Private Health Insurance (Benefit Requirements) Rules 2011

law://au/li/2011/f2011l02160@2026-11-12

Contents

Private Health Insurance (Benefit Requirements) Rules 2011made under item 3A of the table in section 333-20 of thePrivate Health Insurance Act 2007Compilation No. 109Compilation date: 1 November 2026Includes amendments: F2026L01398About this compilationThis compilationThis is a compilation of the Private Health Insurance (Benefit Requirements) Rules 2011 that shows the text of the law as amended and in force on 1 November 2026 (the compilation date).The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.Uncommenced amendmentsThe effect of uncommenced amendments is not shown in the text of the compiled law. The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. Any uncommenced amendments affecting the law are accessible on the Register (www.legislation.gov.au).Application, saving and transitional provisionsIf the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.Editorial changesFor more information about any editorial changes made in this compilation, see the endnotes.Presentational changesThe Legislation Act 2003 provides for First Parliamentary Counsel to make presentational changes to a compilation. Presentational changes are applied to give a more consistent look and feel to legislation published on the Register, and enable the user to more easily navigate those documents.ModificationsIf the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. Any modifications affecting the law are accessible on the Register.Self-repealing provisionsIf a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.ContentsPart 1 Preliminary1. Name of Rules3. DefinitionsPart 2 Minimum benefit requirements4. Psychiatric care, rehabilitation and palliative care5. Other hospital treatments6. Benefit not to exceed hospital fees or chargesSchedule 1―Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and TasmaniaPart 1 General1. Circumstances2. Minimum benefitPart 2 Type A procedures3. Interpretation4. Advanced surgical patient5. Obstetric patient6. Surgical patient7. Psychiatric patient8. Rehabilitation patient9. Other patientPart 3 Certified Type B procedures and certified overnight Type C procedures10. Certified Type B procedures11. Certified overnight Type C proceduresSchedule 2 - Overnight shared ward accommodation for private patients at public hospitals in the Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia and Western Australia1. Circumstances2. Minimum benefitSchedule 3―Same-day accommodation: hospitals in all States/TerritoriesPart 1 General1. Circumstances2. Minimum benefitPart 2 Type B procedures3. Interpretation4. Band 15. Non-band specific Type B day procedures6. Other bands7. Certified Type C procedurePart 3 Type C procedures8. InterpretationSchedule 4―Nursing-home type patient accommodation: hospitals in all States/Territories1. Circumstances2. Interpretation3. Application4. Provision of acute care5. Ceasing and resuming hospital treatment6. Minimum benefitSchedule 5―Second-tier default benefits1. Interpretation1A. Categorisation of private hospitals1B. Internal review of a categorisation determination2. Circumstances3. Minimum benefit4. TransitionalEndnotesEndnote 1—About the endnotesEndnote 2—Abbreviation keyEndnote 3—Legislation historyEndnote 4—Amendment history

Part 1 Preliminary #

1. Name of Rules #

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

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; andNote: 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-Overnight accommodation for private patients at private hospitals in all States/TerritoriesColumn 1 | Column 2Class of patient | Minimum benefit payable per nightAdvanced surgical patient- first 14 days | $565- over 14 days | $393Surgical patient or obstetric patient- first 14 days | $524- over 14 days | $393Psychiatric patient- first 42 days | $524- 43 – 65 days | $455- over 65 days | $393Rehabilitation patient- first 49 days | $524- 50 - 65 days | $455- over 65 days | $393Other patients- first 14 days | $455- over 14 days | $393Table 2-Victoria-overnight shared ward accommodation for private patients at public hospitalsColumn 1 | Column 2Class of patient | Minimum benefit payable per nightAdvanced surgical patient- first 14 days | $565- over 14 days | $393Surgical patient or obstetric patient- first 14 days | $524- over 14 days | $393Psychiatric patient- first 42 days | $524- 43 – 65 days | $455- over 65 days | $393Rehabilitation patient- first 49 days | $524- 50 - 65 days | $455- over 65 days | $393Other patients- first 14 days | $455- over 14 days | $393Table 3-Tasmania-overnight shared ward accommodation for private patients at public hospitalsColumn 1 | Column 2Class of patient | Minimum benefit payable per nightAdvanced surgical patient- first 14 days | $565- over 14 days | $393Surgical patient or obstetric patient- first 14 days | $524- over 14 days | $393Psychiatric patient- first 42 days | $524- 43 – 65 days | $455- over 65 days | $393Rehabilitation patient- first 49 days | $524- 50 - 65 days | $455- over 65 days | $393Other patients- first 14 days | $455- over 14 days | $393

