other features A statement that indicates any other features of the policy that the insurer wishes to draw attention to. The statement must consist of at most 100 words. Example: Benefits for travel or accommodation, or discounts. Note: This statement (if included) is in addition to the statement (if included) that is referred to in item 10 of Schedule 2.
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Part 2—Amendments commencing on 1 April 2019
Private Health Insurance (Complying Product) Rules 2015
[6] After rule 14
Insert:
15. Information provided to insured persons
(1) This rule is made for the purposes of section 96‑25 of the Act.
(2) When giving an insured person a copy of a private health information statement in accordance with section 93‑15 or subsection 93‑20 (1) of the Act, the private health insurer must inform the person of the following:
(a) the name of each person who is covered by the policy;
(b) if the product subgroup to which the policy belongs covers hospital treatment—the following statements for each adult who is covered by the policy and to whom a lifetime health cover loading applies, with the bracketed text replaced with the appropriate amounts:
(i) “Your Lifetime Health Cover Loading is [Number]%.”;
(ii) “You have [Number] years remaining until you have reached 10 continuous years of cover and your loading is removed.”.
(3) However, the insurer does not need to inform the person of the information referred to in subrule (2) more than once in any 12 month period.
(4) The information referred to in subrule (2) may be accompanied by either or both of the following:
(a) information additional to the information and form of words that are required by subrule 12 (1);
(b) other information about the policy and how it pertains to the person.
Example for paragraph (4) (b): An insurer may also inform an insured person of:
the premium for hospital treatment and for general treatment that applies in relation to each adult insured under the policy, taking account of matters such as loadings, rebates and discounts; and
the remaining portion (if any) of the waiting period for any or each treatment covered by the policy.
(5) If the private health information statement and the additional information referred to in subrule (2) and paragraphs (4)(a) and (b) are set out in the same document, the additional information must not obscure or contradict the information and form of words that that are required by subrule 12 (1).
Example: The document on which a private health information statement is provided might include information about the monthly premium that is payable by the insured person under the policy that is additional to the information required by item 6 of the table to clause 2 of Schedule 1. That additional information could be included adjacent to the required information, so long as the additional information did not obscure or contradict the required information.
16. Information provided to persons about product subgroups
For subsection 93‑5 (2) of the Act, if a person asks an insurer for information about a complying health insurance product, the insurer must give the person a copy of the private health information statement for a product subgroup of that product:
(a) by post; or
(b) if the person has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the person.
Example: If requested by an insured person, a private health information statement may be provided in an electronic format, including via a web page.
[8] Before subrule 20(1)
Insert:
(1A) This rule does not apply in relation to an insurance policy that:
(a) covers hospital treatment (whether or not the policy also covers general treatment); and
(b) has “gold”, “silver”, “bronze” or “basic” in its name.
[9] Subrule 20(3)
Repeal the subrule, substitute:
(3) For this rule, a private health information statement is in the old form if it contains the information, and is in the form, for a standard information statement set out in these Rules as in force immediately before the commencement of Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018.
Note: Part 1 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 January 2019.
[10] Clause 2 of Schedule 1 (table item 1)
Repeal the item, substitute:
1 | Policy name The name of the policy. Note 1: See rules 11H and 11J for rules governing the naming of policies that cover hospital treatment and the naming of policies that cover general treatment. Note 2: See rule 21 for a transitional provision relating to this item.
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[11] Clause 2 of Schedule 2 (table item 3)
Repeal the item, substitute:
3 | What’s included and what’s not included in the policy An indication of: (a) treatments that are covered by the policy, consisting of the words: “This policy includes cover for”; and (b) treatments that are not covered by the policy, consisting of the words: “This policy does not include cover for”; followed, in each case, by: (c) the relevant clinical categories; and (d) whichever of the following (if any) is appropriate: (i) accident cover; (ii) benefits for travel or accommodation. Note: See rule 21 for a transitional provision relating to this item.
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[12] Clause 2 of Schedule 2 (table item 4)
Repeal the item, substitute:
4 | Restrictions A list of all clinical categories (if any) that have restricted cover. Note: See rule 21 for a transitional provision relating to this item.
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[13] Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, paragraph (b))
Omit “treatments”, substitute “clinical categories”.
[14] Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, after note 2)
Insert:
Note 3: See rule 21 for a transitional provision relating to this item.
[15] Amendments of listed provisions—private health information statements
Further amendments | |||
Item | Provision | Omit | Substitute |
1 | Rule 4 (note at the end of the rule) | standard information statement | private health information statement |
2 | Paragraph 9AA(2)(a) | standard information statement | private health information statement |
3 | Part 3 (heading) | Standard information statements | Private health information statements |
4 | Part 3 (note to the Part heading, first bullet point) | standard information statements | private health information statements |
5 | Rule 12 (heading) | Standard information statements | Private health information statements |
6 | Subrule 12 (1) | standard information statement | private health information statement |
7 | Rule 13 (heading) | standard information statements | private health information statements |
8 | Paragraph 13 (2) (a) | standard information statement | private health information statement |
9 | Paragraph 13 (2) (b) | standard information statement | private health information statement |
10 | Subrule 13 (2) (example) | standard information statement | private health information statement |
11 | Rule 20 (heading) | standard information statements | private health information statements |
12 | Subrule 20(2) | standard information statement | private health information statement |
13 | Schedule 1 (heading) | standard information statement | private health information statement |
14 | Schedule 1, clause 2 (heading) | standard information statement | private health information statement |
15 | Schedule 1, clause 2 (table heading) | standard information statement | private health information statement |
16 | Schedule 1, clause 2, table item 13 | standard information statement | private health information statement |
17 | Schedule 2 (heading) | standard information statement | private health information statement |
18 | Schedule 3 (heading) | standard information statement | private health information statement |
Part 3—Amendments commencing on 1 April 2020
Private Health Insurance (Complying Product) Rules 2015
[16] Rule 20
Repeal the rule.
[17] Clause 2 of Schedule 1 (table item 1)
Repeal the item, substitute:
1 | Policy name The name of the policy. Note: See rules 11H and 11J for rules governing the naming of policies that cover hospital treatment and the naming of policies that cover general treatment.
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[18] Clause 2 of Schedule 2 (table item 3, column headed “Additional information and form of words”, note)
Repeal the note.
[19] Clause 2 of Schedule 2 (table item 4, column headed “Additional information and form of words”, note)
Repeal the note.
[20] Clause 2 of Schedule 2 (table item 5, column headed “Additional information and form of words”, note 3)
Repeal the note.
Schedule 3—Product tiers and related amendments
Part 1—Amendments commencing on 1 April 2019
Private Health Insurance (Complying Product) Rules 2015
[1] Rule 4
Insert:
basic policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers at least the treatments in all of the clinical categories indicated for a basic policy in Schedule 4; and
(c) is not a gold, silver or bronze policy.
bronze policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers at least the treatments in all of the clinical categories indicated for a bronze policy in Schedule 4; and
(c) is not a gold or silver policy.
clinical category, for hospital treatment, means a clinical category that is set out in Schedule 5.
gold policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers the treatments in all of the clinical categories indicated for a gold policy in Schedule 4.
MBS item means an item in any of the following:
(a) the general medical services table, made under section 4 of the Health Insurance Act 1973, as in force from time to time;
(b) the diagnostic imaging services table, made under section 4AA of the Health Insurance Act 1973, as in force from time to time;
(c) the pathology services table, made under section 4A of the Health Insurance Act 1973, as in force from time to time.
product tier means:
(a) for a gold policy—“gold”; and
(b) for a silver policy—“silver”; and
(c) for a bronze policy—“bronze”; and
(d) for a basic policy—“basic”.
silver policy means an insurance policy that:
(a) covers hospital treatment; and
(b) covers at least the treatments in all of the clinical categories indicated for a silver policy in Schedule 4; and
(c) is not a gold policy.
[1A] Rule 4 (note at the end of the rule)
Insert, in the appropriate alphabetical position in the list of terms that have the same meaning as in the Act, “medical practitioner”.
[2] After Part 2A
Insert:
Part 2B Requirements relating to product tiers for, and names of, insurance policies
Note 1: This Part specifies additional requirements that an insurance policy must meet in order to be a complying health insurance policy, for the purposes of paragraph 63‑10 (g) of the Act.
Note 2: Nothing in this Part affects the operation of Division 72 of the Act (which relates to benefit requirements for policies that cover hospital treatment) or the operation of the Private Health Insurance (Benefit Requirements) Rules for the calculation of minimum benefits where restricted cover is allowed under rule 11G.
11E. Product tiers for insurance policies that cover hospital treatment
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
(2) The policy must be one of the following:
(a) a gold policy;
(b) a silver policy;
(c) a bronze policy;
(d) a basic policy.
11F. Coverage of treatments for insurance policies that cover hospital treatment
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
Application of rule
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
Treatments that must be covered by policy
(2) The policy must cover:
(a) all hospital treatments that are within the scope of cover that is identified, in Schedule 5, for each clinical category in relation to which the policy provides cover (see subrules (5) and (6)); and
(b) all hospital treatments that are not within the scope of cover of such a clinical category, but that are:
(i) associated treatments for complications (see subrule (7)); or
(ii) associated unplanned treatments (see subrule (8)).
(3) However, the policy is not required to cover cosmetic surgery that is not medically necessary.
Treatments that may be covered by policy
(4) The policy may also provide either or both of the following:
(a) accident cover;
(b) benefits for travel or accommodation relating to a treatment referred to in subrule (2) or paragraph (a).
Interpretation
(5) For paragraph (2) (a), the scope of cover of a particular clinical category includes, but is not limited to:
(a) all hospital treatments involving the provision of an MBS item listed in Schedule 5 against that clinical category; and
(b) all hospital treatments:
(i) that are provided in relation to a treatment of a kind referred to in paragraph (2) (a) or (5) (a); and
(ii) involving the provision of an MBS item listed in:
(A) the common treatments list in Schedule 6; or
(B) the support treatments list in Schedule 7.
(6) Paragraph (5) (b) does not apply in relation to the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”.
(7) For subparagraph (2) (b) (i), a hospital treatment is an associated treatment for complications if it is:
(a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and
(b) provided for a complication that arises during that episode.
(8) For subparagraph (2) (b) (ii), a hospital treatment is an associated unplanned treatment if it is:
(a) provided during an episode in which hospital treatment of a kind described in paragraph (2) (a) is being provided; and
(b) an unplanned treatment that:
(i) is provided as part of planned surgery performed during that episode; and
(ii) is, in the view of the medical practitioner who provides the unplanned treatment, medically necessary and urgent.
11G. Provision of restricted and unrestricted cover
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
Gold policies
(1) A gold policy must provide unrestricted cover for all hospital treatments in all clinical categories.
