Private Health Insurance (Benefit Requirements) Rules 2011

I, NICOLA ROXON, the Minister for Health and Ageing, make these Rules under item 3A of the table in section 333-20 of the Private Health Insurance Act 2007.

Dated           26th October 2011

____________________________________

NICOLA ROXON

Minister for Health and Ageing

Contents

Part 1                   Preliminary                                                                                            3

1.           Name of Rules                                                                                        3

2.           Commencement and Revocation                                                             3

3.           Definitions                                                                                              3

Part 2                   Minimum benefit requirements                                                              5

4.           Psychiatric care, rehabilitation and palliative care                                      5

5.           Other hospital treatments                                                                        5

6.           Benefit not to exceed hospital fees or charges                                         5

Schedule 1―Overnight accommodation:  private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania                                                                         6

Schedule 2―Overnight accommodation:  shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia                                         17

Schedule 3―Same-day accommodation:  hospitals in all States/Territories                     18

Schedule 4―Nursing-home type patient accommodation:  hospitals in all States/Territories   31

Schedule 5―Second-tier default benefits                                                                         34

Part 1        Preliminary

1.               Name of Rules

These Rules are the Private Health Insurance (Benefit Requirements) Rules 2011.

2.               Commencement and Revocation

(1)        These Rules commence on 1 November 2011, or if registered after 1 November 2011, the day after registration.

(2)        These Rules revoke the Private Health Insurance (Benefit Requirements) Rules 2010.

3.               Definitions

In these Rules:

Act means the Private Health Insurance Act 2007.

ACT means the Australian Capital Territory.

certified Type B procedure means a Type B procedure certified in accordance with clause 10 of Schedule 1.

certified overnight Type C procedure means a Type C procedure certified in accordance with clause 11 of Schedule 1.

certified Type C procedure means a Type C procedure certified in accordance with clause 7 of Schedule 3.

continuous period of hospitalisation, for the purpose of counting days of hospital treatment, includes any two periods during which a patient was, or is, receiving hospital treatment as a patient at a hospital, whether or not the same hospital, where the periods are separated from each other by a period of not more than 7 days during which the patient was not receiving hospital treatment as a patient at any hospital.

diagnostic imaging services table means the table prescribed under subsection 4AA (1) of the Health Insurance Act 1973.

fee in the MBS means the Schedule fee as defined in subsection 8 (1A) of the Health Insurance Act 1973.

general medical services table means the table prescribed under subsection 4 (1) of the Health Insurance Act 1973.

insurer means a private health insurer.

item has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.

MBS comprises the:

(a)                    general medical services table;

(b)                   diagnostic imaging services table; and

(c)                    pathology services table.

negotiated agreement means an agreement entered into between a hospital and an insurer, that includes provisions to the effect that, except to the extent (if any) provided in the agreement, the hospital agrees to accept payment by the insurer in satisfaction of any amount that would, apart from the agreement, be owed to the hospital, in relation to an episode of hospital treatment, by an insured person under a policy.

              NSW means the State of New South Wales.

nursing-home type patient  has the meaning given by Schedule 4

Note:         Item 19 of Schedule 2 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 also deals with nursing-home type patients.

outreach service means a service referred to in subsection 16 (1) of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007, unless subsection 16 (2) of that Act applies to the particular service.

participating midwife has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.

pathology services table means the table prescribed under subsection 4A (1) of the Health Insurance Act 1973.

policy means a complying health insurance policy.

private hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a private hospital.

Note:         Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

professional service has the same meaning as in subsection 3 (1) of the Health Insurance Act 1973.

public hospital means a hospital in respect of which there is in force a statement under subsection 121-5 (8) of the Act that the hospital is a public hospital.

Note:         Section 15 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the status of certain hospitals for which a declaration had been made before the commencement of the Act.

Type A procedure means:

(a)                    a procedure specified in clauses 3 to 9 of Schedule 1; or

(b)                   a certified Type B procedure; or

(c)                    a certified overnight Type C procedure.

Type B procedure means:

(a)                    a procedure specified in clauses 3 to 7 of Schedule 3 other than a certified Type B procedure; or

(b)                   a certified Type C procedure.

Type C procedure means a procedure specified in clause 8 of Schedule 3 other than a certified Type C procedure.

Part 2          Minimum benefit requirements

4.               Psychiatric care, rehabilitation and palliative care

(1)        For item 1 in the table in subsection 72-1 (2) of the Act, the minimum benefit for hospital treatment specified in that item is the amount set out, or worked out using the method for working out the minimum benefit for that treatment, in Schedules 1, 2, 3 or 5 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.

Note:         Item 1 in the table in subsection 72-1 (2) of the Act requires that each policy that covers hospital treatment must cover any part of hospital treatment that is psychiatric care, rehabilitation or palliative care if the treatment is provided in a hospital and no medicare benefit is payable for that part of the treatment.

(2)        Despite subrule (1), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person's policy in respect of that treatment.

5.               Other hospital treatments

(1)        For item 5 in the table in subsection 72-1 (2) of the Act, for a policy that covers any type of hospital treatment provided in a hospital, other than treatment referred to in rule 4, the minimum benefit for that treatment is the amount set out, or worked out using the method for working out the minimum benefit, for that treatment in Schedules 1, 2, 3, 4 or  5 where the treatment is provided in the circumstances specified in the particular Schedule relevant to that treatment.

(2)    Despite subsection (1), if a policy covers a type of hospital treatment, other than treatment referred to in rule 4, and the insurer for that policy has a negotiated agreement with the hospital in which the treatment is provided, the minimum benefit for that treatment is the amount specified for the treatment in the negotiated agreement.

(3)    Despite subrules (1) and (2), the minimum benefit for the treatment may be reduced by the amount of any co-payment or excess that is required to be paid under the insured person’s policy in respect of that treatment.

6.               Benefit not to exceed hospital fees or charges

(1)        In respect of treatment referred to in rule 4 and in rule 5 other than hospital treatment for a nursing-home type patient (as set out in Schedule 4), the amount of benefit payable by the insurer in respect of hospital treatment for a person will not exceed the fees or charges incurred in respect of that hospital treatment.

(2)        In respect of treatment referred to in rule 5 of this Part, the amount of benefit payable by the insurer in respect of hospital treatment for a nursing-home type patient (as set out in Schedule 4) will not exceed an amount equal to the fees or charges incurred in respect of that hospital treatment less the amount of the patient contribution in relation to the patient for each day on which the patient was a patient in the hospital.