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 (1)(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 MBS item numbers for this clause are those set out in the following table, but only where those items have a fee in the MBS greater than $1020.84:Type A procedures: Advanced surgical patient – list of MBS items30175, 30176, 30177, 30179, 30250, 30251, 30255, 30275, 30294, 30296, 30297, 30315, 30317, 30318, 30320, 30323, 30324, 30336, 30382, 30384, 30388, 30396, 30415, 30417, 30418, 30421, 30425, 30427, 30428, 30430, 30448, 30449, 30454, 30455, 30457, 30458, 30460, 30461, 30463, 30464, 30469, 30472, 30517, 30518, 30521, 30526, 30529, 30532, 30533, 30560, 30565, 30577, 30583, 30584, 30589, 30590, 30593, 30594, 30596, 30599, 30601, 30606, 30608, 30619, 30640, 30655, 30657, 30680, 30682, 30684, 30686, 30725, 30730, 30732, 30750, 30751, 30752, 30753, 30754, 30755, 30756, 30762, 30771, 30780, 30792, 30810, 31002, 31005, 31409, 31412, 31429, 31432, 31435, 31438, 31466, 31468, 31472, 31514, 31516, 31520, 31522, 31523, 31526, 31528, 31529, 31572, 31581, 31584, 32000, 32003, 32004, 32005, 32006, 32009, 32012, 32015, 32018, 32024, 32025, 32026, 32028, 32030, 32033, 32036, 32039, 32042, 32047, 32051, 32054, 32060, 32063, 32069, 32106, 32108, 32117, 32118, 32221, 32232, 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, 35414, 35548, 35551, 35552, 35561, 35562, 35585, 35591, 35592, 35596, 35597, 35632, 35641, 35661, 35667, 35668, 35669, 35671, 35717, 35720, 35721, 35723, 35724, 35753, 35754, 35756, 36503, 36506, 36516, 36519, 36522, 36525, 36528, 36529, 36531, 36532, 36533, 36543, 36564, 36567, 36570, 36573, 36576, 36588, 36591, 36594, 36597, 36600, 36603, 36606, 36610, 36611, 36645, 36656, 37014, 37015, 37016, 37018, 37019, 37021, 37029, 37040, 37042, 37045, 37047, 37048, 37053, 37200, 37203, 37207, 37209, 37210, 37211, 37213, 37214, 37220, 37245, 37309, 37338, 37340, 37341, 37343, 37344, 37372, 37375, 37384, 37390, 37405, 37411, 37423, 37426, 37432, 37607, 37610, 37822, 37824, 37825, 37831, 37842, 37848, 37851, 38212, 38244, 38247, 38248, 38249, 38251, 38252, 38270, 38272, 38273, 38276, 38287, 38290, 38293, 38307, 38308, 38309, 38310, 38311, 38313, 38314, 38316, 38317, 38319, 38320, 38322, 38323, 38358, 38368, 38375, 38429, 38431, 38461, 38463, 38467, 38471, 38474, 38477, 38484, 38487, 38493, 38495, 38499, 38502, 38508, 38509, 38512, 38514, 38515, 38516, 38517, 38518, 38522, 38550, 38553, 38554, 38555, 38556, 38557, 38558, 38568, 38571, 38600, 38615, 38616, 38618, 38620, 38624, 38653, 38670, 38673, 38677, 38680, 38700, 38703, 38706, 38709, 38715, 38718, 38721, 38724, 38727, 38730, 38733, 38736, 38739, 38742, 38745, 38748, 38751, 38754, 38757, 38760, 38764, 38766, 38816, 38817, 38818, 38820, 38821, 38822, 38823, 38824, 38831, 38832, 38833, 38834, 38838, 38840, 38841, 38842, 38846, 38848, 38852, 38853, 38857, 38858, 38859, 38864, 39109, 39113, 39124, 39139, 39315, 39503, 39604, 39610, 39612, 39615, 39638, 39639, 39641, 39651, 39654, 39656, 39700, 39703, 39710, 39712, 39715, 39718, 39720, 39801, 39803, 39815, 39818, 39821, 39900, 39903, 40004, 40012, 40104, 40106, 40109, 40112, 40119, 40600, 40700, 40703, 40706, 40709, 40712, 40801, 40803, 40804, 40805, 40806, 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, 41618, 41623, 41635, 41638, 41703, 41705, 41728, 41734, 41785, 41834, 41837, 41840, 41843, 41879, 41887, 41888, 41890, 42521, 42539, 42543, 42545, 42557, 42569, 42626, 42653, 42656, 42662, 42672, 42705, 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, 43838, 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, 45060, 45061, 45062, 45070, 45071, 45500, 45501, 45502, 45503, 45504, 45505, 45507, 45520, 45523, 45527, 45528, 45529, 45530, 45531, 45535, 45538, 45539, 45540, 45541, 45558, 45561, 45562, 45563, 45564, 45565, 45566, 45567, 45571, 45587, 45588, 45596, 45597, 45599, 45624, 45641, 45644, 45646, 45660, 45661, 45686, 45717, 45718, 45767, 45773, 45776, 45779, 45782, 45785, 45788, 45791, 45871, 45873, 45874, 46060, 46062, 46064, 46066, 46068, 46070, 46072, 46080, 46082, 46084, 46086, 46088, 46090, 46104, 46105, 46106, 46107, 46108, 46109, 46110, 46111, 46112, 46116, 46117, 46118, 46119, 46120, 46121, 46122, 46123, 46124, 46128, 46129, 46133, 46134, 46135, 46136, 46150, 46151, 46152, 46153, 46154, 46155, 46156, 46157, 46158, 46159, 46160, 46161, 46170, 46171, 46172, 46173, 46174, 46175, 46176, 46177, 46178, 46179, 46180, 46181, 46182, 46183, 46184, 46185, 46315, 46318, 46321, 46324, 46325, 46380, 46393, 46394, 46395, 46477, 46504, 46507, 47486, 47489, 47491, 47501, 47511, 47519, 47531, 47534, 47558, 47566, 47588, 47591, 47956, 47983, 47984, 48254, 48421, 48422, 48426, 48427, 48433, 48446, 48448, 48450, 48452, 48512, 48918, 48919, 48921, 48924, 48939, 48942, 48951, 48954, 48958, 48959, 48960, 49106, 49115, 49116, 49117, 49210, 49230, 49306, 49318, 49319, 49321, 49372, 49374, 49376, 49378, 49380, 49382, 49384, 49386, 49388, 49390, 49392, 49394, 49396, 49398, 49512, 49516, 49517, 49518, 49519, 49521, 49524, 49525, 49527, 49530, 49533, 49536, 49542, 49544, 49548, 49551, 49554, 49564, 49565, 49592, 49594, 49712, 49715, 49716, 49717, 49740, 49742, 49744, 49763, 49764, 49765, 49766, 49767, 49768, 49769, 49770, 49776, 49778, 49779, 49780, 49781, 49784, 49785, 49786, 49787, 49788, 49789, 49790, 49797, 49798, 49814, 49815, 49836, 49838, 50212, 50215, 50218, 50221, 50224, 50233, 50236, 50239, 50245, 50300, 50303, 50306, 50321, 50324, 50336, 50351, 50354, 50372, 50378, 50384, 50394, 50395, 50399, 50411, 50414, 50417, 50420, 50423, 50450, 50451, 50455, 50456, 50460, 50461, 50465, 50466, 50470, 50471, 50475, 50476, 50592, 50604, 50608, 50612, 50620, 50624, 50628, 50632, 50636, 50640, 50644, 51011, 51012, 51013, 51014, 51015, 51021, 51022, 51023, 51024, 51025, 51026, 51031, 51032, 51033, 51034, 51035, 51036, 51041, 51042, 51043, 51044, 51045, 51051, 51052, 51053, 51054, 51055, 51056, 51057, 51058, 51059, 51061, 51062, 51063, 51064, 51065, 51066, 51071, 51072, 51073, 51102, 51103, 51130, 51131, 51160, 51165, 51170, 51171, 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), 16527, 16528, 16530, 16531, 16533 or 16534 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 82118, 82120, 82123, 82125 or 82127 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 (1)(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 MBS item numbers for this clause are those set out in the following table, but only where those items have a fee in the MBS within the range of $303.99 to $1020.84:Type A procedures: Surgical patient – list of MBS items13218, 13251, 13700, 13834, 13837, 13851, 14234, 14237, 16567, 16570, 16571, 16573, 30016, 30023, 30024, 30166, 30169, 30229, 30235, 30241, 30244, 30246, 30247, 30253, 30256, 30272, 30286, 30287, 30289, 30293, 30299, 30305, 30306, 30310, 30311, 30314, 30326, 30330, 30332, 30385, 30387, 30392, 30399, 30400, 30408, 30414, 30416, 30419, 30422, 30431, 30433, 30440, 30443, 30445, 30450, 30451, 30452, 30479, 30481, 30484, 30485, 30490, 30491, 30492, 30494, 30495, 30515, 30520, 30530, 30559, 30562, 30563, 30600, 30611, 30615, 30618, 30621, 30622, 30623, 30626, 30629, 30635, 30637, 30639, 30641, 30642, 