Silver policies and bronze policies
(2) A silver policy or a bronze policy:
(a) must provide restricted cover or unrestricted cover for all hospital treatments in the following clinical categories:
(i) rehabilitation;
(ii) hospital psychiatric services;
(iii) palliative care; and
(b) must provide unrestricted cover for all hospital treatments in:
(i) the other clinical categories that a silver policy or a bronze policy, as appropriate, is required to cover; and
(ii) any other clinical categories that the policy covers.
Basic policies
(3) A basic policy must provide restricted cover or unrestricted cover for all hospital treatments in:
(a) all of the clinical categories that a basic policy is required to cover; and
(b) any other clinical categories that the policy covers.
11H. Naming of insurance policies that cover hospital treatment
Note: See rule 21 for transitional provisions relating to this rule that apply until 31 March 2020.
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
(2) The policy must include a name that contains the policy’s product tier.
(3) If the policy covers one or more clinical categories additional to those required for a policy of that product tier in Schedule 4, the name may also contain “plus” or “+”.
(4) The name must not contain:
(a) the name of any other metal; or
(b) the name of any gemstone or any semi-precious stone; or
(c) unless permitted by subrule (3)—either “plus” or “+”.
11J. Naming of insurance policies that cover general treatment only
(1) For paragraph 63‑10 (g) of the Act, this rule applies to an insurance policy that covers general treatment only.
(2) The policy must include a name that does not contain:
(a) the name of any metal; or
(b) the name of any gemstone or any semi-precious stone; or
(c) either “plus” or “+”.
Insert:
Application of rule
(1) This rule applies to an insurance policy that covers hospital treatment (whether or not the policy also covers general treatment).
(2) This rule applies until 31 March 2020.
Transitional provisions
(3) If the policy does not have any of the following:
(a) “gold”, “silver”, “bronze” or “basic”;
(b) the name of any other metal;
(c) the name of any gemstone or semi‑precious stone;
in its name, the policy need not comply with Part 2B.
(4) If the policy:
(a) does not have any of the words referred to in subrule (3) in its name; and
(b) does not use the clinical categories to indicate the treatments it covers;
each of the following:
(c) item 1 of clause 2 of Schedule 1;
(d) item 3 of clause 2 of Schedule 2;
(e) item 4 of clause 2 of Schedule 2;
(f) item 5 of clause 2 of Schedule 2;
as in force immediately before the commencement of Part 2 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 applies in relation to the policy.
Note: Part 2 of Schedule 2 to the Private Health Insurance (Reforms) Amendment Rules 2018 commenced on 1 April 2019.
[4] After Schedule 3
Add:
Schedule 4—Product tiers and clinical categories
Note: See rule 4 and Part 2B.
1. Product tiers and clinical categories
For the definition of gold policy, silver policy, bronze policy and basic policy in rule 4, and for rule 11H, the following table sets out the clinical categories that are indicated for policies of each product tier.
Clinical category | Basic | Bronze | Silver | Gold |
Rehabilitation | R | R | R | |
Hospital psychiatric services | R | R | R | |
Palliative care | R | R | R | |
Brain and nervous system | RCP | | | |
Eye (not cataracts) | RCP | | | |
Ear, nose and throat | RCP | | | |
Tonsils, adenoids and grommets | RCP | | | |
Bone, joint and muscle | RCP | | | |
Joint reconstructions | RCP | | | |
Kidney and bladder | RCP | | | |
Male reproductive system | RCP | | | |
Digestive system | RCP | | | |
Hernia and appendix | RCP | | | |
Gastrointestinal endoscopy | RCP | | | |
Gynaecology | RCP | | | |
Miscarriage and termination of pregnancy | RCP | | | |
Chemotherapy, radiotherapy and immunotherapy for cancer | RCP | | | |
Pain management | RCP | | | |
Skin | RCP | | | |
Breast surgery (medically necessary) | RCP | | | |
Diabetes management (excluding insulin pumps) | RCP | | | |
Heart and vascular system | RCP |
| | |
Lung and chest | RCP |
| | |
Blood | RCP |
| | |
Back, neck and spine | RCP |
| | |
Plastic and reconstructive surgery (medically necessary) | RCP |
| | |
Dental surgery | RCP |
| | |
Podiatric surgery (provided by a registered podiatric surgeon) | RCP |
| | |
Implantation of hearing devices | RCP |
| | |
Cataracts | RCP |
|
| |
Joint replacements | RCP |
|
| |
Dialysis for chronic kidney failure | RCP |
|
| |
Pregnancy and birth | RCP |
|
| |
Assisted reproductive services | RCP |
|
| |
Weight loss surgery | RCP |
|
| |
Insulin pumps | RCP |
|
| |
Pain management with device | RCP |
|
| |
Sleep studies | RCP |
|
| |
| Indicates the clinical category is a minimum requirement of the product tier. The clinical category must be covered on an unrestricted basis. |
R | Indicates the clinical category is a minimum requirement of the product tier. The clinical category may be offered on a restricted cover basis in Basic, Bronze and Silver product tiers only. |
RCP | Restricted cover permitted: indicates the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories on a restricted or unrestricted basis. |
| A blank cell indicates that the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories; however it must be on an unrestricted basis. |
Schedule 5—Clinical categories
Note 1: Rule 11F is the principal provision that deals with what must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 6 and Schedule 7.
Note 2: The treatments that must be covered are any hospital treatments that are in the scope of cover of a clinical category in relation to which the policy provides cover. The scope of cover includes, without limitation:
any hospital treatment involving the provision of an MBS item number listed in column 3 below; and
except for the clinical category “Podiatric surgery (provided by a registered podiatric surgeon)”—any hospital treatment:
– that is provided in relation to a treatment within the scope of cover of a particular clinical category or that involves the provision of an MBS item number listed in column 3 below; and
– that involves the provision of an MBS item number listed in Schedule 6 (common treatments) or Schedule 7 (support treatments).
Note 3: MBS items are mentioned in the table below against a clinical category, or in the common treatments or support treatments lists in Schedules 6 and 7. Where an MBS item is mentioned for a clinical category in column 3 in the table below, the treatment including that MBS item is most likely to be provided under that clinical category, or a clinical category in the same or a higher product tier (according to Schedule 4). However, the mention of an MBS item against a particular category does not mean it is only covered under that clinical category.
In this Schedule, the scope of cover of a particular clinical category is taken not to include any treatment that is, or treatments that are, expressly stated to be listed separately under another clinical category.
For rule 4, and Part 2B, the clinical categories are set out in the following table.
Clinical category | Scope of cover (see Note 1) | Treatments that must be covered (MBS Items) (see Notes 1, 2 and 3) |
Rehabilitation | Hospital treatment for physical rehabilitation for a patient related to surgery or illness. For example: inpatient and admitted day patient rehabilitation, stroke recovery, cardiac rehabilitation. |
|
Hospital psychiatric services | Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders. For example: psychoses such as schizophrenia, mood disorders such as depression, eating disorders and addiction therapy. | Treatments involving the provision of the following MBS items: 170 171 172 289 297 320 322 324 326 328 342 344 346 348 350 352 364 366 367 369 370 855 857 858 861 864 866 2700 2701 2712 2713 2715 2717 2721 2723 2725 2727 6018 6019 6023 6024 6025 6026 6028 6029 6031 6032 6034 6035 6037 6038 6042 14224 80000 80001 80005 80010 80011 80015 80020 80021 80100 80101 80105 80110 80111 80115 80120 80121 80125 80126 80130 80135 80136 80140 80145 80146 80150 80151 80155 80160 80161 80165 80170 80171 82000 82015 |
Palliative care | Hospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain. | Treatments involving the provision of the following MBS items: 3003 3005 3010 3014 3015 3018 3023 3028 3032 3040 3044 3051 3055 3062 3069 3074 3078 3083 3088 3093 |
Assisted reproductive services | Hospital treatment for fertility treatments or procedures. For example: retrieval of eggs or sperm, In vitro Fertilisation (IVF), and Gamete Intra-fallopian Transfer (GIFT). Treatment of the female reproductive system is listed separately under Gynaecology. Pregnancy and birth-related services are listed separately under Pregnancy and birth. | Treatments involving the provision of the following MBS items: 13200 13201 13202 13203 13206 13209 13212 13215 13218 13221 13251 13290 13292 14203 14206 37605 37606 |
Back, neck and spine | Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion. For example: sciatica, prolapsed or herniated disc, and spine curvature disorders such as scoliosis, kyphosis and lordosis. Joint replacements are listed separately under Joint replacements. Joint fusions are listed separately under Bone, joint and muscle. Spinal cord conditions are listed separately under Brain and nervous system. Management of back pain is listed separately under Pain management. Pain management that requires a device is listed separately under Pain management with device. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 30672 40300 40301 40309 40312 40315 40316 40318 40321 40324 40327 40330 40333 40336 40339 44133 47681 47684 47687 47690 47693 47696 47699 47702 47705 47708 47711 47714 47717 47720 47723 48600 48603 48606 48612 48613 48615 48618 48621 48624 48627 48632 48636 48639 48640 48642 48645 48648 48651 48654 48657 48660 48663 48666 48669 48672 48675 48678 48681 48684 48687 48690 48691 48692 48693 48694 50600 50604 50608 50612 50616 50620 50624 50628 50632 50636 50640 50644 |
Blood | Hospital treatment for the investigation and treatment of blood and blood-related conditions. For example: blood clotting disorders and bone marrow transplants. Treatment for cancers of the blood is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS item: 13700 |