Schedule 1―Overnight accommodation:  private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania

Part 1―General

1.               Circumstances

For rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is:

(a)                    provided to a patient who is not a nursing-home type patient; and

(b)                   provided to a patient:

(i)                      at a private hospital; or

(ii)                    as shared ward accommodation at a public hospital in Victoria or Tasmania; and

Note:         The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital.  This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

(c)                    provided for the purpose of permitting the provision to the patient of hospital treatment that is:

(i)                      a Type A procedure; and

(ii)                    for a period that includes part of an overnight stay.

Note:         A Type A procedure is defined to include a certified Type B procedure and a certified overnight Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.

2.               Minimum benefit

(1)        The minimum benefit for hospital treatment provided in the circumstances specified in this Schedule is the amount set out in the tables in this Schedule for that hospital treatment.

(2)        When counting the days referred to in the tables in this Schedule to determine the minimum benefit in respect of any particular patient, days forming part of a continuous period of hospitalisation are to be counted.

Table 1―Accommodation at private hospitals in all States/Territories

Table 2― Victoria:  shared ward accommodation at a public hospital

Table 3― Tasmania:  shared ward accommodation at a public hospital

Part 2          Type A procedures

3.               Interpretation

A Type A procedure is a procedure specified in this Part provided to a patient in one of the categories of patients in clauses 4 to 9.

4.               Advanced surgical patient

(1)        In this Schedule, advanced surgical patient has the meaning given by this clause.

(2)        A patient is taken to be an advanced surgical patient upon admission to a hospital:

(a)                    from and including the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3) is rendered to the patient at that hospital, unless the particular advanced surgical procedure to be rendered is recognised as requiring a longer pre‑operative period; or

(b)                   if a longer pre-operative period than that referred to in paragraph (a) is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or

(c)                    if the advanced surgery is rendered to a patient during an admission, from the day the advanced surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before).

Note:         The effect of the reference in subclause (2) (a) to a professional service, being a service for which a medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply.

(3)        The item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS greater than $837.05:

15600  30177  30250  30251  30255  30275  30294  30296  30297  30309  30315  30317  30318  30320  30321  30323  30324  30335  30336  30379  30382  30384  30388  30396  30405  30415  30417  30418  30421  30425  30427  30428  30430  30438  30448  30449  30454  30455  30457  30458  30460  30461  30463  30464  30466  30467  30469  30472  30500  30502  30503  30506  30508  30509  30512  30514  30517  30518  30521  30523  30524  30526  30527  30529  30532  30533  30535  30536  30538  30539  30541  30542  30545  30547  30548  30550  30551  30553  30554  30556  30557  30560  30565  30566  30577  30578  30580  30583  30584  30589  30590  30593  30594  30596  30599  30601  30602  30603  30605  30606  30680  30682  30684  30686  31002  31409  31412  31429  31432  31435  31438  31464  31466  31468  31472  31524  32000  32003  32004  32005  32006  32009  32012  32015  32018  32024  32025  32026  32028  32030  32033  32036  32039  32042  32047  32051  32054  32060  32063  32069  32104  32106  32108  32117  32209  32220  32221  32514  32517  32700  32703  32708  32710  32711  32712  32715  32718  32721  32724  32730  32733  32739  32742  32745  32748  32751  32754  32763  33050  33055  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  33800  33803  33811  33812  33815  33818  33821  33824  33827  33830  33833  33836  33839  33842  34112  34115  34118  34121  34124  34127  34136  34139  34142  34148  34151  34154  34157  34160  34163  34166  34169  34172  34175  34509  34512  34518  34533  34803  34806  34809  34812  34815  34818  34821  34833  35003  35006  35009  35307  35312  35315  35320  35412  35561  35562  35595  35597  35641  35661  35664  35667  35670  35697  35753  35754  36500  36503  36506  36516  36519  36522  36525  36526  36527  36528  36529  36531  36532  36533  36540  36543  36564  36567  36570  36573  36576  36588  36591  36594  36597  36600  36603  36606  36645  36648  36656  37014  37029  37042  37045  37047  37053  37200  37203  37207  37209  37210  37211  37220  37230  37309  37341  37343  37375  37384  37390  37405  37411  37423  37426  37432  37444  37607  37610  37824  37842  37848  37851  38212  38231  38237  38240  38246  38270  38272  38287  38290  38293  38309  38312  38315  38318  38358  38368  38384  38390  38418  38421  38424  38427  38438  38440  38441  38446  38447  38449  38450  38453  38455  38456  38457  38466  38468  38469  38470  38477  38478  38480  38481  38483  38487  38488  38489  38493  38497  38498  38500  38501  38503  38504  38506  38507  38508  38509  38512  38515  38518  38550  38553  38556  38559  38562  38565  38568  38571  38572  38600  38603  38615  38618  38624  38640  38643  38647  38650  38653  38654  38656  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  39106  39112  39124  39139  39315  39500  39503  39603  39609  39612  39615  39640  39642  39646  39650  39653  39654  39656  39658  39660  39662  39706  39709  39712  39715  39718  39800  39803  39806  39815  39818  39821  39903  40000  40003  40012  40103  40106  40109  40112  40118  40300  40301  40303  40306  40309  40312  40315  40316  40318  40321  40330  40331  40332  40334  40335  40339  40342  40345  40348  40351  40600  40700  40703  40706  40712  40801  40803  40850  40851  40860  41518  41521  41530  41533  41536  41539  41542  41551  41554  41557  41560  41563  41564  41566  41569  41572  41575  41576  41578  41579  41581  41584  41587  41590  41593  41596  41599  41608  41614  41615  41617  41623  41635  41638  41728  41734  41782  41785  41834  41837  41840  41843  41879  42521  42539  42543  42545  42557  42569  42626  42653  42656  42659  42662  42672  42710  42716  42725  42731  42746  42749  42752  42767  42773  42776  42779  42801  42842  42851  42860  43801  43804  43807  43810  43813  43816  43819  43822  43825  43828  43831  43834  43837  43840  43843  43846  43852  43855  43861  43864  43870  43873  43876  43879  43882  43900  43903  43906  43909  43912  43915  43936  43945  43951  43954  43957  43963  43966  43969  43972  43975  43978  43984  43987  43990  43993  43996  44334  44373  45006  45036  45215  45415  45418  45460  45461  45464  45465  45466  45468  45469  45471  45472  45474  45475  45477  45478  45480  45481  45483  45484  45490  45491  45492  45494  45500  45501  45502  45503  45504  45505  45520  45528  45530  45533  45539  45558  45559  45561  45562  45563  45564  45565  45566  45570  45587  45588  45596  45597  45599  45624  45638  45639  45641  45644  45646  45647  45660  45661  45686  45720  45723  45726  45729  45731  45732  45735  45738  45741  45744  45747  45752  45753  45754  45767  45770  45773  45776  45779  45782  45785  45788  45791  45853  45861  45863  45869  45871  45873  45897  46315  46318  46321  46393  46477  46504  46507  47486  47489  47501  47504  47507  47510  47519  47525  47531  47534  47566  47588  47591  47687  47690  47693  47699  47702  48203  48427  48512  48606  48612  48613  48618  48621  48624  48627  48630  48632  48639  48640  48645  48648  48651  48654  48657  48660  48669  48672  48681  48684  48687  48690  48691  48692  48918  48921  48924  48933  48939  48942  48951  48954  48957  48960  49106  49115  49116  49117  49210  49211  49306  49312  49318  49319  49321  49324  49327  49330  49333  49339  49342  49345  49512  49517  49518  49519  49521  49524  49527  49530  49533  49536  49539  49542  49548  49551  49554  49564  49715  49716  49717  49836  49838  49842  50212  50215  50218  50221  50224  50227  50230  50233  50236  50239  50300  50303  50306  50321  50324  50327  50336  50351  50354  50366  50372  50378  50384  50394  50399  50408  50411  50414  50417  50420  50423  50450  50451  50455  50456  50460  50461  50465  50466  50470  50471  50475  50476  50604  50608  50612  50620  50624  50628  50632  50636  50640  50644  52123  52126  52129  52158  52337  52342  52345  52348  52351  52354  52357  52360  52363  52366  52369  52372  52375  52379  52380  52382  52430  52446  52821  53209  53212  53221  53224  53227  53230  53233