30643, 30644, 30645, 30646, 30648, 30651, 30652, 30662, 30664, 30665, 30672, 30676, 30688, 30690, 30692, 30694, 30720, 30721, 30722, 30723, 30724, 30731, 30760, 30761, 30763, 30770, 30790, 30791, 30800, 31000, 31001, 31003, 31004, 31245, 31250, 31350, 31355, 31400, 31403, 31406, 31423, 31426, 31454, 31460, 31462, 31500, 31503, 31506, 31509, 31512, 31513, 31515, 31519, 31525, 31554, 31569, 31575, 31578, 31585, 32021, 32023, 32045, 32046, 32057, 32066, 32094, 32096, 32105, 32123, 32129, 32131, 32139, 32159, 32162, 32165, 32183, 32186, 32213, 32216, 32231, 32233, 32237, 32507, 32508, 32511, 32736, 32757, 32760, 32766, 32769, 33070, 33545, 33548, 33551, 33554, 33806, 33810, 33845, 33848, 34100, 34103, 34106, 34130, 34133, 34145, 34500, 34503, 34515, 34521, 34524, 34527, 34528, 34529, 34534, 34538, 34800, 34824, 34827, 34830, 35000, 35012, 35100, 35202, 35300, 35303, 35306, 35309, 35317, 35319, 35321, 35327, 35330, 35331, 35360, 35361, 35362, 35363, 35401, 35404, 35406, 35408, 35410, 35508, 35533, 35534, 35536, 35560, 35564, 35565, 35566, 35568, 35570, 35571, 35573, 35577, 35578, 35581, 35582, 35595, 35599, 35610, 35612, 35616, 35622, 35623, 35631, 35635, 35636, 35637, 35649, 35653, 35657, 35658, 35673, 35680, 35694, 35697, 35700, 35726, 35750, 35751, 35759, 36502, 36508, 36509, 36530, 36537, 36546, 36549, 36552, 36558, 36579, 36585, 36604, 36607, 36608, 36609, 36612, 36615, 36618, 36621, 36624, 36627, 36633, 36636, 36639, 36649, 36652, 36654, 36663, 36664, 36666, 36803, 36806, 36809, 36811, 36818, 36821, 36822, 36823, 36842, 36845, 36854, 36863, 37000, 37004, 37008, 37020, 37023, 37026, 37038, 37039, 37044, 37046, 37050, 37201, 37208, 37221, 37224, 37227, 37306, 37318, 37327, 37330, 37333, 37336, 37342, 37345, 37348, 37351, 37354, 37381, 37387, 37396, 37402, 37408, 37417, 37418, 37429, 37438, 37601, 37604, 37605, 37606, 37613, 37616, 37619, 37800, 37801, 37803, 37804, 37807, 37809, 37810, 37812, 37813, 37818, 37819, 37821, 37827, 37828, 37830, 37833, 37834, 37836, 37839, 37845, 37854, 38200, 38203, 38206, 38209, 38213, 38256, 38274, 38275, 38325, 38326, 38350, 38353, 38356, 38362, 38365, 38372, 38373, 38374, 38376, 38416, 38417, 38422, 38425, 38426, 38472, 38485, 38511, 38523, 38609, 38612, 38619, 38621, 38627, 38637, 38830, 38837, 38839, 38845, 38847, 38849, 38850, 38851, 39015, 39018, 39121, 39125, 39126, 39127, 39128, 39129, 39130, 39134, 39137, 39138, 39300, 39303, 39306, 39307, 39309, 39312, 39318, 39319, 39321, 39324, 39327, 39328, 39330, 39336, 39339, 39342, 39906, 40701, 40704, 40705, 40708, 40852, 40854, 40856, 40858, 40905, 41512, 41515, 41524, 41527, 41545, 41548, 41603, 41611, 41620, 41629, 41671, 41692, 41707, 41710, 41713, 41725, 41737, 41743, 41746, 41749, 41752, 41770, 41776, 41779, 41786, 41789, 41793, 41813, 41825, 41867, 41873, 41876, 41880, 41881, 41885, 41910, 42505, 42506, 42509, 42510, 42512, 42515, 42518, 42527, 42530, 42533, 42536, 42542, 42548, 42551, 42554, 42563, 42574, 42596, 42599, 42602, 42605, 42623, 42629, 42665, 42695, 42698, 42701, 42702, 42703, 42704, 42707, 42713, 42719, 42734, 42743, 42758, 42761, 42764, 42770, 42802, 42805, 42815, 42833, 42836, 42839, 42848, 42854, 42857, 42869, 43021, 43022, 43050, 43521, 43527, 43530, 43533, 43805, 43832, 43835, 43841, 43849, 43858, 43867, 43930, 43933, 43939, 43960, 43981, 43999, 44101, 44102, 44108, 44111, 44114, 44130, 44133, 44325, 44328, 44331, 44346, 44350, 44354, 44359, 44361, 44364, 44367, 44370, 45000, 45003, 45009, 45012, 45015, 45018, 45035, 45045, 45048, 45051, 45054, 45072, 45201, 45202, 45203, 45206, 45207, 45209, 45221, 45227, 45233, 45440, 45443, 45451, 45496, 45497, 45512, 45522, 45524, 45532, 45534, 45537, 45542, 45545, 45547, 45548, 45551, 45553, 45554, 45556, 45568, 45572, 45575, 45578, 45581, 45584, 45585, 45590, 45592, 45594, 45602, 45605, 45608, 45609, 45611, 45614, 45620, 45623, 45627, 45629, 45632, 45635, 45652, 45653, 45656, 45658, 45659, 45668, 45669, 45671, 45675, 45676, 45677, 45680, 45683, 45689, 45692, 45695, 45698, 45701, 45704, 45707, 45710, 45713, 45714, 45716, 45761, 45794, 45809, 45811, 45813, 45815, 45825, 45827, 45831, 45837, 45841, 45845, 45849, 45865, 45888, 45891, 45939, 46050, 46092, 46094, 46103, 46113, 46114, 46115, 46127, 46130, 46131, 46132, 46142, 46143, 46300, 46303, 46308, 46309, 46312, 46322, 46330, 46333, 46335, 46336, 46339, 46340, 46341, 46342, 46345, 46351, 46354, 46357, 46360, 46367, 46372, 46375, 46378, 46379, 46381, 46384, 46387, 46390, 46399, 46401, 46408, 46411, 46414, 46417, 46423, 46426, 46432, 46434, 46441, 46442, 46444, 46453, 46468, 46471, 46474, 46480, 46483, 46489, 46492, 46493, 46500, 46502, 46503, 46510, 46522, 47007, 47012, 47021, 47027, 47033, 47045, 47047, 47049, 47052, 47053, 47054, 47063, 47066, 47310, 47313, 47316, 47319, 47357, 47364, 47370, 47373, 47381, 47384, 47385, 47386, 47387, 47390, 47393, 47399, 47402, 47408, 47417, 47420, 47426, 47429, 47432, 47435, 47438, 47441, 47447, 47450, 47451, 47453, 47456, 47459, 47465, 47468, 47480, 47483, 47495, 47498, 47514, 47516, 47528, 47537, 47546, 47549, 47552, 47555, 47559, 47561, 47565, 47568, 47570, 47573, 47577, 47582, 47585, 47592, 47593, 47597, 47600, 47603, 47612, 47615, 47618, 47621, 47624, 47630, 47648, 47657, 47741, 47753, 47765, 47766, 47786, 47789, 47790, 47791, 47792, 47795, 47953, 47954, 47955, 47967, 47975, 47982, 48245, 48248, 48251, 48257, 48400, 48403, 48406, 48409, 48412, 48415, 48419, 48420, 48423, 48424, 48430, 48435, 48442, 48444, 48454, 48456, 48507, 48900, 48903, 48906, 48909, 48915, 48925, 48927, 48932, 48943, 48944, 48945, 48948, 48952, 48953, 48972, 48980, 48983, 48986, 49100, 49104, 49105, 49109, 49112, 49113, 49114, 49118, 49121, 49124, 49127, 49200, 49203, 49206, 49209, 49213, 49215, 49218, 49219, 49220, 49221, 49224, 49227, 49233, 49236, 49239, 49300, 49303, 49309, 49315, 49360, 49363, 49366, 49500, 49503, 49506, 49509, 49515, 49534, 49569, 49570, 49572, 49574, 49576, 49578, 49580, 49582, 49584, 49586, 49590, 49596, 49703, 49706, 49709, 49718, 49724, 49727, 49728, 49730, 49732, 49734, 49736, 49738, 49760, 49761, 49762, 49771, 49772, 49773, 49774, 49775, 49777, 49782, 49783, 49791, 49792, 49793, 49794, 49795, 49796, 49812, 49818, 49821, 49824, 49827, 49830, 49833, 49837, 49839, 49845, 49854, 49857, 49860, 49866, 50107, 50112, 50118, 50130, 50201, 50203, 50206, 50209, 50242, 50309, 50312, 50333, 50335, 50339, 50345, 50357, 50360, 50369, 50375, 50381, 50393, 50396, 50426, 50428, 50508, 50512, 50524, 50528, 50532, 50536, 50540, 50544, 50548, 50552, 50556, 50560, 50564, 50568, 50572, 50576, 50580, 50584, 50588, 50596, 50600, 50616, 50654, 50950, 50952, 51020, 51110, 51111, 51114, 51115, 51140, 51141, 51145, 51150, 51900, 51904, 51906, 52018, 52035, 52048, 52051, 52054, 52059, 52063, 52066, 52078, 52090, 52092, 52094, 52095, 52105, 52111, 52114, 52117, 52120, 52122, 52130, 52131, 52138, 52141, 52144, 52147, 52148, 52182, 52184, 52186, 52300, 52303, 52306, 52312, 52315, 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, 53015, 53016, 53017, 53019, 53215, 53220, 53226, 53236, 53239, 53242, 53406, 53409, 53412, 53413, 53414, 53415, 53416, 53418, 53419, 53422, 53423, 53424, 53425, 53427, 53429, 53453, 53455, 53460