Bone, joint and muscle | Hospital treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system. For example: carpal tunnel, fractures, hand surgery, joint fusion, bone spurs, osteomyelitis and bone cancer. Chest surgery is listed separately under Lung and chest. Spinal cord conditions are listed separately under Brain and nervous system. Spinal column conditions are listed separately under Back, neck and spine. Joint reconstructions are listed separately under Joint reconstructions. Joint replacements are listed separately under Joint replacements. Podiatric surgery performed by a registered podiatric surgeon is listed separately under Podiatric surgery (provided by a registered podiatric surgeon). Management of back pain is listed separately under Pain management. Pain management that requires a device is listed separately under Pain management with device. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 18350 18351 18353 18354 18360 18361 18365 30103 30107 30111 30114 30226 30229 30232 30235 30238 30241 30244 32036 39331 43500 43503 43506 43509 43512 43515 43518 43521 43524 43876 43879 44325 44328 44331 44334 44338 44342 44346 44350 44354 44358 44359 44361 44364 44367 44370 44373 44376 45605 45788 45851 45855 45857 45859 45861 45863 45867 45869 45871 45873 45875 45945 45978 45981 45987 45993 45996 46300 46303 46306 46307 46327 46330 46333 46336 46339 46342 46348 46351 46354 46357 46360 46363 46366 46369 46372 46375 46378 46381 46384 46387 46390 46393 46396 46399 46402 46405 46459 46462 46464 46465 46468 46471 46474 46477 46480 46483 47000 47003 47006 47009 47012 47015 47018 47021 47024 47027 47030 47033 47036 47039 47042 47045 47048 47051 47054 47057 47060 47063 47066 47069 47072 47301 47304 47307 47310 47313 47316 47319 47348 47351 47354 47357 47361 47362 47364 47367 47370 47373 47378 47381 47384 47385 47386 47387 47390 47393 47396 47399 47402 47405 47408 47411 47414 47417 47420 47423 47426 47429 47432 47435 47438 47441 47444 47447 47450 47451 47453 47456 47459 47462 47465 47466 47467 47468 47471 47474 47477 47480 47483 47486 47489 47492 47495 47498 47501 47504 47507 47510 47513 47516 47519 47522 47525 47528 47531 47534 47537 47540 47543 47546 47549 47552 47555 47558 47561 47564 47565 47566 47567 47570 47573 47576 47579 47582 47585 47588 47591 47594 47597 47600 47603 47606 47609 47612 47615 47618 47621 47624 47627 47630 47633 47636 47639 47642 47645 47648 47651 47654 47657 47663 47666 47672 47678 47703 47726 47729 47732 47753 47756 47762 47765 47768 47771 47774 47777 47780 47783 47786 47789 47900 47903 47920 47921 47924 47927 47930 47933 47936 47948 47951 47954 47957 47960 47963 47966 47969 47972 47975 47978 47981 47982 48200 48203 48206 48209 48212 48215 48218 48221 48224 48227 48230 48233 48236 48239 48242 48400 48403 48406 48409 48412 48415 48418 48421 48424 48427 48500 48503 48506 48509 48512 48912 48936 48939 48942 48945 48954 49100 49106 49109 49118 49200 49203 49206 49212 49218 49300 49303 49306 49360 49363 49366 49500 49509 49512 49545 49566 49569 49700 49712 49718 49721 49724 49727 49728 49800 49803 49806 49809 49812 49815 49818 49821 49824 49827 49830 49833 49836 49837 49838 49845 49848 49851 49854 49860 49863 49866 49878 50100 50102 50103 50104 50109 50112 50115 50118 50121 50130 50200 50201 50203 50206 50209 50212 50215 50218 50221 50224 50227 50230 50233 50236 50239 50300 50303 50306 50309 50312 50315 50318 50321 50324 50327 50330 50336 50339 50342 50345 50348 50349 50351 50352 50353 50354 50357 50360 50363 50366 50369 50372 50375 50378 50381 50384 50387 50390 50393 50394 50396 50399 50402 50405 50408 50426 50450 50451 50455 50456 50460 50461 50465 50466 50470 50471 50475 50476 50500 50504 50508 50512 50516 50520 50524 50528 50532 50536 50540 50544 50548 50552 50556 50560 50564 50568 50572 50576 50580 50584 50588 50650 50654 50658 52056 52057 52058 52059 52060 52061 52062 52063 52064 52066 52069 52072 52073 52075 52078 52081 52084 52087 52090 52092 52094 52095 52096 52097 52098 52099 52102 52105 52114 52126 52129 52130 52131 52180 52182 52184 52186 53200 53203 53206 53209 53212 53215 53218 53220 53221 53224 53225 53226 53227 53230 53233 53236 53239 53400 53403 53406 53409 53410 53411 53412 53413 53414 53415 53416 53418 53419 53422 53423 53424 53425 53427 53429 53439 |
Brain and nervous system | Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system. For example: stroke, brain or spinal cord tumours, head injuries, epilepsy and Parkinson’s disease. Treatment of spinal column (back bone) conditions is listed separately under Back, neck and spine. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 6004 6007 6009 6011 6013 6015 6016 14227 14230 14233 14236 14239 14242 18377 35000 35003 35006 35009 35012 35412 35414 39003 39006 39009 39012 39013 39015 39018 39300 39303 39306 39309 39312 39315 39318 39321 39324 39327 39330 39333 39500 39503 39600 39603 39606 39609 39612 39615 39640 39642 39646 39650 39653 39654 39656 39658 39660 39662 39700 39703 39706 39709 39712 39715 39718 39721 39800 39803 39806 39812 39815 39818 39821 39900 39903 39906 40000 40003 40006 40009 40012 40015 40018 40100 40103 40106 40109 40112 40115 40118 40303 40306 40331 40332 40334 40335 40342 40345 40348 40351 40600 40700 40701 40702 40703 40704 40705 40706 40707 40708 40709 40712 40800 40801 40803 40850 40851 40852 40854 40856 40858 40860 40862 40903 40905 43987 48630 52800 52803 52806 52809 52812 52815 52818 52821 52824 52826 52828 52830 52832 |
Breast surgery (medically necessary) | Hospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction and/or reduction following breast surgery or a preventative mastectomy. For example: breast lesions, breast tumours, asymmetry due to breast cancer surgery, and gynecomastia. This clinical category does not require benefits to be paid for cosmetic breast surgery that is not medically necessary. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 30299 30300 30302 30303 31500 31503 31506 31509 31512 31515 31516 31519 31524 31525 31530 31533 31536 31539 31542 31545 31548 31551 31554 31557 31560 31563 31566 45520 45522 45524 45527 45528 45530 45533 45536 45539 45542 45545 45546 45548 45551 45552 45553 45554 45555 45556 45557 45558 45559 |
Cataracts | Hospital treatment for surgery to remove a cataract and replace with an artificial lens. | Treatments involving the provision of the following MBS items: 42698 42701 42702 42703 42704 42705 42707 42710 42713 42716 |
Chemotherapy, radiotherapy and immunotherapy for cancer | Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours. Surgical treatment of cancer is listed separately under each body system. | Treatments involving the provision of the following MBS items: 13760 13915 13918 13921 13924 13927 13930 13933 13936 13939 13942 13945 13948 14221 14245 15000 15003 15006 15009 15012 15100 15103 15106 15109 15112 15115 15211 15214 15215 15218 15221 15224 15227 15230 15233 15236 15239 15242 15245 15248 15251 15254 15257 15260 15263 15266 15269 15272 15275 15303 15304 15307 15308 15311 15312 15315 15316 15319 15320 15323 15324 15327 15328 15331 15332 15335 15336 15338 15339 15342 15345 15348 15351 15354 15357 15500 15503 15506 15509 15512 15513 15515 15518 15521 15524 15527 15530 15533 15536 15539 15550 15553 15555 15556 15559 15562 15565 15600 15700 15705 15710 15715 15800 15850 15900 16003 16006 16009 16012 16015 16018 30400 34521 34524 34527 34528 34529 34530 34533 34534 34539 34540 35404 35406 35408 50950 50952 |
Dental surgery | Hospital treatment for surgery to the teeth and gums. For example: surgery to remove wisdom teeth, and dental implant surgery. | Treatments involving the provision of the following MBS items: 75006 75030 75033 75034 75036 75037 75039 75042 75045 75048 75049 75050 75051 75156 75200 75203 75206 75400 75403 75406 75409 75412 75415 75600 75603 75606 75609 75612 75615 75618 75621 75800 75803 75806 75809 75812 75815 75818 75821 75824 75827 75830 75833 75836 75839 75842 75845 75848 75851 75854 |
Diabetes management (excluding insulin pumps) | Hospital treatment for the investigation and management of diabetes. For example: stabilisation of hypo- or hyper- glycaemia, contour problems due to insulin injections. Treatment for diabetes-related conditions is listed separately under each body system affected. For example, treatment for diabetes-related eye conditions is listed separately under Eye. Treatment for ulcers is listed separately under Skin. Provision and replacement of insulin pumps is listed separately under Insulin pumps. | Treatments involving the provision of the following MBS items: 31346 81100 81105 |
Dialysis for chronic kidney failure | Hospital treatment for dialysis treatment for chronic kidney failure. For example: peritoneal dialysis and haemodialysis. | Treatments involving the provision of the following MBS items: 13100 13103 13104 13106 13109 13110 13112 |
Digestive system | Hospital treatment for the investigation and treatment of the digestive system, including the oesophagus, stomach, gall bladder, pancreas, spleen, liver and bowel. For example: oesophageal cancer, irritable bowel syndrome, gall stones and haemorrhoids. Endoscopy is listed separately under Gastrointestinal endoscopy. Hernia and appendicectomy procedures are listed separately under Hernia and appendix. Bariatric surgery is listed separately under Weight loss surgery. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 11800 11801 11810 13506 14212 30373 30375 30376 30378 30379 30382 30384 30385 30387 30392 30393 30396 30397 30399 30402 30406 30408 30409 30411 30412 30414 30415 30416 30417 30418 30419 30421 30422 30425 30427 30428 30430 30431 30433 30434 30436 30437 30438 30439 30440 30441 30442 30443 30445 30446 30448 30449 30450 30451 30452 30454 30455 30457 30458 30460 30461 30463 30464 30466 30467 30469 30472 30481 30482 30483 30492 30495 30496 30497 30499 30500 30502 30503 30505 30506 30508 30509 30515 30517 30518 30520 30521 30523 30524 30526 30527 30529 30530 30532 30533 30535 30536 30538 30539 30541 30542 30544 30545 30547 30548 30550 30551 30553 30554 30556 30557 30559 30560 30562 30563 30564 30565 30566 30575 30577 30578 30580 30581 30583 30584 30586 30587 30589 30590 30593 30594 30596 30597 30599 30600 30601 30602 30603 30605 30606 30608 30619 30621 30622 30623 30626 30627 30636 30637 30639 31450 31452 31454 31456 31458 31460 31462 31464 31466 31468 31470 31472 32000 32003 32004 32005 32006 32009 32012 32015 32018 32021 32024 32025 32026 32028 32029 32030 32033 32039 32042 32045 32046 32047 32051 32054 32057 32060 32063 32066 32069 32096 32099 32102 32103 32104 32105 32106 32108 32111 32112 32114 32115 32117 32120 32123 32126 32129 32131 32132 32135 32138 32139 32142 32145 32147 32150 32153 32156 32159 32162 32165 32166 32168 32171 32174 32175 32177 32180 32183 32186 32200 32203 32206 32209 32210 32212 32213 32214 32215 32216 32217 32218 32220 32221 41816 41822 41825 41828 41831 41832 43801 43804 43807 43810 43813 43816 43819 43822 43825 43828 43831 43834 43840 43843 43846 43849 43852 43855 43858 43864 43867 43870 43873 43900 43903 43906 43930 43933 43936 43942 43945 43948 43951 43954 43957 43960 43963 43966 43969 43972 43975 43978 43990 43993 43996 43999 44101 44102 44104 44105 |
Ear, nose and throat | Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck. For example: damaged ear drum, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer. Tonsils, adenoids and grommets are listed separately under Tonsils, adenoids and grommets. The implantation of a hearing device is listed separately under Implantation of hearing devices. Orthopaedic neck conditions are listed separately under Back, neck and spine. Sleep studies are listed separately under Sleep studies. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer.
