PHI 47/16 – Changes to the Private Health Insurance (Benefit Requirements) and (Complying Product) Rules

Page last updated: 29 June 2016

PHI 47/16 – Changes to the Private Health Insurance (Benefit Requirements) and (Complying Product) Rules (PDF 129 KB)

The Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No. 4)(the Benefit Requirements Amendment Rules) were registered with the Federal Register of Legislation (FRL) and commenced on 1 July 2016(FRL No: F2016L01101)

The Benefit Requirements Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011.

Overnight accommodation benefits and same day accommodation benefits at private hospitals and public hospitals

Increases to overnight accommodation benefits and same day accommodation benefits at private hospitals and public hospitals have been made to reflect the March 2015 to March 2016 Consumer Price Index (CPI) increase of 1.3%. Queensland’s rate will increase by 1.7% in accordance with the March to March Brisbane CPI.

The Benefit Requirements Amendment Rules update the minimum benefit payable per night for patients in private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania, providing that the patient is not classified as a nursing-home type patient. The following rates will apply:

Advanced surgical patient

  • first 14 days – $415
  • over 14 days – $289

Surgical patient or obstetric patient

  • first 14 days – $386
  • over 14 days – $289

Psychiatric patient

  • first 42 days – $386
  • 43–65 days – $334
  • over 65 days – $289

Rehabilitation patient

  • first 49 days – $386
  • 50–65 days – $334
  • over 65 days – $289

Other patients

  • first 14 days – $334
  • over 14 days – $289

An amendment has been made to the minimum benefit payable per night for patients in shared ward accommodation at public hospitals in the Australian Capital Territory (ACT), New South Wales (NSW), Queensland, South Australia and Western Australia, providing that the patient is not classified as a nursing-home type patient.  The new rates are as follows:

  • ACT – $343;
  • NSW – $343;
  • Queensland – $352;
  • South Australia – $343;
  • Western Australia – $343; and
  • Northern Territory – $339 (unchanged)

New rates for minimum benefit for same-day accommodation in public hospitals and in private hospitals are implemented in each State and Territory and are as follows:

Public Hospitals

State/Territories

Band 1

Band 2

Band 3

Band 4

NSW

$249

$279

$306

$343

ACT

$249

$279

$306

$343

Queensland

$255

$287

$315

$352

South Australia

$249

$285

$314

$343

Tasmania

$242

$288

$333

$386

Victoria

$244

$289

$335

$386

Western Australia

$283

$283

$283

$283

Northern Territory

Remains at $246

Remains at $281

Remains at $326

Remains at $339

Private Hospitals

Band 1

Band 2

Band 3

Band 4

Private Hospitals

$215

$271

$330

$386

Nursing-home type patients – Schedule 4

Increases were made to the minimum benefits for Nursing-Home Type patients (NHTP) in public hospitals in the ACT to reflect the twice annual pension increase which occurred 20 March, 2015. The following new rate will apply:

State/Territory

Minimum benefit per night

Australian Capital Territory

$119.55

The existing rates for other states and territories remain in force and are as follows:

State/Territory

Minimum benefit per night

New South Wales

$119.65

Northern Territory

$90.69

Queensland

$117.00

South Australia

$115.00

Tasmania

$138.80

Victoria

$127.00

Western Australia

$138.10

Second Tier Default Benefits – Schedule 5

The purpose of the amendments to Schedule 5 was to insert a reference to the new list of Second-tier eligible facilities compiled by the Second Tier Advisory Committee. Further information about this is available in PHI Circular 47/16.

Medicare Benefit Schedule (MBS) item numbers

The Benefit Requirements Amendment Rules amend MBS items in Schedule 1 and 3 of the Private Health Insurance (Benefit Requirements) 2011. The changes are necessary to maintain consistency between the MBS item codes listed in the Principal Rules and the MBS from 1 July 2016. 15 MBS items have been removed from the Benefit Requirements Amendment Rules to reflect changes made through the MBS Review process.

Item 1 - Schedule 1, Part 2 Type A procedures, Clause 6 Surgical patient, Subclause (3)

Item 1 amends Schedule 1, Part 2 Type A procedures, Clause 6 Surgical patient, Subclause (3) of the Principal Rules by deleting two MBS item numbers (41849 and 41852).

Item 2 - Schedule 3, Part 2 Type B Procedures, Clause 4 Band 1, Subclause (1)(a), T8: Surgical Operations

Item 2 amends Schedule 3, Part 2 Type B Procedures, Clause 4 Band 1, Subclause (1)(a), T8: Surgical Operations of the Principal Rules by deleting three MBS item numbers (32078, 32081 and 41680).

Item 3 - Schedule 3, Part 2 – Type B Procedures, Clause 5 Non-band specific Type B day procedures, (1)

Item 3 amends Schedule 3, Part 2 – Type B Procedures, Clause 5 Non-band specific Type B day procedures, (1) of the Principal Rules by deleting four MBS item numbers (41695, 41761, 41849 and 41852).

Item 4 - Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the general medical services table, Category 2 – Diagnostic procedures & investigations, D1

Item 4 amends Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the general medical services table, Category 2 – Diagnostic procedures & investigations, D1 of the Principal Rules by deleting two MBS item numbers (11321 and 11500).

Item 5 - Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the general medical services table, Category 2 – Diagnostic procedures & investigations, T4

Item 5 amends Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the general medical services table, Category 2 – Diagnostic procedures & investigations, T4 of the Principal Rules by deleting one MBS item number (16504).

Item 6 - Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the diagnostic imaging services table, Category 5 – Diagnostic Imaging Services, I3

Item 6 amends Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the diagnostic imaging services table, Category 5 – Diagnostic Imaging Services, I3 of the Principal Rules by deleting four MBS item numbers (58924, 59503, 59736 and 59760).

Item 7 - Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the diagnostic imaging services table, Category 5 – Diagnostic Imaging Services, I4

Item 7 amends Schedule 3, Part 3 – Type C Procedures, Clause 8. Interpretation, Items in the diagnostic imaging services table, Category 5 – Diagnostic Imaging Services, I4 of the Principal Rules by deleting one MBS item number (61465).

Details of the amendments are set out in the Benefit Requirements Amendment Rules, which are available on the FRL website via the following link: (https://www.legislation.gov.au/Details/F2016L01101)

Changes to the Private Health Insurance (Complying Product) Rules 2015

The Private Health Insurance (Complying Product) Amendment Rules 2016 (No. 3) (Complying Product Amendment Rules) were registered with FRL (FRL No: F2016L01102) and commenced on 1 July 2016.

These Rules amend the Private Health Insurance (Complying Product) Rules 2015.

These amendments update the patient contribution rates for Nursing –home type patients in the Australian Capital Territory to $57.85

State/Territory

Contribution Rates

Australian Capital Territory

From $56.90 to $57.85

The existing rates for other states and territories remain in force and are as follows:

State/Territory

Contribution Rates

New South Wales

$57.85

Northern Territory

$57.85

Queensland

$57.85

Tasmania

$57.85

Victoria

$57.85

Western Australia

$57.85

Private hospitals nationally

$57.85

Details of the amendment is set out in the Complying Product Amendment Rules, which is available on the FRL website via the following link: (https://www.legislation.gov.au/Details/F2016L01102 )

NB: Please note that information contained within this circular is provided as a courtesy notification only. It is the responsibility of industry members to ensure they are operating in compliance with the Private Health Insurance Act 2007 and all other relevant Commonwealth legislation.