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 shared ward accommodation for private patients at public hospitals in the Australian Capital Territory, New South Wales, 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; andNote: 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 1-Overnight shared ward accommodation for private patients at public hospitals in the Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia and Western AustraliaColumn 1 | Column 2State/Territory | Minimum benefit payable per nightAustralian Capital Territory | $467New South Wales | $467Northern Territory | $467Queensland | $479South Australia | $467Western Australia | $467

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-Same day accommodation for private patients at public hospitals in all States/TerritoriesColumn 1 | Column 2 | Column 3 | Column 4 | Column 5Public hospitals | Band 1 | Band 2 | Band 3 | Band 4New South Wales | $339 | $377 | $416 | $467Australian Capital Territory | $339 | $377 | $416 | $467Northern Territory | $339 | $389 | $448 | $467Queensland | $345 | $391 | $428 | $479South Australia | $339 | $389 | $427 | $467Tasmania | $328 | $392 | $452 | $524Victoria | $333 | $393 | $456 | $524Western Australia | $385 | $385 | $385 | $385Table 2- Same day accommodation for private patients at private hospitals in all States/TerritoriesColumn 1 | Column 2 | Column 3 | Column 4 | Column 5Private hospitals | Band 1 | Band 2 | Band 3 | Band 4All States and Territories | $294 | $368 | $448 | $524