5.               Obstetric patient

(1)        In this Schedule, obstetric patient has the meaning given by this clause.

(2)        A patient shall be taken to be an obstetric patient during an admission to a hospital from and including:

(a)                    whichever is the earlier of:

(i)      the day on which the patient commences labour leading to delivery in that hospital; or

(ii)     the day on which a professional service with the item number 16406, 16515, 16518, 16519, 16522 (excluding caesarean), 16525, 16527 or 16528 is rendered to the patient in that hospital; or

(b)                   if the circumstances in paragraph (a) do not apply, the day before a professional service with the item number 16520 and 16522 (including caesarean) is rendered to the patient at that hospital, unless the particular obstetric procedure to be rendered is recognised as requiring a longer pre-operative period; or

(c)                    the day on which a professional service with the item number 82120 or 82125 is rendered to a patient by a participating midwife.

(3)        In this clause, the item numbers specified are the item numbers in the general medical services table.

6.               Surgical patient

(1)        In this Schedule, surgical patient has the meaning given by this clause.

(2)        A patient shall be taken to be a surgical patient upon admission to a hospital from and including:

(a)                    the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3), is rendered to the patient at that hospital, unless the particular surgical procedure to be rendered is recognised as requiring a longer pre-operative period; or

(b)                   if a longer pre-operative period is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or

(c)                    if the surgery is rendered to a patient during an admission, from the day the surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before).

Note:         The effect of the reference in subclause (2) (a) to a professional service, being the service for which a medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply.

(3)        The item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS within the range of $249.26 to $837.05:

13212  13218  13251  13700  14230  14233  14236  14242  15303  15304  15307  15308  15311  15312  15315  15316  15319  15320  15323  15324  15327  15328  15331  15332  15335  15336  15345  16567  16570  16571  16573  30017  30020  30023  30024  30068  30110  30111  30114  30165  30168  30171  30174  30190  30197  30225  30229  30235  30241  30244  30246  30247  30253  30256  30272  30286  30289  30293  30299  30300  30302  30303  30306  30308  30310  30313  30314  30330  30332  30373  30375  30376  30378  30385  30387  30391  30392  30393  30394  30399  30400  30402  30403  30408  30414  30416  30419  30422  30431  30433  30434  30436  30437  30440  30443  30445  30446  30450  30451  30452  30475  30479  30481  30484  30485  30490  30491  30492  30493  30494  30495  30496  30497  30499  30505  30511  30515  30520  30530  30544  30559  30562  30563  30564  30568  30569  30571  30572  30575  30581  30586  30587  30597  30600  30609  30612  30614  30615  30616  30617  30620  30621  30635  30638  30641  30644  30672  30675  30676  30688  30690  30692  30694  30696  30710  31000  31001  31225  31245  31250  31260  31270  31275  31295  31300  31305  31310  31315  31320  31325  31330  31335  31340  31350  31355  31400  31403  31406  31423  31426  31450  31452  31454  31460  31462  31470  31500  31503  31506  31509  31512  31515  31518  31521  31527  31539  31545  31554  32021  32029  32045  32046  32057  32066  32090  32093  32094  32096  32099  32102  32103  32105  32111  32112  32120  32123  32126  32129  32131  32138  32139  32150  32159  32162  32165  32180  32183  32186  32200  32203  32206  32210  32213  32214  32216  32504  32507  32508  32511  32736  32757  32760  32766  32769  33070  33545  33548  33551  33554  33806  33810  33845  33848  34100  34103  34106  34109  34130  34133  34145  34500  34503  34515  34521  34524  34527  34528  34538  34800  34824  34827  34830  35000  35012  35100  35202  35300  35303  35306  35309  35317  35319  35321  35324  35327  35330  35331  35360  35361  35362  35363  35404  35406  35408  35410  35508  35530  35533  35536  35539  35542  35548  35551  35560  35564  35565  35566  35568  35570  35571  35573  35577  35578  35596  35599  35602  35605  35612  35613  35622  35623  35634  35635  35636  35637  35638  35645  35648  35649  35653  35657  35658  35673  35676  35677  35678  35680  35683  35684  35687  35688  35694  35700  35710  35712  35713  35716  35717  35720  35723  35726  35750  35756  35759  36502  36509  36537  36546  36549  36552  36558  36579  36585  36604  36605  36607  36608  36609  36612  36615  36618  36621  36624  36627  36630  36633  36636  36639  36642  36649  36652  36654  36803  36806  36809  36811  36818  36821  36825  36833  36840  36842  36845  36854  36857  36863  37000  37004  37008  37020  37023  37026  37038  37043  37044  37050  37201  37202  37206  37208  37212  37215  37219  37221  37224  37227  37233  37306  37318  37327  37330  37333  37336  37340  37342  37345  37348  37351  37354  37372  37381  37387  37396  37402  37408  37417  37418  37420  37429  37438  37601  37604  37605  37606  37613  37616  37619  37800  37803  37806  37809  37812  37818  37821  37827  37830  37833  37836  37839  37845  37854  38200  38203  38206  38209  38213  38215  38218  38222  38225  38228  38234  38241  38243  38256  38275  38300  38303  38306  38350  38353  38356  38362  38365  38371  38387  38393  38415  38430  38448  38452  38458  38460  38462  38464  38473  38475  38485  38490  38496  38505  38577  38588  38609  38612  38613  38621  38627  38637  39015  39018  39109  39118  39121  39125  39126  39127  39128  39130  39134  39137  39138  39140  39300  39303  39306  39309  39312  39318  39321  39323  39324  39327  39330  39331  39333  39600  39606  39700  39703  39721  39812  39900  39906  40006  40009  40015  40100  40115  40324  40327  40333  40336  40709  40800  40852  40854  40856  40858  40903  40905  41512  41515  41524  41527  41545  41548  41603  41611  41620  41629  41671  41672  41707  41710  41713  41716  41722  41725  41729  41731  41737  41743  41746  41749  41752  41767  41770  41773  41776  41779  41786  41787  41789  41792  41793  41813  41819  41820  41825  41831  41849  41852  41855  41858  41861  41864  41867  41868  41870  41873  41876  41880  41881  41885  41895  41898  41901  41905  41910  42506  42509  42510  42512  42515  42518  42527  42530  42533  42536  42542  42548  42551  42554  42560  42563  42566  42574  42584  42590  42596  42599  42602  42605  42608  42623  42629  42635  42638  42641  42665  42680  42686  42692  42695  42698  42701  42702  42703  42704  42707  42713  42719  42722  42734  42737  42740  42743  42758  42761  42764  42770  42771  42782  42783  42785  42786  42788  42789  42791  42792  42802  42805  42806  42807  42808  42809  42810  42815  42818  42833  42836  42839  42848  42854  42857  42863  42866  42869  43021  43022  43506  43509  43512  43515  43518  43521  43524  43849  43858  43867  43930  43933  43939  43960  43981  43999  44102  44108  44111  44114  44130  44133  44325  44328  44331  44350  44354  44359  44361  44364  44367  44370  45000  45003  45009  45012  45015  45018  45019  45020  45024  45026  45035  45042  45045  45048  45051  45200  45203  45206  45207  45209  45218  45221  45227  45233  45236  45239  45240  45403  45406  45409  45412  45439  45442  45445  45448  45451  45462  45485  45486  45487  45488  45489  45493  45496  45497  45498  45512  45519  45522  45524  45527  45536  45542  45545  45548  45551  45552  45553  45554  45555  45556  45557  45560  45568  45569  45572  45575  45578  45581  45584  45585  45586  45590  45593  45602  45605  45608  45611  45614  45620  45623  45626  45629  45632  45635  45652  45653  45656  45659  45662  45665  45668  45669  45671  45675  45676  45677  45680  45683  45689  45692  45695  45698  45701  45704  45707  45710  45713  45714  45716  45755  45758  45761  45794  45803  45809  45811  45813  45815  45817  45819  45821  45825  45827  45831  45833  45835  45837  45839  45841  45843  45845  45849  45855  45857  45859  45865  45867  45875  45877  45879  45885  45888  45891  45939  45984  45987  45990  45993  46300  46303  46306  46307  46309  46312  46324  46325  46330  46333  46336  46339  46342  46345  46351  46354  46357  46360  46372  46375  46378  46381  46384  46387  46390  46396  46399  46402  46405  46408  46411  46414  46417  46423  46426  46429  46432  46435  46441  46442  46444  46447  46453  46462  46468  46471  46474  46480  46483  46489  46492  46500  46501  46502  46503  46510  46522  47012  47021  47027  47033  47048  47051  47054  47063  47066  47333  47345  47357  47366  47372  47375  47381  47384  47385  47386  47387  47390  47393  47399  47402  47408  47417  47420  47426  47429  47432  47435  47438  47441  47447  47450  47451  47453  47456  47459  47468  47480  47483  47495  47498  47513  47516  47522  47528  47537  47546  47549  47552  47555  47558  47561  47564  47565  47567  47570  47573  47582  47585  47597  47600  47603  47609  47612  47615  47618  47621  47624  47630  47648  47654  47657  47684  47696  47705  47711  47717  47720  47723  47732  47741  47753  47756  47765  47768  47771  47774  47777  47780  47783  47786  47789  47920  47930  47936  47954  47957  47966  47969  47975  47982  48200  48206  48209  48212  48215  48218  48221  48224  48227  48230  48233  48236  48239  48242  48400  48403  48406  48409  48412  48415  48418  48421  48424  48500  48503  48506  48615  48636  48642  48663  48666  48675  48678  48693  48900  48903  48906  48909  48912  48915  48927  48930  48936  48945  48948  49100  49103  49109  49112  49118  49121  49200  49203  49206  49209  49215  49218  49221  49224  49227  49300  49303  49309  49315  49336  49346  49360  49363  49366  49500  49503  49506  49509  49515  49534  49545  49557  49558  49559  49560  49561  49562  49563  49566  49569  49700  49703  49706  49709  49712  49718  49724  49727  49728  49812  49815  49818  49821  49824  49827  49830  49833  49837  49839  49845  49854  49857  49860  49863  49866  50100  50102  50103  50104  50106  50109  50112  50118  50121  50127  50130  50201  50203  50206  50209  50309  50312  50315  50318  50333  50339  50342  50345  50353  50357  50360  50363  50369  50375  50381  50387  50393  50396  50402  50405  50426  50500  50504  50508  50512  50516  50520  50524  50528  50532  50536  50540  50544  50548  50552  50556  50560  50564  50568  50572  50576  50580  50584  50588  50600  50616  50650  50654  50950  50952  51900  51904  51906  52018  52035  52039  52048  52051  52054  52059  52063  52066  52078  52090  52092  52094  52095  52105  52108  52111  52114  52117  52120  52122  52130  52131  52138  52141  52144  52147  52148  52182  52184  52186  52300  52303  52306  52312  52315  52321  52324  52330  52333  52336  52339  52378  52424  52440  52442  52444  52450  52452  52456  52458  52460  52480  52482  52484  52600  52603  52609  52612  52615  52618  52621  52624  52626  52627  52633  52800  52803  52806  52809  52812  52815  52818  52824  52828  52830  52832  53006  53009  53015  53016  53017  53019  53215  53218  53220  53225  53226  53236  53239  53242  53406  53409  53412  53413  53414  53415  53416  53418  53419  53422  53423  53424  53425  53427  53429  53453  53455  53460  55135  57351  57356

7.               Psychiatric patient

In this Schedule, a psychiatric patient is a patient in a hospital who is admitted for the purposes of undertaking a specific psychiatric treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient’s disease, injury or condition.