| Treatments involving the provision of the following MBS items: 11300 18368 30104 30105 30246 30247 30250 30251 30253 30255 30256 30259 30262 30266 30269 30272 30275 30278 30281 30283 30286 30287 30289 30293 30294 30296 30297 30306 30308 30309 30310 30313 30314 30315 30317 30318 30320 30326 30618 31400 31403 31406 31409 31412 31420 31423 31426 31429 31432 31435 31438 41500 41503 41506 41509 41512 41515 41518 41521 41524 41527 41530 41533 41536 41539 41542 41545 41548 41551 41554 41557 41560 41563 41564 41566 41569 41572 41575 41576 41578 41579 41581 41584 41587 41590 41593 41596 41599 41608 41611 41614 41615 41620 41623 41626 41629 41635 41638 41641 41644 41647 41650 41653 41656 41659 41662 41668 41671 41672 41674 41677 41683 41686 41689 41692 41698 41701 41704 41707 41710 41713 41716 41719 41722 41725 41728 41729 41731 41734 41737 41740 41743 41746 41749 41752 41755 41764 41767 41770 41773 41776 41779 41782 41785 41786 41787 41804 41807 41810 41813 41834 41837 41840 41843 41846 41855 41858 41861 41864 41867 41868 41870 41873 41876 41879 41880 41881 41884 41885 41886 41889 41892 41895 41898 41901 41904 41905 41907 41910 43832 45645 45646 47735 47738 47741 51900 51902 52021 52024 52025 52027 52030 52033 52034 52035 52055 52132 52133 52135 52138 52141 52147 52148 52158 53000 53003 53004 53006 53009 53012 53015 53016 53017 53019 53052 53054 53056 53058 53060 53062 53064 53068 53070 53458 53459 53460 |
Eye (not cataracts) | Hospital treatment for the investigation and treatment of the eye and the contents of the eye socket. For example: retinal detachment, tear duct conditions, eye infections and medically managed trauma to the eye. Cataract procedures are listed separately under Cataracts. Eyelid procedures are listed separately under Plastic and reconstructive surgery. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 18366 18369 18370 18372 18374 42503 42506 42509 42510 42512 42515 42518 42521 42524 42527 42530 42533 42536 42539 42542 42543 42545 42548 42551 42554 42557 42563 42569 42572 42573 42574 42575 42576 42581 42584 42587 42590 42593 42596 42599 42602 42605 42608 42610 42611 42614 42615 42617 42620 42622 42623 42626 42629 42632 42635 42638 42641 42644 42647 42650 42651 42652 42653 42656 42662 42665 42667 42668 42672 42673 42676 42677 42680 42683 42686 42689 42692 42695 42719 42725 42731 42734 42738 42739 42740 42741 42743 42744 42746 42749 42752 42755 42758 42761 42764 42767 42770 42773 42776 42779 42782 42783 42785 42786 42788 42789 42791 42792 42794 42801 42802 42805 42806 42807 42808 42809 42810 42811 42812 42815 42818 42821 42824 42833 42836 42839 42842 42845 42848 42851 42854 42857 42869 43021 43022 43023 |
Gastrointestinal endoscopy | Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope. For example: colonoscopy, gastroscopy, endoscopic retrograde cholangiopancreatography (ERCP). Non-endoscopic procedures for the digestive system are listed separately under Digestive system. | Treatments involving the provision of the following MBS items: 11820 11823 30473 30475 30478 30479 30484 30485 30488 30490 30491 30494 30568 30569 30680 30682 30684 30686 30687 30688 30690 30692 30694 32023 32072 32075 32084 32087 32088 32089 32090 32093 32094 32095 |
Gynaecology | Hospital treatment for the investigation and treatment of the female reproductive system. For example: endometriosis, polycystic ovaries, female sterilisation and cervical cancer. Fertility treatments are listed separately under Assisted reproductive services. Pregnancy and birth-related conditions are listed separately under Pregnancy and birth. Miscarriage or termination of pregnancy is listed separately under Miscarriage and termination of pregnancy. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 30062 35410 35500 35502 35503 35506 35507 35508 35509 35513 35517 35518 35520 35523 35527 35530 35533 35534 35536 35539 35542 35545 35548 35551 35554 35557 35560 35561 35562 35564 35565 35566 35568 35569 35570 35571 35572 35573 35577 35578 35581 35582 35585 35595 35596 35597 35599 35602 35605 35608 35611 35612 35613 35614 35615 35616 35618 35620 35622 35623 35626 35627 35630 35633 35634 35635 35636 35637 35638 35641 35644 35645 35646 35647 35648 35649 35653 35657 35658 35661 35664 35667 35670 35673 35680 35684 35688 35691 35694 35697 35700 35703 35706 35709 35710 35713 35717 35720 35723 35726 35729 35730 35750 35753 35754 35756 35759 |
Heart and vascular system | Hospital treatment for the investigation and treatment of the heart, heart-related conditions and vascular system. For example: heart failure and heart attack, monitoring of heart conditions, varicose veins and removal of plaque from arterial walls. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 13400 32500 32501 32504 32507 32508 32511 32514 32517 32520 32522 32523 32526 32528 32529 32700 32703 32708 32710 32711 32712 32715 32718 32721 32724 32730 32733 32736 32739 32742 32745 32748 32751 32754 32757 32760 32763 32766 32769 33050 33055 33070 33075 33080 33100 33103 33109 33112 33115 33116 33118 33119 33121 33124 33127 33130 33133 33136 33139 33142 33145 33148 33151 33154 33157 33160 33163 33166 33169 33172 33175 33178 33181 33500 33506 33509 33512 33515 33518 33521 33524 33527 33530 33533 33536 33539 33542 33545 33548 33551 33554 33800 33803 33806 33810 33811 33812 33815 33818 33821 33824 33827 33830 33833 33836 33839 33842 33845 33848 34100 34103 34106 34109 34112 34115 34118 34121 34124 34127 34130 34142 34145 34148 34151 34154 34157 34160 34163 34166 34169 34172 34175 34500 34503 34506 34509 34512 34515 34518 34800 34803 34806 34809 34812 34815 34818 34821 34824 34827 34830 34833 35100 35103 35200 35202 35300 35303 35306 35307 35309 35312 35315 35317 35319 35320 35321 35324 35327 35330 35331 35360 35361 35362 35363 38200 38203 38206 38209 38212 38213 38215 38218 38220 38222 38225 38228 38231 38234 38237 38240 38241 38243 38246 38256 38270 38272 38273 38274 38275 38276 38285 38286 38287 38288 38290 38293 38300 38303 38306 38309 38312 38315 38318 38350 38353 38356 38358 38359 38362 38365 38368 38371 38384 38387 38390 38393 38447 38449 38450 38452 38470 38473 38475 38477 38478 38480 38481 38483 38485 38487 38488 38489 38490 38493 38495 38496 38497 38498 38500 38501 38503 38504 38505 38506 38507 38508 38509 38512 38515 38518 38550 38553 38556 38559 38562 38565 38568 38571 38572 38577 38588 38600 38603 38609 38612 38613 38615 38618 38621 38624 38627 38637 38650 38653 38654 38670 38673 38677 38680 38700 38703 38706 38709 38712 38715 38718 38721 38724 38727 38730 38733 38736 38739 38742 38745 38748 38751 38754 38757 38760 38763 38766 59903 59912 59925 59971 59972 59973 |
Hernia and appendix | Hospital treatment for the investigation and treatment of a hernia or appendicitis. Digestive conditions are listed separately under Digestive system. | Treatments involving the provision of the following MBS items: 30571 30572 30574 30609 30614 30615 30640 30645 30646 43805 43835 43837 43838 43841 43939 44108 44111 44114 |
Implantation of hearing devices | Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device. Stapedectomy is listed separately under Ear, nose and throat. | Treatments involving the provision of the following MBS items: 41603 41604 41617 41618 |
Insulin pumps | Hospital treatment for the provision and replacement of insulin pumps for treatment of diabetes. |
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Joint reconstructions | Hospital treatment for surgery for joint reconstructions. For example: torn tendons, rotator cuff tears and damaged ligaments. Joint replacements are listed separately under Joint replacements. Bone fractures are listed separately under Bone, joint and muscle. Procedures to the spinal column are listed separately under Back, neck and spine. Podiatric surgery performed by a registered podiatric surgeon is listed separately under Podiatric surgery (provided by a registered podiatric surgeon). | Treatments involving the provision of the following MBS items: 46345 46408 46411 46414 46417 46420 46423 46426 46429 46432 46435 46438 46441 46442 46444 46447 46450 46453 46456 46492 46494 46495 46498 46500 46501 46502 46503 46504 46507 46510 46522 48900 48903 48906 48909 48930 48933 48948 48951 48957 48960 49103 49121 49215 49221 49224 49227 49503 49506 49536 49539 49542 49548 49551 49557 49558 49559 49560 49561 49562 49563 49564 49703 49706 49709 50106 50333 |
Joint replacements | Hospital treatment for surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses. For example: replacement of shoulder, wrist, finger, hip, knee, ankle, or toe joint, spinal disc replacement. Joint fusions are listed separately under Bone, joint and muscle. Spinal fusions are listed separately under Back, neck and spine. Joint reconstructions are listed separately under Joint reconstructions. Podiatric surgery performed by a registered podiatric surgeon is listed separately under Podiatric surgery (provided by a registered podiatric surgeon). | Treatments involving the provision of the following MBS items: 46309 46312 46315 46318 46321 46324 46325 48915 48918 48921 48924 48927 49112 49115 49116 49117 49209 49210 49211 49309 49312 49315 49318 49319 49321 49324 49327 49330 49333 49336 49339 49342 49345 49346 49515 49517 49518 49519 49521 49524 49527 49530 49533 49534 49554 49715 49716 49717 49839 49842 49857 50127 |
Kidney and bladder | Hospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder. For example: kidney stones, adrenal gland tumour and incontinence. Dialysis is listed separately under Dialysis for chronic kidney failure. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 11900 11903 11906 11909 11912 11915 11917 11919 11921 12524 12527 18375 18379 30324 36500 36503 36506 36509 36516 36519 36522 36525 36526 36527 36528 36529 36531 36532 36533 36537 36540 36543 36546 36549 36552 36558 36561 36564 36567 36570 36573 36576 36579 36585 36588 36591 36594 36597 36600 36603 36604 36605 36606 36607 36608 36609 36612 36615 36618 36621 36624 36627 36630 36633 36636 36639 36642 36645 36648 36649 36650 36652 36654 36656 36663 36664 36665 36666 36667 36668 36800 36803 36806 36809 36811 36812 36815 36818 36821 36824 36825 36827 36830 36833 36836 36840 36842 36845 36848 36851 36854 36857 36860 36863 37000 37004 37008 37011 37014 37020 37023 37026 37029 37038 37040 37041 37042 37043 37044 37045 37047 37050 37053 37300 37303 37306 37309 37315 37318 37321 37324 37327 37330 37333 37336 37338 37339 37340 37341 37342 37343 37345 37348 37351 37354 37369 37372 37375 37381 37384 37387 37390 37444 37800 37801 37842 37845 37848 37851 37854 43981 43984 |
Lung and chest | Hospital treatment for the investigation and treatment of the lungs, lung-related conditions, mediastinum and chest. For example: lung cancer, respiratory disorders such as asthma, pneumonia, and treatment of trauma to the chest. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 30090 30696 30710 34133 34136 34139 38415 38418 38421 38424 38427 38430 38436 38438 38440 38441 38446 38448 38453 38455 38460 38462 38464 38466 38468 38469 38640 38643 38647 38656 38800 38803 38809 38812 43861 43909 43912 |