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 the following table in this clause is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule:Type B day procedures: Band 1 – list of MBS items13100, 13103, 13706, 13950, 30210, 32215, 36665, 39000, 41674, 42575, 55600, 55603(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 the following table in this clause is a non-band specific Type B day procedure:Non-band specific Type B day procedures – list of MBS items111, 117, 120, 11801, 11919, 13110, 13212, 13215, 13241, 13318, 13400, 13750, 13755, 13757, 13761, 13762, 13815, 14218, 14224, 14245, 14247, 14249, 16512, 16603, 16618, 18216, 18230, 18240, 18242, 18280, 18284, 18286, 18290, 18294, 18296, 18298, 18375, 18379, 30042, 30045, 30055, 30081, 30084, 30087, 30094, 30104, 30107, 30187, 30189, 30190, 30257, 30262, 30269, 30281, 30283, 30390, 30473, 30475, 30478, 30627, 30630, 30658, 30661, 30679, 30687, 30820, 31225, 31227, 31344, 31345, 31346, 31356, 31357, 31358, 31359, 31360, 31361, 31363, 31364, 31367, 31369, 31370, 31371, 31372, 31373, 31374, 31375, 31376, 31377, 31378, 31379, 31380, 31381, 31382, 31383, 31386, 31387, 31388, 31530, 31551, 31557, 31560, 31563, 31566, 31590, 32075, 32095, 32147, 32150, 32156, 32171, 32218, 32219, 32222, 32223, 32224, 32225, 32226, 32227, 32228, 32229, 32230, 32235, 32236, 32504, 34539, 35324, 35500, 35507, 35513, 35517, 35539, 35545, 35557, 35630, 35633, 35640, 35643, 35644, 35645, 35647, 35648, 35730, 36504, 36505, 36507, 36561, 36650, 36667, 36668, 36812, 36824, 36827, 36833, 36836, 36840, 36860, 37011, 37215, 37216, 37217, 37218, 37219, 37226, 37321, 37324, 37339, 37435, 37623, 37806, 37815, 37816, 38285, 38286, 38288, 38419, 38420, 38428, 39013, 39014, 39100, 39110, 39111, 39116, 39117, 39118, 39119, 39133, 39135, 39140, 39323, 39329, 39331, 39332, 39345, 40702, 41503, 41506, 41509, 41626, 41632, 41644, 41650, 41677, 41693, 41702, 41722, 41801, 41822, 41831, 41855, 41861, 41870, 41886, 42503, 42504, 42572, 42573, 42576, 42584, 42590, 42608, 42610, 42611, 42632, 42635, 42638, 42641, 42647, 42652, 42673, 42680, 42683, 42686, 42689, 42692, 42750, 42810, 42812, 42818, 42845, 42863, 42866, 42872, 43030, 43032, 43034, 43036, 43038, 43040, 43942, 43948, 44104, 44105, 44136, 44338, 44342, 44358, 44376, 45019, 45027, 45030, 45033, 45200, 45212, 45224, 45239, 45510, 45515, 45560, 45589, 45626, 45665, 45674, 45823, 45851, 45855, 45857, 46101, 46102, 46125, 46126, 46140, 46141, 46348, 46363, 46364, 46365, 46370, 46420, 46438, 46450, 46486, 46495, 46501, 46525, 47738, 47906, 47915, 47918, 47927, 48436, 48438, 48440, 49803, 49806, 49809, 49881, 49884, 49887, 49890, 50115, 50352, 51112, 51113, 51120, 51902, 52015, 52025, 52042, 52045, 52057, 52058, 52061, 52062, 52064, 52072, 52073, 52075, 52081, 52084, 52087, 52096, 52097, 52099, 52102, 52108, 52180, 52321, 52826, 53003, 53006, 53009, 53054, 53056, 53058, 53060, 53062, 53064, 53070, 53206, 53218, 53225, 53410, 55118, 58939, 59970, 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, 60500, 71202, 73310, 73313, 73316, 73425, 73426(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 #