Note:         If a patient is receiving psychiatric treatment that is not under a specific psychiatric treatment program, the patient is taken to be in the category of 'other patient'.

8.               Rehabilitation patient

In this Schedule, a rehabilitation patient is a patient in a hospital who is admitted for the purposes of undertaking a specific rehabilitation treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient’s disease, injury or condition.

Note:         If a patient is receiving rehabilitation treatment that is not under a specific rehabilitation treatment program, the patient is taken to be in the category of 'other patient'.

9.               Other patient

(1)        In this Schedule, other patient is deemed to be a patient at a hospital who is receiving any treatment that involves part of an overnight stay, but who is not:

(a)                    an advanced surgical patient;

(b)                   a surgical patient;

(c)                    an obstetric patient;

(d)                   a psychiatric patient; or

(e)                    a rehabilitation patient.

Note:         A patient receiving hospital treatment that is palliative care as described in item 1 of the table in subsection 72-1 (2) of the Act is deemed to be in the category of 'other patient'.

Part 3      Certified Type B procedures and certified overnight Type C procedures

10.            Certified Type B procedures

(1)        Minimum benefits for overnight accommodation are payable for patients receiving a Type B procedure only if certification under subclause (2) is provided.

(2)        Certification must be provided as follows:

(a)                    the practitioner providing the Type B procedure; or

(b)                   a professional employed by a hospital who is involved in the provision of the procedure provided by that hospital,

must certify in writing that:

(c)                    because of the medical condition of the patient specified in the certificate; or

(d)                   because of the special circumstances specified in the certificate,

it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay.

11.            Certified overnight Type C procedures

(1)        Minimum benefits for overnight accommodation are payable for patients receiving a certified Type C procedure only if:

(a)                    certification has first been provided for the Type C procedure in accordance with clause 7 of Schedule 3; and

(b)                   certification under subclause (2) is also provided.

(2)        Certification must be provided as follows the practitioner providing the certified Type C procedure must certify in writing that:

(a)                    because of the medical condition of the patient specified in the certificate; or

(b)                   because of the special circumstances specified in the certificate,

it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay.

Schedule 2―Overnight accommodation:  shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia

1.               Circumstances

For rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided:

(a)                    to a patient who is not a nursing-home type patient; and

(b)                   as shared ward accommodation at a public hospital in the ACT, NSW, Northern Territory, Queensland, South Australia or Western Australia; and

Note:         The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital.  This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

(c)                    for the purpose of permitting the provision to the patient of hospital treatment that is:

(i)                      a Type A procedure; and

(ii)                    for a period that includes part of an overnight stay.

Note:         A Type A procedure is defined to include a certified Type B procedure and a certified overnight Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.

2.               Minimum benefit

The minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in the table in this Schedule for that hospital treatment.

Table

Schedule 3―Same-day accommodation:  hospitals in all States/Territories

Part 1―General

1.               Circumstances

For rules 4 and 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided for the purpose of permitting the provision to the patient of hospital treatment that:

(a)                    is a Type B procedure; and

(b)                   is provided to a patient at a hospital; and

(c)                    does not include part of an overnight stay at a hospital.

Note 1:     A Type B procedure includes a certified Type C procedure―see the definitions of those terms in rule 3 of Part 1 of these Rules.

Note 2:     The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital.  This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

2.               Minimum benefit

(1)        The minimum benefit for hospital treatment provided in the circumstances specified in this Schedule is the amount set out in Table 1 or 2 in this clause for that hospital treatment.

(2)        The references to Bands in the tables are references as follows:

(a)                    Band 1 means Band 1 treatment;

(b)                   Band 2 means Band 2 treatment;

(c)                    Band 3 means Band 3 treatment;

(d)                   Band 4 means Band 4 treatment,

as those bands are described in Part 2 of this Schedule.

Table 1

Table 2

Part 2―Type B procedures

3.               Interpretation

A Type B procedure is a procedure specified as a Band 1, 2, 3 and 4 as described in this Part.

Note:         These procedures normally require hospital treatment that does not include part of an overnight stay.

4.               Band 1

(1)        Hospital treatment that involves a professional service of the type identified by the MBS item number specified in this subclause is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule:

(a)                    category 3―therapeutic procedures, being the items below in the general medical services table:

T1:  Miscellaneous Therapeutic Procedures:

13100  13103  13703  13706  13915  13918  13921  13927  13930

T8:  Surgical Operations:

30210  30473  30475  30476  30478  30679  32075  32078  32081  32084  32087  32090  32095  35500  35539  35545  35703  37011  39000  39100  41604  41647  41674  41680  42575  42741  45027  50658; and

(b)                   category 5―diagnostic imaging services, being the items below in the diagnostic imaging services table:

I1:   Ultrasound:

55118  55600  55603; and

(2)        Other hospital treatment requiring day admission to a hospital that is not Band 2, 3 or 4 treatment is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule.

5.               Non-band specific Type B day procedures

(1)        Hospital treatment that involves a professional service of the type identified by the MBS item number specified in this clause is a non-band specific Type B day procedure.

13110  13212  13215  13292  13750  13755  13757  13948  14218  15338  15513  15539  16512  16603  16618  18216  18230  18242  18274  18276  18280  18284  18286  18290  18294  18296  18298  30041  30042  30045  30055  30081  30084  30087  30094  30096  30099  30102  30103  30104  30106  30107  30187  30189  30190  30223  30225  30262  30269  30281  30282  30283  30390  30391  30409  30484  30493  30653  30656  30659  30660  31225  31230  31235  31240  31255  31256  31257  31258  31260  31261  31262  31263  31265  31266  31267  31268  31270  31271  31272  31273  31275  31276  31277  31278  31280  31281  31282  31283  31285  31286  31287  31288  31290  31291  31292  31293  31295  31300  31305  31310  31315  31320  31325  31330  31335  31340  31345  31346  31350  31355  31441  31456  31458  31530  31551  31557  31560  31563  31566  32093  32094  32145  32147  32150  32153  32156  32168  32171  32177  32180  32504  34109  34130  34500  34503  34506  34524  34539  35324  35507  35508  35509  35512  35513  35516  35517  35520  35523  35526  35527  35542  35557  35569  35572  35611  35615  35616  35617  35618  35622  35623  35626  35627  35630  35633  35637  35639  35640  35643  35644  35645  35646  35647  35648  35687  35688  36650  36812  36815  36818  36821  36824  36827  36830  36833  36836  36860  37219  37315  37318  37321  37354  37369  37435  37622  37623  37803  37806  37809  37812  37815  37854  38285  38286  39013  39118  39133  39135  39140  39331  41503  41506  41509  41626  41629  41632  41644  41650  41653  41665  41668  41677  41695  41701  41716  41761  41764  41800  41801  41816  41819  41822  41825  41831  41849  41852  41855  41858  41861  41864  41886  41889  41892  41898  42503  42572  42573  42584  42593  42610  42611  42673  42680  42683  42686  42689  42692  42812  42818  42833  42845  42869  43942  43948  44102  44105  44136  44338  45019  45020  45030  45033  45039  45200  45224  45239  45506  45515  45626  45665  45668  45823  46327  46330  46336  46363  46366  46369  46396  46420  46423  46438  46441  46450  46486  46489  46494  46495  46501  46510  46525  47738  47906  47915  47918  47927  47972  48600  48603  48945  49218  49557  49700  49800  49803  49806  49809  50100  50115  51902  52015  52025  52042  52045  52057  52058  52061  52062  52064  52072  52073  52075  52081  52084  52087  52097  52099  52102  52144  52180  52300  52303  52321  52826  53003  53006  53009  53054  53056  53058  53060  53062  53064  53070  53206  53215  53218  53225  53410  53459  58939  59903  59912  59925  59970  59971  59972  59973  59974  60000  60003  60006  60009  60012  60015  60018  60021  60024  60027  60030  60033  60036  60039  60042  60045  60048  60051  60054  60057  60060  60063  60066  60069  60072  60075  60078 

