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PHI 78/11

This circular issued by the Private Health Insurance Branch contains information on Private Health Insurance (Benefit Requirements) Rules 2011

Printable version of 78/11 (PDF 31 KB)

7 November 2011

Private Health Insurance (Benefit Requirements) Rules 2011

The Private Health Insurance (Benefit Requirements) Rules 2011 (the Rules) replace the Private Health Insurance (Benefit Requirements) Rules 2010 (the previous Rules).

The Rules were registered with the Federal Register of Legislative Instruments (FRLI) on 31 October 2011 (FRLI No: F2011L0216) and commenced on 1 November 2011.

The Rules differ from the previous Rules by:

• amending the definitions of ‘psychiatric patients’ and ‘rehabilitation patients’, which apply to private patients in a public hospital in Victoria and Tasmania, and in private hospitals nationally;
• allowing hospitals to charge and insurers to pay a rate below the minimum benefit amount;
• updating the list of Medicare Benefit Schedule (MBS) item numbers which attract hospital accommodation benefits;
• increasing the minimum benefits payable per night for Nursing Home Type Patients (NHTPs) at public hospitals in the Northern Territory; and
• removing two facilities from the list of Second Tier default facilities following notification of their closure.

Definitions of ‘psychiatric patient’ and ‘rehabilitation patient’ - Schedule 1

The Rules amend the definitions of psychiatric patients and rehabilitation patients, set out in Schedule 1, Clauses 7 and 8. These apply to private patients in a public hospital in Victoria and Tasmania, and in private hospitals nationally. The amendment clarifies that the decision by the insurer to pay a higher level of hospital accommodation benefits for patients undergoing psychiatric or rehabilitation treatment, must be related to the patient's disease, injury or condition and the relevance and quality of the treatment program.

Allowing hospitals to charge and insurers to pay below the minimum benefit - Part 2

The Rules insert Part 2, Rule 6 to allow hospitals to charge and insurers to pay a rate below the minimum benefit amount.

MBS Item Number Updates - Schedules 1 and 3

To reflect changes in the MBS commencing on 1 November 2011, the list of MBS item numbers which attract hospital accommodation benefits in Schedules 1 and 3 of the Rules is updated by adding two MBS item numbers (32520 and 32522) and removing three MBS item numbers (2710, 35400 and 35402).

The Rules also amend Schedule 1 to revise the threshold fees which identify patients as ‘Surgical patients’ (increased from the previous range of $244.37 to $820.64, to a new range of $249.26 to $837.05), and ‘Advanced surgical patients’ (from greater than $820.64 to greater than $837.05). This reflects an increase of 2% which has been applied as a result of indexation to the MBS effective from 1 November 2011.

Schedule 3 of the Rules is also updated to include an additional nine MBS item numbers (69415, 16501, 16502, 16504, 16505, 16508, 16509, 16511 and 289) that were inadvertently excluded from the Rules in the past.

Nursing-Home Type Patients – Schedule 4

NHTP minimum benefits in Schedule 4 have been updated to reflect the indexation applied to the Adult Pension Basic Rate and maximum daily rate of rental assistance.

The amendment increases the minimum benefits payable for privately insured NHTPs at public hospitals in Northern Territory from $71.76 to $75.23.

The existing rates for all other jurisdictions remain in force.

Second Tier Default Benefits – Schedule 5

Two facilities have been removed from the list of Second Tier default facilities in Schedule 5 following notification of their closure. These hospitals are:

Provider ID	Name	Address
0656781	Peninsula Endoscopy Centre	17 Yuille Street, Frankston VIC 3199
0656171A	Sydney Haematology & Oncology Clinic	13/49 Palmerston Road, Hornsby NSW 2077

The Rules can be viewed on the ComLaw website.

If you require further information please telephone: (02) 6289 9853/24 hr answering machine or email the enquiry to Private Health Insurance Branch

For more information visit 2011 Private Health Insurance (PHI) Circulars.

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