(1) 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 in the following table:Note: These procedures normally do not require hospital treatment.Type C procedures – list of MBS items3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 104, 105, 106, 107, 108, 109, 110, 115, 116, 119, 122, 127, 128, 129, 131, 132, 133, 135, 137, 139, 141, 143, 145, 147, 160, 161, 162, 163, 164, 170, 171, 172, 193, 195, 197, 199, 235, 236, 237, 238, 239, 240, 285, 287, 289, 291, 293, 299, 341, 342, 343, 344, 345, 346, 347, 349, 385, 386, 387, 388, 392, 393, 410, 411, 412, 413, 414, 415, 416, 417, 729, 731, 735, 739, 743, 747, 750, 758, 820, 822, 823, 825, 826, 828, 855, 857, 858, 900, 903, 930, 933, 935, 937, 943, 945, 946, 948, 959, 961, 962, 964, 965, 969, 971, 972, 973, 975, 986, 2721, 2723, 2725, 2727, 2801, 2806, 2814, 2824, 2832, 2840, 2946, 2949, 2954, 2958, 2972, 2974, 3005, 3010, 3014, 3018, 3023, 3028, 3032, 3040, 3044, 3051, 3055, 3062, 4001, 5000, 5001, 5003, 5004, 5010, 5011, 5012, 5013, 5014, 5016, 5017, 5019, 5020, 5021, 5022, 5023, 5027, 5028, 5030, 5031, 5032, 5033, 5035, 5036, 5039, 5040, 5041, 5042, 5043, 5044, 5049, 5060, 5063, 5067, 5200, 5203, 5207, 5208, 5220, 5223, 5227, 5228, 5260, 5263, 5265, 5267, 6007, 6009, 6011, 6013, 6015, 6018, 6019, 6023, 6024, 6028, 6029, 6031, 6032, 6034, 6035, 6037, 6038, 6042, 6051, 6052, 6057, 6058, 6062, 6063, 6064, 6065, 6067, 6068, 6071, 6072, 6074, 6075, 6080, 6081, 6082, 6084, 10801, 10802, 10803, 10804, 10805, 10806, 10807, 10808, 10809, 10816, 10988, 10989, 11000, 11003, 11012, 11015, 11018, 11024, 11027, 11200, 11204, 11205, 11210, 11211, 11215, 11218, 11219, 11220, 11221, 11224, 11235, 11237, 11240, 11241, 11242, 11243, 11244, 11300, 11302, 11306, 11309, 11312, 11315, 11318, 11324, 11332, 11340, 11341, 11343, 11503, 11505, 11506, 11507, 11508, 11512, 11602, 11604, 11605, 11607, 11610, 11611, 11612, 11614, 11615, 11705, 11713, 11719, 11720, 11721, 11724, 11725, 11726, 11727, 11728, 11729, 11730, 11731, 11732, 11736, 11737, 11800, 11810, 11820, 11823, 11830, 11833, 11900, 11912, 11917, 12000, 12001, 12002, 12003, 12004, 12005, 12012, 12017, 12021, 12022, 12024, 12200, 12201, 12306, 12312, 12315, 12320, 12321, 12322, 12325, 12326, 12500, 12524, 12527, 12533, 13104, 13200, 13203, 13207, 13209, 13221, 13260, 13290, 13312, 14050, 14100, 14106, 14115, 14118, 14124, 14201, 14202, 14203, 14206, 14216, 14217, 14219, 14220, 14221, 14227, 14255, 14256, 14257, 14258, 14259, 14260, 14263, 14264, 14265, 14266, 14270, 14272, 14277, 14278, 14280, 14283, 14285, 14288, 15902, 15904, 15906, 15908, 15910, 15912, 15914, 15916, 15918, 15920, 15922, 15924, 15926, 15928, 15930, 15932, 15934, 15936, 15938, 15940, 15942, 15944, 15946, 15948, 15950, 15952, 15954, 15956, 15958, 15960, 15962, 15964, 15966, 15968, 15970, 15972, 15974, 15976, 15978, 15980, 15982, 15984, 15990, 16003, 16006, 16009, 16012, 16015, 16018, 16400, 16407, 16408, 16500, 16509, 16511, 16514, 16600, 17610, 17615, 17620, 17625, 17640, 17645, 17650, 17655, 17690, 18213, 18350, 18351, 18353, 18354, 18355, 18360, 18361, 18362, 18365, 18366, 18368, 18369, 18370, 18372, 18374, 18377, 30003, 30006, 30007, 30026, 30032, 30038, 30061, 30062, 30064, 30071, 30072, 30097, 30191, 30192, 30196, 30202, 30207, 30219, 30278, 30628, 30654, 31206, 31211, 31216, 31220, 31221, 31362, 31365, 31366, 31368, 31537, 31587, 32072, 32135, 32500, 32520, 32522, 32523, 32526, 32528, 32529, 35503, 35608, 35614, 35620, 35626, 35703, 36671, 36672, 36673, 37300, 37388, 37415, 38800, 39141, 40707, 40862, 40863, 41500, 41501, 41647, 41659, 41662, 41764, 41768, 41769, 42587, 42588, 42614, 42615, 42617, 42620, 42644, 42650, 42667, 42668, 42676, 42677, 42744, 42794, 42808, 42811, 45021, 45025, 45546, 45801, 45807, 45829, 45882, 47471, 47735, 47904, 47916, 47924, 50310, 51700, 51703, 52034, 52036, 52055, 52056, 52133, 53000, 53004, 53052, 53458, 55028, 55029, 55030, 55031, 55032, 55033, 55036, 55037, 55038, 55039, 55048, 55049, 55054, 55065, 55066, 55068, 55070, 55071, 55073, 55076, 55079, 55080, 55126, 55127, 55128, 55129, 55132, 55133, 55134, 55137, 55141, 55143, 55145, 55146, 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, 55736, 55739, 55740, 55741, 55742, 55743, 55757, 55758, 55812, 55814, 55844, 55846, 55852, 55854, 55856, 55857, 55858, 55859, 55860, 55861, 55862, 55863, 55864, 55865, 55866, 55867, 55868, 55869, 55870, 55871, 55872, 55873, 55874, 55875, 55876, 55877, 55878, 55879, 55880, 55881, 55882, 55883, 55884, 55885, 55886, 55887, 55888, 55889, 55890, 55891, 55892, 55893, 55894, 55895, 56001, 56007, 56010, 56013, 56016, 56022, 56028, 56030, 56036, 56101, 56107, 56220, 56221, 56223, 56224, 56225, 56226, 56233, 56234, 56237, 56238, 56301, 56307, 56401, 56407, 56409, 56412, 56501, 56507, 56553, 56620, 56622, 56623, 56626, 56627, 56628, 56629, 56630, 56801, 56807, 57001, 57007, 57201, 57341, 57352, 57353, 57354, 57357, 57360, 57364, 57410, 57413, 57506, 57509, 57512, 57515, 57518, 57521, 57522, 57523, 57524, 57527, 57700, 57703, 57706, 57709, 57712, 57715, 57721, 57901, 57902, 57905, 57907, 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, 58927, 58933, 58936, 59103, 59300, 59302, 59303, 59305, 59312, 59314, 59318, 59700, 59703, 59712, 59718, 59724, 59733, 59739, 59751, 59754, 59763, 60503, 60918, 60927, 61310, 61313, 61314, 61321, 61324, 61325, 61328, 61329, 61333, 61336, 61340, 61341, 61345, 61348, 61349, 61353, 61356, 61357, 61360, 61361, 61364, 61368, 61372, 61373, 61376, 61381, 61383, 61384, 61386, 61387, 61389, 61390, 61393, 61394, 61397, 61398, 61402, 61406, 61409, 61410, 61413, 61414, 61421, 61425, 61426, 61429, 61430, 61433, 61434, 61438, 61441, 61442, 61445, 61446, 61449, 61450, 61453, 61454, 61457, 61462, 61466, 61469, 61473, 61480, 61485, 61495, 61499, 61505, 61524, 61527, 61528, 61530, 61541, 61553, 61560, 61563, 61564, 61565, 61612, 61614, 61644, 61647, 63001, 63004, 63007, 63010, 63019, 63020, 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, 63390, 63391, 63395, 63397, 63401, 63404, 63416, 63425, 63428, 63440, 63443, 63446, 63454, 63461, 63464, 63467, 63470, 63473, 63476, 63482, 63487, 63489, 63491, 63494, 63496, 63497, 63507, 63510, 63513, 63516, 63519, 63522, 63531, 63533, 63539, 63540, 63541, 63543, 63545, 63546, 63547, 63549, 63551, 63554, 63557, 63560, 63563, 63564, 63740, 63741, 63743, 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, 66520, 66522, 66523, 66525, 66536, 66539, 66542, 66545, 66548, 66551, 66554, 66557, 66560, 66563, 66566, 66569, 66572, 66575, 66578, 66581, 66584, 66585, 66586, 66587, 66590, 66593, 66596, 66605, 66606, 66607, 66623, 66626, 66629, 66632, 66635, 66638, 66639, 66641, 66642, 66644, 66647, 66650, 66651, 66652, 66653, 66654, 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, 66829, 66830, 66831, 66832, 66833, 66834, 66835, 66836, 66837, 66838, 66839, 66840, 66841, 66842, 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, 69379, 69383, 69384, 69387, 69390, 69393, 69396, 69400, 69401, 69405, 69408, 69411, 69413, 69415, 69421, 69422, 69445, 69451, 69471, 69472, 69474, 69475, 69478, 69481, 69482, 69483, 69484, 69488, 69489, 69491, 69492, 69494, 69495, 69496, 69497, 69498, 69499, 69500, 69505, 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, 71175, 71180, 71183, 71186, 71189, 71192, 71195, 71198, 71200, 71203, 72813, 72814, 72816, 72817, 72818, 72823, 72824, 72825, 72826, 72827, 72828, 72830, 72836, 72838, 72844, 72846, 72847, 72848, 72849, 72850, 72851, 72852, 72855, 72856, 72857, 73043, 73045, 73047, 73049, 73051, 73059, 73060, 73061, 73062, 73063, 73064, 73065, 73070, 73071, 73072, 73074, 73075, 73076, 73287, 73289, 73290, 73291, 73292, 73293, 73294, 73295, 73296, 73297, 73298, 73299, 73300, 73304, 73305, 73306, 73308, 73309, 73311, 73312, 73314, 73315, 73317, 73318, 73320, 73321, 73322, 73323, 73324, 73331, 73332, 73333, 73334, 73335, 73336, 73337, 73338, 73339, 73340, 73341, 73342, 73343, 73344, 73345, 73346, 73347, 73348, 73349, 73350, 73351, 73352, 73353, 73354, 73355, 73356, 73357, 73358, 73359, 73360, 73361, 73362, 73363, 73364, 73365, 73366, 73367, 73368, 73369, 73370, 73371, 73372, 73373, 73374, 73375, 73376, 73377, 73378, 73379, 73380, 73381, 73382, 73383, 73384, 73385, 73386, 73387, 73388, 73389, 73391, 73392, 73393, 73394, 73395, 73396, 73397, 73398, 73399, 73400, 73401, 73402, 73403, 73404, 73405, 73406, 73410, 73411, 73412, 73413, 73416, 73417, 73418, 73419, 73420, 73421, 73422, 73423, 73424, 73427, 73428, 73429, 73430, 73431, 73432, 73433, 73434, 73435, 73436, 73437, 73438, 73439, 73440, 73441, 73442, 73443, 73444, 73445, 73446, 73447, 73448, 73451, 73452, 73453, 73454, 73455, 73456, 73457, 73458, 73459, 73460, 73461, 73462, 73521, 73523, 73525, 73527, 73529, 73801, 73802, 73803, 73804, 73805, 73806, 73807, 73808, 73809, 73810, 73811, 73812, 73813, 73825, 73826, 73920, 73922, 73923, 73924, 73925, 73926, 73927, 73928, 73929, 73930, 73931, 73932, 73933, 73934, 73935, 73936, 73937, 73938, 73939, 73940, 74992, 74993, 74994, 74995, 74996, 74997, 74998, 74999, 82100, 82102, 82104, 82105, 82110, 82115, 82116, 82130, 82135, 82140, 82203, 82226, 82227, 82228, 91868, 91869, 91870, 91871, 91872, 91873, 91874, 91875, 91876, 91877, 91878, 91879, 91880, 91881, 91882, 91883, 91884