Male reproductive system | Hospital treatment for the investigation and treatment of the male reproductive system including the prostate. For example: male sterilisation, circumcision and prostate cancer. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 30628 30631 30635 30641 30642 30643 30644 30649 30654 30658 30663 30666 37200 37201 37202 37203 37206 37207 37208 37209 37210 37211 37212 37215 37217 37218 37219 37220 37221 37223 37224 37227 37230 37233 37245 37393 37396 37402 37405 37408 37411 37415 37417 37418 37420 37423 37426 37429 37432 37435 37438 37601 37604 37613 37616 37619 37623 37803 37804 37806 37807 37809 37810 37812 37813 37815 37816 37818 37819 37821 37822 37824 37825 37827 37828 37830 37831 37833 37834 37836 37839 |
Miscarriage and termination of pregnancy | Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy. | Treatments involving the provision of the following MBS items: 16530 16531 35640 35643 35674 35677 35678 |
Pain management | Hospital treatment for pain management that does not require the insertion or surgical management of a device. For example: treatment of nerve pain and chest pain due to cancer by injection of a nerve block. Pain management using a device (for example an infusion pump or neurostimulator) is listed separately under Pain management with device. | Treatments involving the provision of the following MBS items: 39100 39106 39109 39112 39115 39118 39121 39124 39140 39323 45939 |
Pain management with device | Hospital treatment for the implantation, replacement or other surgical management of a device required for the treatment of pain. For example: treatment of nerve pain, back pain, and pain caused by coronary heart disease with a device (for example an infusion pump or neurostimulator). Treatment of pain that does not require a device is listed separately under Pain management. | Treatments involving the provision of the following MBS items: 14218 39125 39126 39127 39128 39130 39131 39133 39134 39135 39136 39137 39138 39139 |
Plastic and reconstructive surgery (medically necessary) | Hospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether acquired as a result of illness or accident, or congenital. For example: burns requiring a graft, cleft palate, club foot and angioma. Plastic surgery that is medically necessary relating to the treatment of a skin-related condition is listed separately under Skin. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 30003 30006 30010 30014 30017 30020 30176 38457 38458 42860 42863 42866 42872 43882 45000 45003 45006 45009 45012 45015 45018 45019 45020 45021 45024 45025 45026 45027 45030 45033 45035 45036 45039 45042 45045 45048 45051 45054 45200 45201 45202 45203 45206 45207 45209 45212 45215 45218 45221 45224 45227 45230 45233 45236 45239 45240 45400 45403 45406 45409 45412 45415 45418 45439 45442 45445 45448 45451 45460 45461 45462 45464 45465 45466 45468 45469 45471 45472 45474 45475 45477 45478 45480 45481 45483 45484 45485 45486 45487 45488 45489 45490 45491 45492 45493 45494 45496 45497 45498 45499 45500 45501 45502 45503 45504 45505 45506 45512 45515 45518 45519 45560 45561 45562 45563 45564 45565 45566 45568 45569 45570 45572 45575 45578 45581 45584 45585 45586 45587 45588 45590 45593 45596 45597 45599 45602 45608 45611 45614 45617 45620 45623 45624 45625 45626 45629 45632 45635 45638 45639 45641 45644 45647 45650 45652 45653 45656 45659 45660 45661 45662 45665 45668 45669 45671 45674 45675 45676 45677 45680 45683 45686 45689 45692 45695 45698 45701 45704 45707 45710 45713 45714 45716 45720 45723 45726 45729 45731 45732 45735 45738 45741 45744 45747 45752 45753 45754 45755 45758 45761 45767 45770 45773 45776 45779 45782 45785 45791 45794 45797 45799 45801 45803 45805 45807 45809 45811 45813 45815 45817 45819 45821 45823 45825 45827 45829 45831 45833 45835 45837 45839 45841 45843 45845 45847 45849 45853 45865 45877 45879 45882 45885 45888 45891 45894 45897 45900 45975 45984 45990 50411 50414 50417 50420 50423 51904 51906 52010 52036 52045 52048 52106 52108 52111 52117 52120 52122 52123 52300 52303 52306 52309 52312 52315 52318 52319 52321 52324 52327 52330 52333 52336 52337 52339 52342 52345 52348 52351 52354 52357 52360 52363 52366 52369 52372 52375 52378 52379 52380 52382 52420 52424 52430 52440 52442 52444 52446 52450 52452 52456 52458 52460 52480 52482 52484 52600 52603 52606 52609 52612 52615 52618 52621 52624 52626 52627 52630 52633 52636 53242 53453 53455 75024 75027 |
Podiatric surgery (provided by a registered podiatric surgeon) | Hospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon, but limited to cover for: accommodation; and the cost of a prosthesis as listed in the prostheses list set out in the Private Health Insurance (Prostheses) Rules, as in force from time to time. Note: Insurers are not required to pay for any other benefits for hospital treatment for this clinical category but may choose to do so. |
|
Pregnancy and birth | Hospital treatment for investigation and treatment of conditions associated with pregnancy and child birth. Treatment for the baby is covered under the clinical category relevant to their condition. For example, respiratory conditions are covered under Lung and chest. Female reproductive conditions are listed separately under Gynaecology. Fertility treatments are listed separately under Assisted reproductive services. Miscarriage and termination of pregnancy is listed separately under Miscarriage and termination of pregnancy. | Treatments involving the provision of the following MBS items: 16399 16400 16401 16404 16406 16407 16408 16500 16501 16502 16505 16508 16509 16511 16512 16514 16515 16518 16519 16520 16522 16527 16528 16533 16534 16564 16567 16570 16571 16573 16590 16591 16600 16603 16606 16609 16612 16615 16618 16621 16624 16627 82100 82105 82110 82115 82120 82125 |
Skin | Hospital treatment for the investigation and treatment of skin, skin-related conditions and nails. The removal of foreign bodies is also included. Plastic surgery that is medically necessary and relating to the treatment of a skin-related condition is also included. For example: melanoma, minor wound repair and abscesses. Removal of excess skin due to weight loss is listed separately under Weight loss surgery. Chemotherapy and radiotherapy for cancer is listed separately under Chemotherapy, radiotherapy and immunotherapy for cancer. | Treatments involving the provision of the following MBS items: 14050 14053 14100 14106 14109 14112 14115 14118 14124 18362 30023 30024 30026 30029 30032 30035 30038 30042 30045 30049 30052 30055 30064 30071 30099 30180 30183 30185 30186 30187 30189 30190 30192 30195 30196 30197 30202 30203 30205 30207 30210 30213 30214 30216 30219 30223 30676 30679 31000 31001 31002 31206 31211 31216 31220 31221 31225 31245 31250 31340 31345 31356 31357 31358 31359 31360 31361 31362 31363 31364 31365 31366 31367 31368 31369 31370 31371 31372 31373 31374 31375 31376 44136 46486 46489 46513 46516 46528 46531 46534 47904 47906 47912 47915 47916 47918 52000 52003 52006 52009 52039 52042 52051 52054 |
Sleep studies | Hospital treatment for the investigation of sleep patterns and anomalies. For example: sleep apnoea and snoring. | Treatments involving the provision of the following MBS items: 12203 12207 12210 12213 12215 12217 12250 |
Tonsils, adenoids and grommets | Hospital treatment of the tonsils, adenoids and insertion or removal of grommets. | Treatments involving the provision of the following MBS items: 41632 41789 41793 41797 41801 |
Weight loss surgery | Hospital treatment for surgery that is designed to reduce a person’s weight, remove excess skin due to weight loss and reversal of a bariatric procedure. For example: gastric banding, gastric bypass, sleeve gastrectomy. | Treatments involving the provision of the following MBS items: 30165 30168 30171 30172 30177 30179 31569 31572 31575 31578 31581 31584 31587 31590 |
Schedule 6—Common treatments list
Note: Rule 11F is the principal provision that deals with what hospital treatments must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 5 and Schedule 7.
1 Common treatments list
For sub‑subparagraph 11F (5) (b) (ii) (A), the common treatments list is set out in the following table:
Common treatments list |
3 4 20 23 24 35 36 37 43 44 47 51 52 53 54 57 58 59 60 65 92 93 95 96 99 104 105 106 107 108 109 110 111 112 113 114 116 117 119 120 122 128 131 132 133 135 137 139 141 143 145 147 149 160 161 162 163 164 173 179 181 183 185 187 188 189 191 193 195 197 199 202 203 206 212 214 215 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 235 236 237 238 239 240 243 244 245 249 251 252 253 254 255 256 257 259 260 261 262 263 264 265 266 268 269 270 271 272 276 277 279 281 282 283 285 286 287 288 291 293 296 299 300 302 304 306 308 310 312 314 316 318 319 330 332 334 336 338 353 355 356 357 358 359 361 384 385 386 387 388 389 410 411 412 413 414 415 416 417 501 503 507 511 515 519 520 530 532 534 536 585 588 591 594 599 600 701 703 705 707 715 721 723 729 731 732 733 735 737 739 741 743 745 747 750 758 761 763 766 769 772 776 788 789 792 812 820 822 823 825 826 827 828 829 830 832 834 835 837 838 867 868 869 871 872 873 876 880 881 885 891 892 900 903 2100 2122 2125 2126 2137 2138 2143 2147 2179 2195 2199 2220 2497 2501 2503 2504 2506 2507 2509 2517 2518 2521 2522 2525 2526 2546 2547 2552 2553 2558 2559 2598 2600 2603 2606 2610 2613 2616 2620 2622 2624 2631 2633 2635 2664 2666 2668 2673 2675 2677 2799 2801 2806 2814 2820 2824 2832 2840 2946 2949 2954 2958 2972 2974 2978 2984 2988 2992 2996 3000 4001 5000 5003 5010 5020 5023 5028 5040 5043 5049 5060 5063 5067 5200 5203 5207 5208 5220 5223 5227 5228 5260 5263 5265 5267 6051 6052 6057 6058 6059 6060 6062 6063 6064 6065 6067 6068 6071 6072 6074 6075 6087 10905 10907 10910 10911 10912 10913 10914 10915 10916 10918 10921 10922 10923 10924 10925 10926 10927 10928 10929 10930 10945 10946 10947 10948 11830 11833 12000 12003 13015 13020 13025 13030 13210 13757 13870 13873 14200 14201 14202 14209 17615 17620 17625 17640 17645 17650 17655 18216 18219 18282 18284 18286 18288 18290 18292 18294 18296 18298 30058 30061 30068 30072 30075 30078 30081 30084 30087 30093 30094 30096 30097 30224 30225 30321 30323 30329 30330 30332 30335 30336 30388 30390 30391 30394 30403 30405 30611 31350 31355 34538 36502 37607 37610 38456 39000 43915 44130 46519 46525 51700 51703 52012 52015 52018 52144 53600 75001 75004 75150 75153 82130 82135 82140 82150 82151 82152 82200 82205 82210 82215 82220 82221 82222 82223 82224 82225 |
Schedule 7—Support treatments list
Note: Rule 11F is the principal provision that deals with what hospital treatments must be covered by an insurance policy that covers hospital treatment. The operation of rule 11F relies on this Schedule, as well as Schedule 5 and Schedule 6.