(2)        A non-band specific Type B day procedure is Band 2, 3 or 4 treatment depending on anaesthetic type and, where applicable, theatre time as specified in clause 6 of this Schedule.

(3)        If a non-band specific Type B day procedure does not involve anaesthetic or theatre times, the minimum benefit is the benefit for Band 1 treatment.

6.               Other bands

In this Schedule:

Band 2 treatment means procedures, other than those that are Band 1 treatment, carried out under local anaesthetic with no sedation.

Band 3 treatment means procedures, other than those that are Band 1 treatment, carried out under:

(a)                    general anaesthesia; or

(b)                   regional anaesthesia; or

(c)                    intravenous sedation,

where the theatre time, being the actual time in theatre, is less than one hour.

Band 4 treatment means procedures, other than those that are Band 1 treatment, carried out under:

(a)                    general anaesthesia; or

(b)                   regional anaesthesia; or

(c)                    intravenous sedation,

where the theatre time, being the actual time in theatre, is one hour or more.

7.               Certified Type C procedure

Note:   Type C procedures are procedures that do not normally require hospital treatment.

(1)        Benefits for day-only accommodation are payable for patients receiving a Type C procedure only if certification under subclause (2) is provided.

(2)        Certification must be provided as follows, the medical practitioner providing the professional service must certify in writing that:

(a)                    because of the medical condition of the patient specified in the certificate; or

(b)                   because of the special circumstances specified in the certificate,

it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that does not include part of an overnight stay.

Part 3―Type C procedures

8.               Interpretation

A Type C procedure is a procedure specified in this clause by reference to MBS items.

Note:         These procedures normally do not require hospital treatment.

Items in the general medical services table

The following items are items in the general medical services table.

Category 1 – Attendances

A1:

3  4  20  23  24  35  36  37  43  44  47  51

A2:

52  53  54  57  58  59  60  65  92  93  95  96

A3:

104  105  106  107  108  109

A4:

110    116  119  122  128  131  132  133

A28:

141  143  145  147

A5:

160  161  162  163  164

A6:

170  171  172

A7:

173  193  195  197  199

A8:

289  291  293  296  297  299  300  302  304  306  308  310  312  314  316  318  319  320  322  324  326  328  330  332  334  336  338  342  344  346  348  350  352  353  355  356  357  358  359  361  364  366  367  369  370

A9:

10801  10802  10803  10804  10805  10806  10807  10808  10809  10816

A12:

385  386  387  388

A13:

410  411  412  413  414  415  416  417

A15:

721  723  729  731  732  820  822  823  825  826  828  855  857  858

A17:

900  903

A18:

2497  2501  2503  2504  2506  2507  2509  2517  2518  2521  2522  2525  2526  2546  2547  2552  2553  2558  2559 

A19:

2598  2600  2603  2606  2610  2613  2616  2620  2622  2624  2630  2631  2633  2635  2664  2666  2668  2673  2675  2677 

A20:

2713  2721  2723  2725  2727

A21:

501  503  507  511  515  519  520  530  532  534  536

A22:

5000  5003  5010  5020  5023  5028  5040  5043  5049  5060  5063  5067

A23:

5200  5203  5207  5208  5220  5223  5227  5228  5260  5263  5265  5267

A24:

2801  2806  2814  2824  2832  2840  2946  2949  2954  2958  2972  2974  3005  3010  3014  3018  3023  3028  3032  3040  3044  3051  3055  3062

A25:

5906  5908  5910  5912

A26:

6007  6009  6011  6013  6015

A27:

4001

M3:

10950  10951  10952  10953  10954  10956  10958  10960  10962  10964  10966  10968  10970 

M5:

10988  10989

M2:

10993  10994  10995  10996  10998  10999

Category 2 – Diagnostic procedures & investigations

D1:

11000  11003  11006  11009  11012  11015  11018  11024  11027  11200  11203  11204  11205  11210  11211  11212  11215  11218  11221  11222  11224  11225  11235  11237  11240  11241  11242  11243  11300  11306  11309  11312  11315  11318  11321  11324  11327  11332  11333  11336  11339  11500  11503  11506  11509  11512  11602  11604  11605  11610  11611  11612  11614  11615  11700  11701  11702  11708  11709  11710  11711  11712  11713  11715  11718  11721  11722  11724  11727  11800  11810  11820  11823  11830  11833  11900  11903  11906  11909  11912  11915  11917  11919  11921  12000  12003  12012  12015  12018  12021  12200  12201  12306  12309  12312  12315  12318  12321  12323

D2:

12500  12503  12506  12509  12512  12515  12518  12521  12524  12527  12530  12533

Category 3 – Therapeutic procedures

T1:

13104  13200  13203  13206  13209  13221  13290  13312  13709  13760  13839  13842  13939  13942  13945  14050  14053  14100  14106  14109  14112  14115  14118  14124  14200  14201  14202  14203  14206  14209  14215  14221  14227  14245 

T2:

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  15500  15503  15506  15509  15512  15515  15518  15521  15524  15527  15530  15533  15550  15553  15556  15559  15562

15700  15705  15710  15800  15850

T3:

16003  16006  16009  16012  16015  16018

T4:

16400  16500  16501  16502  16504  16505  16508  16509  16511  16514  16600

T6:

17610  17615  17620  17625  17640  17645  17650  17655  17680  17690

T7:

18213

T8:

30003  30006  30026  30032  30038  30061  30062  30064  30071  30097  30185  30186  30192  30195  30196  30202  30203  30205  30207  30213  30214  30216  30219  30628  31200  31205  31210  31215  31220  32072  32115  32132  32135  32142  32500  32501  32520  32522  35502  35503  35554  35608  35614  35620  36663  36664  36665  36666  36667  36668  36800  37041  37217  37218  37300  37303  37415  38800  39115  40862  41500  41659  41662  41698  41704  41755  41828  41846  42587  42614  42615  42617  42620  42644  42650  42667  42668  42676  42677  42744  42782  42783  42785  42786  42788  42789  42791  42792  42794  42797  42806  42807  42808  42809  42811  45021  45025  45026  45546  45799  45801  45805  45807  45829  45847  45851  45882  47471  47735  47904  47912  47916  47924

T11:

18350  18351  18352  18354  18356  18358  18360  18361  18362  18364  18366  18368  18370 18371  18372  18373

Category 4 – Oral and maxillofacial

O1:

51700  51703

O3:

52034  52036  52039  52055  52056  52133

O7:

53000  53004  53052

O9:

53458

O10:

53600

Items in the diagnostic imaging services table

The following items are items in the diagnostic imaging services table.

Category 5 – Diagnostic Imaging Services

I1:

55028  55029  55030  55031  55032  55033  55036  55037  55038  55039  55044  55045  55048  55049  55054  55070  55073  55076  55079, 55113  55114  55115  55116  55117  55238  55244  55246  55248  55252  55274  55276  55278  55280  55282  55284  55292  55294  55296  55700  55703  55704  55705  55706  55707  55708  55709  55712  55715  55718  55721  55723  55725  55729  55731  55733  55736  55739  55812  55814  55816  55818  55820  55822  55824  55826  55828  55830  55832  55834  55836  55838  55840  55842  55844  55846  55852  55854

I2:

56001  56007  56010  56013  56016  56022  56028  56030  56036  56041  56047  56050  56053  56056  56062  56068  56070  56076  56101  56107  56141  56147  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  56501  56507  56541  56547  56552  56554  56619  56625  56659  56665  56801  56807  56841  56847  57001  57007  57041  57047  57201  57247  57341  57345  57350  57355

I3:

57506  57509  57512  57515  57518  57521  57524  57527  57700  57703  57706  57709  57712  57715  57721  57901  57902  57903  57906  57909  57912  57915  57918  57921  57924  57927  57930  57933  57939  57942  57945  57960, 57963  57966  57969  58100  58103  58106  58108  58109  58112  58115  58300  58306  58500  58503  58506  58509  58521  58524  58527  58700  58706  58715  58718  58721  58900  58903  58909  58912  58915  58916  58921  58924  58927  58933  58936  59103  59300  59303  59306  59309  59312  59314  59318  59503  59700  59703  59712  59715  59718  59724  59733  59736  59739  59751  59754  59760  59763  60100  60500  60503  60918  60927

I4:

61302  61303  61306  61307  61310  61313  61314  61316  61317  61320  61328  61340  61348  61352  61353  61356  61360  61361  61364  61368  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  61462  61465  61469  61473  61480  61484  61485  61495  61499  61505  61541  61544  61553 61556  61565  61568

I5:

63001  63004  63007  63010  63040  63043  63046  63049  63052  63055  63058  63061  63064  63067  63070  63073  63101  63111  63114  63125  63128  63131  63151  63154  63161  63164  63167  63170  63173  63176  63179  63182  63185  63201  63204  63219  63222  63225  63228  63231  63234  63237  63240  63243  63271  63274  63277  63280  63301  63304  63307  63322  63325  63328  63331  63334  63337  63340  63361  63385  63388  63391  63401  63404  63416  63425  63428  63440  63443  63446  63461  63464            63467   63470  63473  63476  63491  63494  63497

Category 6 – Pathology services

The following items are items in the pathology services table.

P1:    

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 

P2:

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  66599  66602  66605  66606  66607  66608  66609  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  66900

P3:    

69300  69303  69306  69309  69312  69316  69317  69318  69319  69321  69324  69325  69327  69328  69330  69331  69333  69336  69339  69345  69354  69357  69360  69363  69379  69383  69384  69387  69390  69393  69396  69400  69401  69405  69408  69411  69413  69415  69418  69419  69445  69451  69471  69472  69474  69475  69478  69481  69482  69483  69484  69488  69489  69491  69492  69494  69495  69496  69497  69498  69499  69500 

P4:

71057  71058  71059  71060  71062  71064  71066  71068  71069  71071  71072  71073  71074  71075  71076  71077  71079  71081  71083  71085  71087  71089  71090  71091  71092  71093  71095  71096  71097  71099  71101  71103  71106  71119  71121  71123  71125  71127  71129  71131  71133  71134  71135  71137  71139  71141  71143  71145  71146  71147  71148  71149  71151  71153  71154  71155  71156  71157  71159  71163  71164  71165  71166  71167  71168  71169  71170  71180  71183  71186  71189  71192  71195  71198  71200  71203

P5:

72813  72816  72817  72818  72823  72824   72825  72826   72827  72828   72830  72836  72838  72844  72846  72847   72848  72849   72850  72851   72852  72855  72856  72857

P6:

73043  73045  73047  73049  73051  73053  73055  73057  73059  73060  73061  73062  73063  73064  73065

P7:

73287  73290  73291  73292  73293  73294  73289  73300  73305  73308  73309  73311  73312  73314  73315  73317  73318  73320  73321  73323  73324

P8:

73521  73523  73525  73527  73529

P9:

73801  73802  73803  73804  73805  73806  73807  73808  73809  73810  73811

P10:

73920  73922  73923  73924  73925  73926  73927  73928  73929 

73930  73931  73932  73933  73934  73935  73936  73937  73938 

73939 

P11:

73940

P13:

74992  74993  74994  74995  74996  74997  74998  74999 

Category 8 – Miscellaneous Services

The following items are items in the miscellaneous services table.

M13:

82100  82105  82110  82115  82130  82135  82140

Schedule 4―Nursing-home type patient accommodation:  hospitals in all States/Territories

1.               Circumstances

(1)        For rule 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided:

(a)                    to a nursing-home type patient; and

(b)                   at a hospital.

Note:         The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital.  This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

2.               Interpretation

Nursing-home type patient, in relation to a hospital, means a patient who has been provided with hospital treatment whether:

(a)                    acute care; or

(b)                    accommodation and nursing care, as an end in itself; or

(c)                    a mixture of both,

for a continuous period of hospitalisation exceeding 35 days (35-day period), but a patient receiving acute care immediately after the 35-day period does not become a nursing-home type patient unless the period of acute care ends and the patient is then provided with accommodation and nursing care, as an end in itself, as part of a continuous period of hospitalisation.

