Private Health Insurance clinical category definitions – 1 January 2024

Standard clinical category definitions for private health insurance hospital policies, released on 20 December 2023 and effective at 1 January 2024.


Private Health Insurance clinical category definitions – 1 January 2024

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Definitions of the clinical categories for hospital treatment policies as found in the Private Health Insurance (Complying Product) Rules 2015.

The clinical categories include an indicative list of Medicare Benefits Schedule (MBS) items that should be covered. This list of items is derived from the MBS XML Data file ‘MBS-XML-20240101 (XML 7969)’ released on 15 December 2023 through MBS Online and effective 1 January 2024. The current documents reflect consequential PHI changes made as a result of changes to indexation of the Extended Medicare Safety Net, the introduction of a new co-dependent pathology item, the cessation of 23 items and minor administrative policy changes.

Key MBS item changes of potential interest to stakeholders are summarised below, and outlined in the MBS Online January 2024 News:

  • Indexation of the fixed dollar EMSN benefit cap.
  • A range of COVID-19 health measures are being extended.
  • Cessation of 18 temporary items introduced on 21 July 2021 for smoking cessation counselling have expired and will no longer be available.
  • Introduction of a co-dependent MBS item (73307) to support pathology – genetics services.

Further information including fact sheets and quick reference guides is at MBS Online.

No amendments were made to the clinical category definitions.  

Pathology items are automatically categorised as Support treatments so do not need to be listed in the clinical categories tables in the PHI Rules. All Support items are identified in the Private Health Insurance classification of MBS items 1 January 2024.

The recent modifications to the PHI spreadsheet do not require any corresponding amendments to the PHI Rules.

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For previous versions of PHI Spreadsheet publications, review the Private health insurance clinical category and procedure type collection, or visit the National Library's web archive.

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