1 Support treatments list
For sub‑subparagraph 11F (5) (b) (ii) (B), the support treatments list is set out in the following table:
Support treatments list |
6080 6081 10801 10802 10803 10804 10805 10806 10807 10808 10809 10816 10931 10932 10933 10940 10941 10942 10943 10944 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 10984 10987 10988 10989 10990 10991 10992 10997 11000 11003 11004 11005 11006 11009 11012 11015 11018 11021 11024 11027 11200 11204 11205 11210 11211 11215 11218 11219 11220 11221 11222 11224 11225 11235 11237 11240 11241 11242 11243 11244 11303 11304 11306 11309 11312 11315 11318 11324 11327 11330 11332 11333 11336 11339 11503 11506 11509 11512 11600 11602 11604 11605 11610 11611 11612 11614 11615 11627 11700 11701 11702 11708 11709 11710 11711 11712 11713 11715 11718 11719 11720 11721 11722 11724 11725 11726 11727 11728 12200 12201 12306 12312 12315 12320 12321 12322 12325 12326 12500 12503 12506 12509 12512 12515 12518 12521 12530 12533 13300 13303 13306 13309 13312 13318 13319 13703 13706 13709 13750 13755 13815 13818 13830 13839 13842 13847 13848 13851 13854 13857 13876 13881 13882 13885 13888 17610 17680 17690 18213 18222 18225 18226 18227 18228 18230 18232 18233 18234 18236 18238 18240 18242 18244 18248 18250 18252 18254 18256 18258 18260 18262 18264 18266 18268 18270 18272 18274 18276 18278 18280 20100 20102 20104 20120 20124 20140 20142 20143 20144 20145 20146 20147 20148 20160 20162 20164 20170 20172 20174 20176 20190 20192 20210 20212 20214 20216 20220 20222 20225 20230 20300 20305 20320 20321 20330 20350 20352 20355 20400 20401 20402 20403 20404 20405 20406 20410 20420 20440 20450 20452 20470 20472 20474 20475 20500 20520 20522 20524 20526 20528 20540 20542 20546 20548 20560 20600 20604 20620 20622 20630 20632 20634 20670 20680 20690 20700 20702 20703 20704 20705 20706 20730 20740 20745 20750 20752 20754 20756 20770 20790 20791 20792 20793 20794 20798 20799 20800 20802 20803 20804 20805 20806 20810 20815 20820 20830 20832 20840 20841 20842 20844 20845 20846 20847 20848 20850 20855 20860 20862 20863 20864 20866 20867 20868 20880 20882 20884 20886 20900 20902 20904 20905 20906 20910 20911 20912 20914 20916 20920 20924 20926 20928 20930 20932 20934 20936 20938 20940 20942 20943 20944 20946 20948 20950 20952 20953 20954 20956 20958 20960 21100 21110 21112 21114 21116 21120 21130 21140 21150 21155 21160 21170 21195 21199 21200 21202 21210 21212 21214 21216 21220 21230 21232 21234 21260 21270 21272 21274 21275 21280 21300 21321 21340 21360 21380 21382 21390 21392 21400 21402 21403 21404 21420 21430 21432 21440 21445 21460 21461 21462 21464 21472 21474 21480 21482 21484 21486 21490 21500 21502 21520 21522 21530 21532 21535 21600 21610 21620 21622 21630 21632 21634 21636 21638 21650 21652 21654 21656 21670 21680 21682 21685 21700 21710 21712 21714 21716 21730 21732 21740 21756 21760 21770 21772 21780 21785 21790 21800 21810 21820 21830 21832 21834 21840 21842 21850 21860 21865 21870 21872 21878 21879 21880 21881 21882 21883 21884 21885 21886 21887 21900 21906 21908 21910 21912 21914 21915 21916 21918 21922 21925 21926 21927 21930 21935 21936 21939 21941 21942 21943 21945 21949 21952 21955 21959 21962 21965 21969 21970 21973 21976 21980 21981 21990 21992 21997 22001 22002 22007 22008 22012 22014 22015 22018 22020 22025 22031 22036 22040 22045 22050 22051 22055 22060 22065 22070 22075 22900 22905 23010 23021 23022 23023 23031 23032 23033 23041 23042 23043 23051 23052 23053 23061 23062 23063 23071 23072 23073 23081 23082 23083 23091 23101 23111 23112 23113 23114 23115 23116 23117 23118 23119 23121 23170 23180 23190 23200 23210 23220 23230 23240 23250 23260 23270 23280 23290 23300 23310 23320 23330 23340 23350 23360 23370 23380 23390 23400 23410 23420 23430 23440 23450 23460 23470 23480 23490 23500 23510 23520 23530 23540 23550 23560 23570 23580 23590 23600 23610 23620 23630 23640 23650 23660 23670 23680 23690 23700 23710 23720 23730 23740 23750 23760 23770 23780 23790 23800 23810 23820 23830 23840 23850 23860 23870 23880 23890 23900 23910 23920 23930 23940 23950 23960 23970 23980 23990 24100 24101 24102 24103 24104 24105 24106 24107 24108 24109 24110 24111 24112 24113 24114 24115 24116 24117 24118 24119 24120 24121 24122 24123 24124 24125 24126 24127 24128 24129 24130 24131 24132 24133 24134 24135 24136 25000 25005 25010 25015 25020 25025 25030 25050 25200 25205 30001 51300 51303 51306 51309 51312 51315 51318 51800 51803 53700 53702 53704 53706 55005 55007 55008 55010 55011 55013 55014 55016 55017 55019 55023 55025 55026 55028 55029 55030 55031 55032 55033 55036 55037 55038 55039 55048 55049 55054 55059 55060 55061 55062 55063 55064 55065 55067 55068 55069 55070 55073 55076 55079 55084 55085 55113 55114 55115 55116 55117 55118 55119 55120 55121 55122 55123 55125 55130 55131 55135 55136 55220 55221 55222 55223 55224 55226 55227 55228 55229 55230 55232 55233 55235 55236 55238 55244 55246 55248 55252 55274 55276 55278 55280 55282 55284 55292 55294 55296 55600 55601 55603 55604 55700 55701 55702 55703 55704 55705 55706 55707 55708 55709 55710 55711 55712 55713 55714 55715 55716 55717 55718 55719 55720 55721 55722 55723 55724 55725 55726 55727 55729 55730 55735 55736 55737 55739 55759 55760 55762 55763 55764 55765 55766 55767 55768 55769 55770 55771 55772 55773 55774 55775 55800 55801 55802 55803 55804 55805 55806 55807 55808 55809 55810 55811 55812 55813 55814 55815 55816 55817 55818 55819 55820 55821 55822 55823 55824 55825 55826 55827 55828 55829 55830 55831 55832 55833 55834 55835 55836 55837 55838 55839 55840 55841 55842 55843 55844 55845 55846 55847 55848 55849 55850 55851 55852 55853 55854 55855 56001 56007 56010 56013 56016 56022 56028 56030 56036 56041 56047 56050 56053 56056 56062 56068 56070 56076 56101 56107 56141 56147 56219 56220 56221 56223 56224 56225 56226 56227 56228 56229 56230 56231 56232 56233 56234 56235 56236 56237 56238 56239 56240 56259 56301 56307 56341 56347 56401 56407 56409 56412 56441 56447 56449 56452 56501 56507 56541 56547 56553 56555 56619 56625 56659 56665 56801 56807 56841 56847 57001 57007 57041 57047 57201 57247 57341 57345 57350 57351 57355 57356 57360 57361 57362 57363 57506 57509 57512 57515 57518 57521 57524 57527 57529 57530 57532 57533 57535 57536 57538 57539 57700 57702 57703 57705 57706 57708 57709 57711 57712 57714 57715 57717 57721 57723 57901 57902 57903 57906 57909 57911 57912 57914 57915 57917 57918 57920 57921 57923 57924 57926 57927 57929 57930 57932 57933 57935 57938 57939 57941 57942 57944 57945 57947 57950 57953 57956 57959 57960 57962 57963 57965 57966 57968 57969 58100 58102 58103 58105 58106 58108 58109 58111 58112 58114 58115 58117 58120 58121 58123 58124 58126 58127 58300 58302 58306 58308 58500 58502 58503 58505 58506 58508 58509 58511 58521 58523 58524 58526 58527 58529 58700 58702 58706 58708 58715 58717 58718 58720 58721 58723 58900 58902 58903 58905 58909 58911 58912 58914 58915 58916 58917 58920 58921 58923 58927 58929 58933 58935 58936 58938 58939 58941 59103 59104 59300 59301 59303 59304 59306 59307 59309 59310 59312 59313 59314 59315 59318 59319 59700 59701 59703 59704 59712 59713 59715 59716 59718 59719 59724 59725 59733 59734 59739 59740 59751 59752 59754 59755 59763 59764 59970 59974 60000 60001 60003 60004 60006 60007 60009 60010 60012 60013 60015 60016 60018 60019 60021 60022 60024 60025 60027 60028 60030 60031 60033 60034 60036 60037 60039 60040 60042 60043 60045 60046 60048 60049 60051 60052 60054 60055 60057 60058 60060 60061 60063 60064 60066 60067 60069 60070 60072 60073 60075 60076 60078 60079 60100 60101 60500 60501 60503 60504 60506 60507 60509 60510 60918 60927 61109 61110 61302 61303 61306 61307 61310 61313 61314 61316 61317 61320 61328 61340 61348 61352 61353 61356 61360 61361 61364 61368 61369 61372 61373 61376 61381 61383 61384 61386 61387 61389 61390 61393 61397 61401 61402 61405 61409 61413 61417 61421 61425 61426 61429 61430 61433 61434 61437 61438 61441 61442 61445 61446 61449 61450 61453 61454 61457 61458 61461 61462 61469 61473 61480 61484 61485 61495 61499 61505 61523 61529 61538 61541 61553 61559 61565 61571 61575 61577 61598 61604 61610 61620 61622 61628 61632 61640 61646 61647 61650 61651 61652 61653 61654 61655 61656 61657 61658 61659 61660 61661 61662 61663 61664 61665 61666 61667 61668 61669 61670 61671 61672 61673 61674 61675 61676 61677 61678 61679 61680 61681 61682 61683 61684 61685 61686 61687 61688 61689 61690 61691 61692 61693 61694 61695 61696 61697 61698 61699 61700 61701 61702 61703 61704 61705 61706 61707 61708 61709 61710 61712 61713 61714 61715 61716 61717 61718 61719 61729 63001 63004 63007 63010 63013 63014 63016 63017 63040 63043 63046 63049 63052 63055 63058 63061 63064 63067 63070 63073 63074 63075 63076 63077 63078 63079 63080 63081 63082 63083 63084 63085 63101 63104 63111 63114 63117 63119 63125 63128 63131 63134 63135 63136 63151 63154 63157 63158 63161 63164 63167 63170 63173 63176 63179 63182 63185 63186 63187 63188 63189 63190 63191 63192 63193 63194 63201 63204 63207 63208 63219 63222 63225 63228 63231 63234 63237 63240 63243 63257 63258 63259 63260 63261 63262 63263 63264 63265 63271 63274 63277 63280 63282 63283 63284 63285 63301 63304 63307 63310 63311 63313 