Note 1:     'Continuous period of hospitalisation' is defined in rule 3 of Part 1 of these Rules.

Note 2:     Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.

Note 3:     If there is disagreement as to whether a patient is, or is not, a nursing‑home type patient, an insured person, a private health insurer or a health care provider may make a complaint to the Private Health Insurance Ombudsman under Part 6-2 of the Act.  The Ombudsman has various powers to deal with complaints, including conducting mediation if the complainant agrees.

3.               Application

(1)        Clause 2 of this Schedule applies to a patient who on or after the day on which the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) commence:

(a)                    returns to hospital for hospital treatment at a hospital not later than 7 days after receiving hospital treatment at that hospital or another hospital; or

(b)                   is otherwise admitted to a hospital for hospital treatment at the hospital.

(2)        If subclause (1) does not apply to a patient, the definition of 'nursing‑home type patient' in these Rules before the commencement of the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) continues to apply to that patient.

Note:         Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care.

4.               Provision of acute care

If a nursing-home type patient is provided with acute care at the hospital (the first hospital), or at another hospital, the patient:

(a)                    ceases to be a nursing‑home type patient only for the days on which the acute care is provided; and

(b)                   again becomes a nursing‑home type patient when the provision of acute care ends and the patient is then provided with accommodation and nursing care as an end in itself, whether at the first hospital or another hospital.

5.               Ceasing and resuming hospital treatment

If a nursing-home type patient, or a person referred to in paragraph 4 (a), leaves hospital but returns to a hospital, whether or not at the same hospital, not more than 7 days later and is provided with hospital treatment at the hospital, the patient is a nursing‑home type patient for each subsequent day that the patient is provided with accommodation and nursing care, as an end in itself, until the patient ceases to be provided with hospital treatment at a hospital for a period of more than 7 days.

Note:       If the relevant period of hospitalisation is broken by more than 7 days, clause 2 of this Schedule may again apply to the person.

6.               Minimum benefit

The minimum benefit for hospital treatment provided in the circumstances described in this Schedule is the amount set out in Table 1 or 2 of this Schedule for that hospital treatment.

Table 1

Table 2

Schedule 5―Second-tier default benefits

1.               Interpretation

(1)        In this Schedule:

facility means a private hospital specified in clause 4 of this Schedule.

(2)        In this Schedule, except in subclause (4) of this clause, the ACT is taken to be part of NSW and the Northern Territory is taken to be part of the State of South Australia.

(3)        In this Schedule, private hospitals are comparable if they fall within the same category from the following list:

(a)                    private hospitals which provide psychiatric care for at least 50% of the episodes of hospital treatment;

(b)                   private hospitals which provide rehabilitation care for at least 50% of the episodes of hospital treatment;

(c)                    private hospitals which do not fall into categories (a) or (b), with up to and including 50 licensed beds;

(d)                   private hospitals which do not fall into categories (a) or (b) with more than 50 licensed beds and up to and including 100 licensed beds;

(e)                    private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit;

(f)                    private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, with either (or both) an accident and emergency unit or a specialised cardiac care unit;

(g)                   private hospitals which only provide hospital treatment which does not include any part of an overnight stay.

(4)        In subclause (3), 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.

2.               Circumstances

For rules 4 and 5 of Part 2 of these Rules, the circumstances for hospital treatment to which this Schedule applies are that the treatment is provided to a patient who is not a nursing-home type patient and the treatment is  provided at a facility.

Note:         The definition of hospital treatment in section 121-5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital.  This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121-5 (1) (c) of the Act.

3.               Minimum benefit

(1)        Despite anything in Schedules 1, 2 or 3, but subject to subclause (2) of this clause, the minimum benefit for hospital treatment provided in the circumstances described in clause 2 of this Schedule is the amount worked out in accordance with this clause.

(2)        Where hospital treatment is provided in the circumstances described in clause 2 of this Schedule, but:

(a)        the minimum benefit worked out in accordance with this clause for the hospital treatment is below the amount determined in accordance with Schedules 1, 2 or 3 of these Rules; or

(b)        an amount for the hospital treatment cannot be worked out in accordance with this clause,

the minimum benefit for that hospital treatment is the amount worked out in accordance with Schedules 1, 2 or 3 for that hospital treatment.

(3)        If a hospital ceases to be a facility 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 facility or booked for hospital treatment at the facility (as opposed to merely being on the facility’s waiting list) before the day that the hospital ceased to be a facility is the minimum benefit that would have applied if the hospital continued to be a facility at the time the treatment was provided.

(4)        Subject to subclauses (2) and (8) the minimum benefit payable by an insurer for an episode of hospital treatment 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 in force on 1 August of the first year with all such comparable private hospitals in the State in which the facility is located.

(5)        The formula for calculating the average charge for the equivalent episode of hospital treatment by an insurer in each State is as follows:

Where:   j =     group of equivalent episodes of hospital treatment under the insurer's negotiated agreements;

i =     group of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;

n=     the number of the insurer's negotiated agreements in force on 1 August of the first year with comparable private hospitals in the State;

R_ji =  charge for episode of hospital treatment type j in the negotiated agreement i

R_j =   average charge for episode of hospital treatment type j.

(6)        In subclause (4), each episode of hospital treatment must be identified using the patient classification system and payment structure in the majority of the relevant insurer's negotiated agreements in force on 1 August of the first year with all comparable private hospitals in the State in which the facility is located.

(7)        In subclause (4), for the purpose of calculating the average charge for the equivalent episode of hospital treatment in a State:

(a)                    the charge will include the sum of the amount payable by the insurer under that insurer's negotiated agreement and any excess or co‑payment amounts payable by members, in accordance with the insurer's rules; and

Note:        Policy holders’ financial obligations under such levels of cover will still apply.

(b)                   must not include any charges:

(i)                      referred to in the insurer's negotiated agreements for prostheses; and

(ii)                    that are minimum benefits for prostheses as specified for the purpose of item 4 of the table in subsection 72-1 (2) of the Act, and

(iii)                  referred to in the insurer's negotiated agreements for hospital treatment provided to nursing-home type patients.

(8)        Subject to subclause (2), if an insurer has less than 5 negotiated agreements in force on 1 August of the first year with a particular category of comparable private hospitals in a State, then all of that insurer's negotiated agreements with all classes of private hospitals in that State are to be used to calculate the minimum benefit.

4.               Facilities

The hospitals specified in the table below are facilities for the purpose of this Schedule.

Table