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 agebased 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)

 

1  Name

  This instrument is the Private Health Insurance (Reforms) Amendment Rules 2018.

2  Commencement

 (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.

 

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.

 

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.

3  Authority

  This instrument is made under section 33320 of the Private Health Insurance Act 2007.

4  Schedules

  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 1Amendments to implement agebased 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 agebased discount that might apply in relation to the policy (see Part 2A).

[5] After Part 2

Insert:

Part 2A  Agebased discounts

Note 1: See paragraphs 6310 (g) and 665 (3) (ea) of the Act.

Note 2: Nothing in this Part requires a private health insurer to:

 make agebased discounts available under any product; or

 if agebased discounts are available under a product:

 make such discounts available for all ages between 18 and 29 (inclusive); or

 continue to make agebased discounts available under the product.

 Instead, an agebased 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 agebased discount, the person is entitled to continue to receive the full discount until the person turns 41 (unless the insurer chooses to discontinue agebased 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 agebased 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 635 of the Act).

11A. Definitions

  In this Part:

agebased discount policy means an insurance policy that provides agebased discounts.

discount assessment date, in relation to a person who is insured under an agebased discount policy, means whichever of the following is applicable:

 (a) subject to paragraph (c), if the policy provided agebased discounts at the date the person became insured—that date;

 (b) if the policy provided agebased discounts at a date after the person became insured—the date the person was first eligible for an agebased discount under the policy;

 (c) if:

 (i) the person transferred to the policy (the new policy) from another agebased discount policy (the old policy); and

 (ii) at the time of the transfer, the new policy was stated to be a retained agebased 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 agebased discount policy, means a person to whom a discount applies in accordance with paragraph 11B (c).

retained agebased discount policy means an insurance policy:

 (a) that is an agebased discount policy; and

 (b) that states that it is a retained agebased discount policy.

11B. Requirements for agebased discount policy to be complying health insurance policy

  For paragraph 6310 (g) of the Act, an insurance policy must not provide for an agebased 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 agebased 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 agebased 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 agebased discount

Note: This rule deals only with the calculation of the agebased discount. The premium that is payable in respect of a particular insurance policy is also affected by other provisions of the Act (including Part 23 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 agebased discount that applies under an agebased 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 23 of the Act (lifetime health cover); and

 (b) there were no discounts of the kind allowed under subsection 665 (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 agebased discount

  For paragraph 665 (3) (ea) of the Act, a person is entitled to an agebased discount for a particular period if:

 (a) the person is insured under an agebased 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 2Standard 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 935 (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 935 (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 935 (2) and paragraph 9315 (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 9625 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 6610 (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:

20. Transitional provision relating to the Private Health Insurance (Reforms) Amendment Rules 2018—standard information statements

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 1Information and form of words for standard information statement—all policies

1.  Interpretation

  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.

 

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.

 

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.

 

4

Contact details

A contact phone number and website address of the private health insurer.

 

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.

 

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.

 

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.

 

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..

 

9

Who is covered

The insured groups that may be covered, expressed as whichever of the following is applicable:

  (a) only one person;

  (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.

 

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 nonemergency; 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.

 

11

Date available

If, and only if, the policy is not yet available—the date from which the policy will be available.

 

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]”

 

13

Unique identifier

The unique identifier for the standard information statement that is generated by the privatehealth.gov.au system.

 

Schedule 2Additional information, and form of words, for standard information statement—hospital treatment

1.  Interpretation

  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”.

 

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”.

 

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.

 

4

Restrictions

A list of all restrictions (if any) that apply.

 

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 preexisting 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 tablefor 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.

 

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.

 

7

Extra cost per day (copayments)

If there are no co-paymentsthe 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 copayment is $[number] per year” (with the bracketed text replaced with the appropriate figures).

 

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.”.

 

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.”.

 

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 agedbased 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.

 

Schedule 3Additional information, and form of words, for standard information statementgeneral 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.

1.  Interpretation

  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 wordsgeneral 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 wordsgeneral 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.

 

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..

 

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.

 

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.

 

5

Waiting period (months)

For each treatment that is covered by the policywhichever 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.

 

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 “Sublimits 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.

 

7

Examples of maximum benefitsgeneral 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 policythe 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.

 

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.

 

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.

 

 

Part 2Amendments 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 9625 of the Act.

 (2) When giving an insured person a copy of a private health information statement in accordance with section 9315 or subsection 9320 (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.

[7]   After rule 15

16.  Information provided to persons about product subgroups

  For subsection 935 (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.

 

[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.

 

[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.

 

[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 provisionsprivate 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.

 

[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 3Product 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 6310 (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 6310 (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 6310 (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 6310 (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 6310 (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 “+”.

[3] After rule 20

Insert:

21. Transitional provisions relating to the Private Health Insurance (Reforms) Amendment Rules 2018—product tiers

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 semiprecious 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 4Product 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.

1  Interpretation

  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.

2  Clinical categories

  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.

 

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 6Common 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 subsubparagraph 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 7Support 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 subsubparagraph 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              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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 4Second tier administrative reforms

Private Health Insurance (Benefit Requirements) Rules 2011

[1]   Clause 1 of Schedule 5

Repeal the clause, substitute:

1.  Interpretation

 (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.

 (8) If State or Territory legislation in the State or Territory where the private hospital is located regulates the number of beds or patients that a private hospital is permittedin subclause (7), a reference to licensed beds is a reference to the beds or patients that a private hospital is permitted, under State or Territory legislation in the State or Territory where the private hospital is located.

 (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 permittedin 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 hospitalusing the most recent year of Hospital Casemix Protocol Data available to the Department for the private hospital; and

 (b) otherwiseon 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) otherwiseare 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 secondtier 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:

4. Transitional

 (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 admissionsat the earliest opportunity before admission for the hospital treatment; or

 (b) for unplanned admissionsas 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).

7B. Application fee

  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.

7C. Assessment criteria

  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.

7E. Transitional arrangements

 (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 5Removal 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 6Information 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”.