63322 63325 63328 63331 63334 63337 63340 63341 63342 63343 63345 63346 63347 63348 63361 63364 63385 63388 63391 63392 63393 63394 63395 63396 63397 63398 63401 63404 63407 63408 63416 63419 63425 63428 63432 63433 63440 63443 63446 63447 63448 63449 63455 63457 63458 63461 63464 63467 63470 63473 63476 63479 63481 63482 63484 63486 63487 63488 63489 63490 63491 63494 63497 63498 63499 63501 63502 63504 63505 63507 63508 63510 63511 63513 63514 63516 63517 63519 63520 63522 63523 63541 63542 63543 63544 63547 63548 63551 63552 63554 63555 63557 63558 63560 63561 63740 63741 63743 63744 63746 63747 64990 64991 65060 65066 65070 65072 65075 65078 65079 65081 65082 65084 65087 65090 65093 65096 65099 65102 65105 65108 65109 65110 65111 65114 65117 65120 65123 65126 65129 65137 65142 65144 65147 65150 65153 65156 65157 65158 65159 65162 65165 65166 65171 65175 65176 65177 65178 65179 65180 65181 66500 66503 66506 66509 66512 66517 66518 66519 66536 66539 66542 66545 66548 66551 66554 66557 66560 66563 66566 66569 66572 66575 66578 66581 66584 66587 66590 66593 66596 66605 66606 66607 66610 66623 66626 66629 66632 66635 66638 66639 66641 66642 66644 66647 66650 66651 66652 66653 66655 66656 66659 66660 66662 66663 66665 66666 66667 66671 66674 66677 66680 66683 66686 66695 66696 66697 66698 66701 66704 66707 66711 66712 66714 66715 66716 66719 66722 66723 66724 66725 66728 66731 66734 66743 66749 66750 66751 66752 66755 66756 66757 66758 66761 66764 66767 66770 66773 66776 66779 66780 66782 66783 66785 66788 66789 66790 66791 66792 66800 66803 66804 66805 66806 66812 66815 66816 66817 66819 66820 66821 66822 66825 66826 66827 66828 66830 66831 66832 66833 66834 66835 66836 66837 66838 66839 66840 66841 66900 69300 69303 69306 69309 69312 69316 69317 69318 69319 69321 69324 69325 69327 69328 69330 69331 69333 69336 69339 69345 69354 69357 69360 69363 69378 69379 69380 69381 69382 69383 69384 69387 69390 69393 69396 69400 69401 69405 69408 69411 69413 69415 69445 69451 69471 69472 69474 69475 69478 69481 69482 69483 69484 69488 69489 69491 69492 69494 69495 69496 69497 69498 69499 69500 71057 71058 71059 71060 71062 71064 71066 71068 71069 71071 71072 71073 71074 71075 71076 71077 71079 71081 71083 71085 71087 71089 71090 71091 71092 71093 71095 71096 71097 71099 71101 71103 71106 71119 71121 71123 71125 71127 71129 71131 71133 71134 71135 71137 71139 71141 71143 71145 71146 71147 71148 71149 71151 71153 71154 71155 71156 71157 71159 71163 71164 71165 71166 71167 71168 71169 71170 71180 71183 71186 71189 71192 71195 71198 71200 71203 72813 72816 72817 72818 72823 72824 72825 72826 72827 72828 72830 72836 72838 72844 72846 72847 72848 72849 72850 72851 72852 72855 72856 72857 72858 72859 73043 73045 73047 73049 73051 73059 73060 73061 73062 73063 73064 73065 73066 73067 73070 73071 73072 73073 73074 73075 73076 73287 73289 73290 73291 73292 73293 73294 73295 73296 73297 73300 73305 73308 73309 73311 73312 73314 73315 73317 73318 73320 73321 73323 73324 73325 73326 73327 73332 73333 73334 73335 73336 73337 73338 73339 73340 73341 73342 73343 73345 73346 73347 73348 73349 73350 73521 73523 73525 73527 73529 73801 73802 73803 73804 73805 73806 73807 73808 73809 73810 73811 73828 73829 73830 73831 73832 73833 73834 73835 73836 73837 73839 73840 73844 73899 73900 73920 73922 73923 73924 73925 73926 73927 73928 73929 73930 73931 73932 73933 73934 73935 73936 73937 73938 73939 73940 74990 74991 74992 74993 74994 74995 74996 74997 74998 74999 75009 75012 75015 75018 75021 75023 81000 81005 81010 81110 81115 81120 81125 81300 81305 81310 81315 81320 81325 81330 81335 81340 81345 81350 81355 81360 82005 82010 82020 82025 82030 82035 82300 82306 82309 82312 82315 82318 82324 82327 82332 |
Part 2—Amendments commencing on 1 April 2020
Private Health Insurance (Complying Product) Rules 2015
[5] Rule 11E (note to section heading)
Repeal the note.
[6] Rule 11F (note to section heading)
Repeal the note.
[7] Rule 11G (note to section heading)
Repeal the note.
[8] Rule 11H (note to section heading)
Repeal the note.
[9] Rule 21
Repeal the rule.
Schedule 4—Second tier administrative reforms
Private Health Insurance (Benefit Requirements) Rules 2011
[1] Clause 1 of Schedule 5
Repeal the clause, substitute:
(1) In this Schedule:
authorised officer means a departmental officer authorised by the Secretary of the Department to make a determination under subclause 1A (2), (3) or (4) or to review a determination under subclause 1B (3).
comparable has the meaning given by subclause 1A (6).
Hospital Casemix Protocol Data has the meaning given by rule 4 of the Private Health Insurance (Health Insurance Business) Rules 2018.
second-tier eligible hospital means a hospital in the class set out in rule 7A of the Private Health Insurance (Health Insurance Business) Rules 2018.
(2) In this Schedule, except in subclauses 1A (8) and (9), the Australian Capital Territory is taken to be part of New South Wales, and the Northern Territory is taken to be part of South Australia.
[2] After clause 1 of Schedule 5
Insert:
1A. Categorisation of private hospitals
(1) If, as at 1 January 2019, a departmental officer authorised by the Secretary of the Department for the purpose has, in anticipation of the commencement of this provision, caused to be published on the Department’s website a list of all the hospitals for which a declaration is in force under subsection 121-5 (6) of the Act that places each hospital in a category set out in subclause (7), then each hospital is taken to be determined to be in that category.
(2) If such a list has not been published, then as soon as practicable an authorised officer must determine which category of hospital from the categories set out in subclause (7) each private hospital for which a declaration is in force under subsection 121-5 (6) of the Act is to be placed in, and cause a list of the hospitals in each category to be published on the Department’s website.
Note: If a patient is admitted to a hospital between 1 January 2019 and 31 August 2019 insurers may continue to work out the average charge on the basis of the provisions of this Schedule as in force immediately before the commencement of Schedule 4 to the Private Health Insurance (Reforms) Amendment Rules 2018. However, insurers must use the Department’s published list of hospitals under subclause (1) or (2) to determine in which category a hospital claiming second-tier default benefits is placed.
(3) If a private hospital is declared under subsection 121-5 (6) of the Act after 1 January 2019, an authorised officer must determine which category of hospital from the categories set out in subclause (7) that private hospital is to be placed in.
(4) If a hospital has been placed in a category by a determination under this clause, an authorised officer may before 1 June of a particular year determine a different category of hospital from the categories set out in subclause (7) that the private hospital is to be placed in.
(5) A list of the hospitals in each category as of 1 August of each year must be published on the Department’s website.
(6) Private hospitals are comparable if they are placed in the same category by a determination made under subclause (1), (2), (3) or (4).
(7) For the purposes of this clause, the categories are the following:
(a) private hospitals that provide psychiatric care, including treatment of addictions, for at least 50% of the episodes of hospital treatment, and do not fall into category (g);
(b) private hospitals that provide rehabilitation care for at least 50% of the episodes of hospital treatment, and do not fall into categories (a) or (g);
(c) private hospitals that do not fall into categories (a), (b) or (g), with up to and including 50 licensed beds;
(d) private hospitals that do not fall into categories (a), (b) or (g), with more than 50 licensed beds and up to and including 100 licensed beds;
(e) private hospitals that do not fall into categories (a), (b) or (g), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit or an intensive care unit;
(f) private hospitals that do not fall into categories (a), (b) or (g), with more than 100 licensed beds, with either (or any combination of) an accident and emergency unit or a specialised cardiac care unit or an intensive care unit;
(g) private hospitals that provide episodes of hospital treatment only for periods of not more than 24 hours.
(9) If State or Territory legislation in the State or Territory where the private hospital is located does not regulate the number of beds or patients that a private hospital is permitted—in subclause (7), a reference to licensed beds is a reference to the beds and bed equivalents the private hospital operates.
(10) An authorised officer must calculate proportions for the purposes of paragraphs (7) (a) and (b):
(a) if Hospital Casemix Protocol Data is available for the private hospital—using the most recent year of Hospital Casemix Protocol Data available to the Department for the private hospital; and
(b) otherwise—on the basis of any relevant information available to the Department about the episodes of hospital treatment at the private hospital.