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-Nursing-home type patient benefit for private patients at public hospitals in States/TerritoriesColumn 1 | Column 2State/Territory | Minimum benefit payable per nightAustralian Capital Territory | $159.85New South Wales | $199.50Northern Territory | $169.10Queensland | $155.90South Australia | $157.00Tasmania | $203.88Victoria | $175.39Western Australia | $159.15Table 2-Nursing-home type patient benefit for private patients at private hospitals in all States/TerritoriesColumn 1 | Column 2Private Hospitals | Minimum benefit payable per nightAll States and Territories | $26.15

Schedule 5―Second-tier default benefits #

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.

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 permitted—in 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 permitted—in subclause (7), a reference to licensed beds is a reference to the beds and bed equivalents the private hospital operates.(10) An authorised officer must calculate proportions for the purposes of paragraphs (7)(a) and (b):(a) if Hospital Casemix Protocol Data is available for the private hospital—using the most recent year of Hospital Casemix Protocol Data available to the Department for the private hospital; and(b) otherwise—on the basis of any relevant information available to the Department about the episodes of hospital treatment at the private hospital.

1B. Internal review of a categorisation determination #

(1) A private hospital subject to a determination made under subclause 1A(1), (2), (3) or (4) may request internal review of its categorisation by the determination.(2) An application for internal review under subclause (1) must be made in writing within 28 days after the day the determination is notified to the hospital.(3) If an application for internal review is made, an authorised officer (who must not be the authorised officer who made the original determination) must:(a) review the determination; and(b) either confirm the determination or make a fresh one within 28 days after the day on which the application was received by the Department.

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 second-tier eligible 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.

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 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.(4) Subject to subclauses (2) and (8), the minimum benefit payable by an insurer for an episode of hospital treatment at a second-tier eligible hospital for which the admission date was between 1 September of a particular year (the first year) and 31 August of the next year is an amount no less than 85% of the average charge for the equivalent episode of hospital treatment, under that insurer’s negotiated agreements as in force on 1 August of the first year, with all private hospitals:(a) that:(i) if the second-tier eligible hospital is on the list published on the Department’s website under subclause 1A(5)—were comparable on 1 August of the first year with the second-tier eligible hospital; and(ii) otherwise—are in the same category as the second-tier eligible hospital in the list published on the Department’s website under subclause 1A(5) as at 1 August of the first year; and(b) that are in the same State as the second-tier eligible hospital.Note: See clause 4 for a transitional arrangement for admissions to second-tier eligible hospitals between 1 January 2019 and 31 August 2019.(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;Rji = charge for episode of hospital treatment type j in the negotiated agreement iRj = 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 second-tier eligible hospital 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; andNote: 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 medical devices and human tissue products; and(ii) that are minimum benefits for medical devices and human tissue products 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. 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).

Endnotes #

Endnote 1—About the endnotes #

The endnotes provide information about this compilation and the compiled law.The following endnotes are included in every compilation:Endnote 1—About the endnotesEndnote 2—Abbreviation keyEndnote 3—Legislation historyEndnote 4—Amendment historyAbbreviation key—Endnote 2The abbreviation key sets out abbreviations that may be used in the endnotes.Legislation history and amendment history—Endnotes 3 and 4Amending laws are annotated in the legislation history and amendment history.The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.Editorial changesThe Legislation Act 2003 authorises First Parliamentary Counsel to make editorial and presentational changes to a compiled law in preparing a compilation of the law for registration. The changes must not change the effect of the law. Editorial changes take effect from the compilation registration date.If the compilation includes editorial changes, the endnotes include a brief outline of the changes in general terms. Full details of any changes can be obtained from the Office of Parliamentary Counsel.Misdescribed amendmentsA misdescribed amendment is an amendment that does not accurately describe how an amendment is to be made. If, despite the misdescription, the amendment can be given effect as intended, then the misdescribed amendment can be incorporated through an editorial change made under section 15V of the Legislation Act 2003.If a misdescribed amendment cannot be given effect as intended, the amendment is not incorporated and “(md not incorp)” is added to the amendment history.

Endnote 2—Abbreviation key #

ad = added or inserted | orig = originalam = amended | p = page(s)amdt = amendment | para = paragraph(s)/subparagraph(s)C[x] = Compilation No. x | /sub-subparagraph(s)ch = Chapter(s) | pres = presentcl = clause(s) | prev = previouscont. = continued | (prev…) = previouslydef = definition(s) | pt = Part(s)Dict = Dictionary | r = regulation(s)/Court rule(s)disallowed = disallowed by Parliament | reloc = relocateddiv = Division(s) | renum = renumbereded = editorial change | rep = repealedexp = expires/expired or ceases/ceased to have | rs = repealed and substitutedeffect | s = section(s)/subsection(s)gaz = gazette | /rule(s)/subrule(s)/order(s)/suborder(s)LA = Legislation Act 2003 | sch = Schedule(s)LIA = Legislative Instruments Act 2003 | SLI = Select Legislative Instrument(md) = misdescribed amendment can be given | SR = Statutory Ruleseffect | sub ch = Sub-Chapter(s)(md not incorp) = misdescribed amendment | sub div = Subdivision(s)cannot be given effect | sub pt = Subpart(s)mod = modified/modification | underlining = whole or part notNo. = Number(s) | commenced or to be commencedOrd = Ordinance