1B. Internal review of a categorisation determination
(1) A private hospital subject to a determination made under subclause 1A (1), (2), (3) or (4) may request internal review of its categorisation by the determination.
(2) An application for internal review under subclause (1) must be made in writing within 28 days after the day the determination is notified to the hospital.
(3) If an application for internal review is made, an authorised officer (who must not be the authorised officer who made the original determination) must:
(a) review the determination; and
(b) either confirm the determination or make a fresh one within 28 days after the day on which the application was received by the Department.
[3] At the end of clause 2 of Schedule 5
Omit “facility”, insert “second-tier eligible hospital”.
[4] Subclause 3(3) of Schedule 5
Repeal the subclause, substitute:
(3) If a hospital ceases to be a second-tier eligible hospital for the purposes of this Schedule, the minimum benefit in relation 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.
[5] Subclause 3(4) of Schedule 5
Repeal the subclause, substitute:
(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.
[6] Subclause 3(6) of Schedule 5
Omit “facility”, substitute “second-tier eligible hospital”.
[7] Clause 4 of Schedule 5
Repeal the clause, substitute:
(1) If a patient is admitted to a second-tier eligible hospital between 1 January 2019 and 31 August 2019:
(a) an insurer may instead work out the average charge on the basis of the repealed provisions; and
(b) if the insurer does so, comparable has the same meaning as in the repealed provisions.
(2) For subclause (1), the repealed provisions are the provisions of this Schedule as in force immediately before the commencement of Schedule 4 to the Private Health Insurance (Reforms) Amendment Rules 2018.
Note: For the purpose of determining which category the second-tier eligible hospital to which the patient was admitted is placed in, an insurer must use the Department’s determination in respect of that hospital under subclause 1A (1), (2), (3) or (4).
Private Health Insurance (Health Insurance Business) Rules 2018
[8] Rule 3
Insert:
accredited means assessed as being fully compliant with the National Safety and Quality Health Service Standards by a body approved by the Australian Commission on Safety and Quality in Health Care to assess health service organisations against the National Safety and Quality Health Service Standards.
Hospital Casemix Protocol Data means the data provided by hospitals to insurers that is the subject of rule 4.
makes provision for informed financial consent: a hospital makes provision for informed financial consent if it has procedures in place to inform a patient or nominee, in writing, of what hospital charges, insurer benefits and out-of-pocket costs (where applicable) are expected in respect of the hospital treatment. A patient or nominee must be informed:
(a) for scheduled admissions—at the earliest opportunity before admission for the hospital treatment; or
(b) for unplanned admissions—as soon after the admission as the circumstances reasonably permit.
minimum benefit means the minimum benefit calculated in accordance with clause 3 of Schedule 5 of the Private Health Insurance (Benefit Requirements) Rules 2011.
National Safety and Quality Health Service Standards means the standards developed by the Australian Commission on Safety and Quality in Health Care.
Note: Development of the National Safety and Quality Health Service Standards is a function of the Australian Commission on Safety and Quality in Health Care under paragraph 9 (1) (e) of National Health Reform Act 2011.
[9] After Part 2
Insert:
Part 2A Second-tier eligible hospitals class
7A. Second-tier eligible hospitals class
For the purposes of subsection 121-8 (1) of the Act, second-tier eligible hospitals constitutes a class of hospital (the second-tier eligible hospitals class).
For the purposes of paragraph 121-8 (2) (b) of the Act, the application fee is $850 for each hospital that the application seeks to have included in the second-tier eligible hospitals class.
For the purposes of subsection 121-8A (1) of the Act, to be included in the second-tier eligible hospitals class, a hospital must:
(a) be a private hospital; and
(b) be accredited; and
(c) not bill patients directly for the minimum benefit payable by the patient’s insurer; and
(d) make provision for informed financial consent; and
(e) submit Hospital Casemix Protocol Data to health insurers electronically with every claim for second-tier default benefits.
Note: If a hospital is included in the second-tier eligible hospitals class by the Minister under section 121-8A of the Act, it will be a second-tier eligible hospital for the purposes of Schedule 5 to the Private Health Insurance (Benefit Requirements) Rules 2011, and therefore eligible to claim second-tier default benefits as specified in that Schedule.
7D. Notification of change in circumstances
A hospital that is included in the second-tier eligible hospitals class must notify the Department in writing of any change in circumstances that may prevent that hospital from continuing to meet the assessment criteria set out in rule 7C as soon as practicable.
(1) A hospital that is a facility for the purposes of clause 4 of Schedule 5 to the Private Health Insurance (Benefit Requirements) Rules 2011 immediately before the commencement of Schedule 4 to the Private Health Insurance (Reforms) Amendment Rules 2018 is taken to be included in the second-tier eligible hospitals class.
(2) A hospital referred to in subrule (1) is taken to be included in the second-tier eligible hospitals class until the eligibility expiry date for that hospital.
(3) Despite subrule (2), if the date on which a hospital’s accreditation will expire falls within the 12 months following the hospital’s eligibility expiry date, then the hospital is taken to be included in the second-tier eligible hospitals class until the day on which that hospital’s accreditation will expire.
(4) In this rule:
eligibility expiry date means the date on which the hospital’s approval on the list of second-tier eligible facilities existing on 1 January 2019 expires.
Note: Hospitals that are specified in the Second Tier Advisory Committee approved list on 1 January 2019 will be second-tier eligible hospitals for the purposes of Schedule 5 of the Private Health Insurance (Benefit Requirements) Rules 2011, and therefore eligible to claim second-tier default benefits as specified in that Schedule. Unless subrule (3) applies, when the approval under the pre-existing arrangements expires, the hospital will be required to apply under s 121-8 of the Act to be included in the second-tier eligible hospitals class.
Schedule 5—Removal of coverage of some natural therapies
Private Health Insurance (Health Insurance Business) Rules 2018
[1] Rule 3
Insert:
excluded natural therapy treatment means any of the following treatments:
(a) Alexander technique;
(b) aromatherapy;
(c) Bowen therapy;
(d) Buteyko;
(e) Feldenkrais;
(f) Western herbalism;
(g) homeopathy;
(h) iridology;
(i) kinesiology;
(j) naturopathy;
(k) Pilates;
(l) reflexology;
(m) Rolfing;
(n) shiatsu;
(o) tai chi;
(p) yoga.
[2] At the end of Rule 8
Add:
; and (e) excluded natural therapy treatment.
[3] Rule 11
Repeal the rule, substitute:
11. General treatment—excluded treatment
(1) For paragraph 121-10 (3) (b) of the Act, the following treatments or classes of treatment are specified:
(a) treatment which primarily takes the form of sport, recreation or entertainment, other than treatment that is part of a chronic disease management program or a health management program if the programs have been approved by the private health insurer;
(b) excluded natural therapy treatment.
(2) In this rule:
health management program means a program that is intended to ameliorate a person’s specific health condition or conditions, but does not include treatment that is excluded natural therapy treatment.
Schedule 6—Information provision
Private Health Insurance (Incentives) Rules 2012 (No. 2)
[1] Rule 4 (note)
Omit “standard information statement”, substitute “private health information statement”.
[2] Rule 4 (definition of Australian Government Rebate on private health insurance)
Repeal the definition, substitute:
Australian Government Rebate on private health insurance means:
(a) the premiums reduction scheme; or
(b) the private health insurance tax offset.
[3] Rule 7
Repeal the rule.
[4] Paragraph 8(1)(a)
Repeal paragraph 8(1)(a), substitute:
(a) if a participant in respect of a complying health insurance policy on issue from the insurer during any time in the previous financial year requests the following information from a participating insurer:
(i) the amount of the premium paid for the policy during the previous financial year;
(ii) the reduction, under the premiums reduction scheme, for the premium;
the participating insurer must issue to the participant a statement in accordance with rule 9;
[5] Subparagraph 8(1)(c)(ii)
Omit “annual”.
[6] Rule 9
Repeal the rule, substitute:
9. Requirements for statements to participants
(1) A statement under paragraph 8 (1) (a) must:
(a) be in writing; and
(b) set out, clearly and distinctly:
(i) if requested by the participant—the amount of the premium paid for the policy during a particular financial year; and
(ii) if requested by the participant—the amount of the reduction under the premiums reduction scheme for the premium; and
(c) be provided within 14 days of receipt of the request; and
(d) be provided:
(i) by post; or
(ii) if the participant has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the participant.
Example: If requested by the participant, the information may be provided in an electronic format, including via a web page.
(2) A statement under paragraph 8 (1) (a) may be accompanied by other information.
Private Health Insurance (Lifetime Health Cover) Rules 2017
[7] Subrule 8(1)
Repeal the subrule, substitute:
1) For the purposes of paragraph 40 (1) (a) of the Act, the following requirements are specified:
(a) the insurer must provide information about increases under Part 2-3 in the amounts of premiums payable for the policy holder’s hospital cover in respect of the policy holder, if requested by the policy holder;
(b) the insurer must provide the following information to a policy holder affected by section 34-1 or section 34-5 of the Act, if requested by the policy holder:
(i) the amount by which the policy holder’s premiums payable for hospital cover are increased as a result of the operation of those sections;
(ii) the private health insurer’s record of the number of days the policy holder has not had hospital cover since his or her lifetime health cover base day, other than days to which paragraph 34-20 (1) (a) of the Act applies.
Note: Paragraph 34-20 (1) (a) of the Act deals with permitted days without hospital cover.
[8] Subrule 8(3)
Repeal the subrule, substitute:
3) The information required to be provided by subrule 8 (1) must:
(a) be provided:
(i) by post; or
(ii) if the policy holder has requested that the information be provided in another manner—if reasonably practicable, in the manner requested by the policy holder; and
(b) in the case of joint policy holders, set out the details applying to the joint policy holder making the request; and
(c) be provided to the policy holder within 14 days of receipt of the request.
Example: For subparagraph (a) (ii), if requested by the policy holder, the information may be provided in an electronic format, including via a web page.
Schedule 7—Amendments relating to accredited podiatrists
Private Health Insurance (Complying Product) Rules 2015
[1] Rule 4 (definition of accredited podiatrist)
Repeal the definition (including the note).
[2] Rule 4
Insert:
registered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.
Note: The registration requirements for a registered podiatric surgeon for the purpose of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules as made from time to time.
[3] Subrule 8(1) (table item 2, column headed “Kind of policy”, subparagraph (b)(ii))
Omit “an accredited podiatrist”, substitute “a registered podiatric surgeon”.
Private Health Insurance (Prostheses) Rules 2018 (No. 2)
[4] Rule 4 (definition of accredited podiatrist)
Repeal the definition (including the note).
[5] Rule 4
Insert:
registered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.
Note: The registration requirements for a registered podiatric surgeon for the purpose of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules as made from time to time.
[6] Paragraph 7(a)
Omit “an accredited podiatrist”, substitute “a registered podiatric surgeon”.