Endnote 3—Legislation history #

Endnote 4—Amendment history #

Provision affected | How affectedSchedule 1Part 1, Subclause 2(2) | am F2012L01264; F2013L01190; F2014L00801; F2015L00926; F2016L01101; F2017L00830Part 2, Subclause 4(3) | am F2012L02114; F2012L02151; F2013L01190; F2013L01321; F2014L00801; F2015L01356; F2015L01711; F2015L02118; F2016L00589; F2016L01101 F2016L01665; F2016L01846; F2017L00603; F2017L01401Part 2, Subclause 5(2)(a) | am. F2017L01401Part 2, Subclause 6(3) | am F2012L00604; F2012L01264; F2012L02114; F2012L02502; F2013L00497; F2013L01190; F2013L01321; F2014L00801; F2014L01016; F2014L01434; F2015L01356; F2015L02118; F2016L00589; F2016L00979; F2016L01101; F2016L01846; F2017L00461; F2017L00603; F2017L00830; F2017L01401Schedule 2Clause 2, Tablers F2012L01264; F2013L01190; F2014L00801; F2015L00926; F2016L01101; F2017L00830Schedule 3Part 1, Subclause 2(2), Table 1 | rs F2012L01264; F2013L01190; F2014L00801; F2015L00926; F2017L00830Part 1, Subclause 2(2), Table 2 | rs F2012L01264; F2013L01190; F2014L00801; F2015L00926; F2016L01101; F2017L00830Part 2, Paragraph 4(1)(a) | am. F2012L00604; F2016L00979; F2016L01101; F2017L01401Part 2, Paragraph 4 (1)(c) | ad. F2015L01356Part 2, Subclause 5(1) | am F2012L00604; F2012L00905; F2012L01264; F2012L02114; F2012L02502; F2013L01321; F2013L01753; F2014L01434; F2015L01356; F2016L00979; F2016L01101; F2016L01665; F2017L00461; F2017L00603; F2017L00830; F2017L01401; F2018L00544Part 3, Clause 8 | am F2012L00604; F2012L00905; F2012L01264; F2012L02114; F2013L00497; F2013L01190; F2013L01321; F2013L01866; F2014L00309; F2014L00801; F2014L01434; F2015L00926; F2015L01356; F2015L02118; F2016L01101; F2016L01665; F2016L01846; F2017L00084; F2017L00603; F2017L01217; F2017L01401; F2017L01527; F2018L00544Schedule 4Clause 6, Table 1am F2012L00604; F2012L01264; F2012L01887; F2012L02111; F2013L00497; F2013L01190; F2014L00309; F2014L00801; F2014L01235; F2015L00324; F2015L00926; F2015L01451; F2016L00352; F2016L01101; F2016L01446; F2016L01463; F2017L00242; F2017L00830; F2017L00894; F2017L01217; F2018L00323rs F2013L01714Clause 6, Table 2 | am. F2012L00604; F2012L01887; F2013L00497; F2013L01714; F2014L00309; F2014L01235; F2015L00324; F2015L01451: F2016L00352; F2016L01446; F2017L00242; F2017L01217; F2018L00323Schedule 5Subclause 1(1) | am. F2013L00003Clause 4, Tableam. F2011L02731; F2012L00604; F2012L00822; F2012L01264; F2012L01887; F2012L02502rs. F2013L00003Subclause 4(1)am. F2013L00497; F2013L01190; F2013L02113; F2014L00309; F2014L00801; F2014L01016; F2014L01235; F2014L01775; F2015L00324; F2015L00926; F2015L01451; F2015L02118; F2016L00352; F2016L01101; F2016L01446; F2016L01967; F2017L00242; F2017L00830; F2017L01217; F2017L01603; F2018L00323rs. F2013L01753Endnote 4—Amendment history from 1 July 2018Provision affected | How affectedPart 1s 2..................... | rep LIA s 48DSchedule 1Schedule 1................ | am F2018L00927; F2018L01474; F2018L01797; F2019L00925; F2019L01384; F2020L00190; F2020L00539; F2020L00862; F2020L01244; F2020L01378; F2021L00155; F2021L00856; F2021L00906; F2021L01461; F2022L00080; F2022L00635; F2022L00897; F2022L00954; F2022L01404; F2022L01417; F2023L00901; F2023L00926; F2023L01257; F2023L01411; F2024L00179; F2024L00701; F2024L00824; F2025L00206; F2025L00707; F2025L00743; F2025L01278; F2026L00127; F2026L00730; F2026L00857; F2026L01398Schedule 2Schedule 2 heading.......... | rs F2020L00862Schedule 2................ | am F2018L00927; F2019L00925; F2020L00862; F2021L00856; F2022L00897; F2023L00901; F2024L00824; F2025L00743; F2026L00857Schedule 3Schedule 3................ | am F2018L00927; F2018L01474; F2018L01797; F2019L00048; F2019L00493; F2019L00639; F2019L00925; F2019L01384; F2020L00190; F2020L00539; F2020L00862; F2020L00978; F2020L01244; F2020L01378; F2021L00155; F2021L00856; F2021L00906; F2021L01461; F2021L01879; F2022L00080; F2022L00230ed C75am F2022L00462; F2022L00635; F2022L00897; F2022L00924; F2022L01010; F2022L01279; F2022L01404; F2022L01417; F2023L00232; F2023L00901; F2023L00926; F2023L01036; F2023L01257; F2023L01411; F2024L00179; F2024L00701; F2024L00824; F2024L01330; F2024L01690; F2025L00021; F2025L00206; F2025L00707ed C101am F2025L00743; F2025L01278; F2026L00127; F2026L00730; F2026L00857; F2026L01007; F2026L01398Schedule 4Schedule 4................ | am F2018L00927; F2018L01315; F2019L00327; F2019L00925; F2019L01221; F2020L00272; F2020L00862; F2021L00264; F2021L00856; F2021L01295; F2022L00303; F2022L00897; F2022L01182; F2023L00252; F2023L00901; F2023L01257; F2024L00326; F2024L00824ed C92am F2024L01186 (sch 2 (item 2) md not incorp); F2024L01259; F2025L00366; F2025L00743; F2025L01116; F2026L00273ed C105am F2026L00857; F2026L01240Schedule 5Schedule 5................ | am F2018L00927; F2018L01315; F2018L01797ed C53am F2018L01414; F2023L00891

Sourced from the Federal Register of Legislation at legislation.gov.au, © Commonwealth of Australia, licensed under CC BY 4.0. Compilations may have been reformatted.