Private Health Insurance (Accreditation) Rules 2011
I, NICOLA ROXON, Minister for Health and Ageing, make these Rules under item 5 of the table in section 333-20 of the Private Health Insurance Act 2007. 
Dated      13 October 2011
 
____NICOLA ROXON_________
 
Nicola Roxon
Minister for Health and Ageing
 
 
 
 
 
 
 
 
Contents
 
 
Part 1                   Preliminary                                                                                            3
1.           Name of Rules                                                                                        3
2.           Commencement and revocation                                                               3
3.           Application                                                                                             3
4.           Definitions                                                                                              3
Part 2                                                                                                                                 5
5.           Standards                                                                                              5
6.           Treatments provided by hospitals and health care organisations               5
7.           Treatments by health care providers regulated under State and Territory laws  6
8.           Treatments provided by podiatric surgeons                                              6
9.           Treatments provided by allied health professionals                                   6
10.          Treatments provided by other health care providers                                  7
11.          Premises where treatments are provided                                                  7
 
 
 
Part 1        Preliminary
1.               Name of Rules
These Rules are the Private Health Insurance (Accreditation) Rules 2011.
2.               Commencement and revocation
(1)        These Rules commence on the day after the date of registration.
(2)        These Rules revoke the Private Health Insurance (Accreditation) Rules 2008.
3.               Application
These Rules apply in respect of all policies existing on, or issued on or after 1 July 2008.
4.               Definitions
Note:   Terms used in these Rules have the same meaning as in the Act―see section 13 of the Legislative Instruments Act 2003.  These terms include 'general treatment', 'hospital', 'hospital treatment' and 'medical practitioner'.
(1)        In these rules:
appropriate accrediting body means a body accredited by:
(a)                    the International Society for Quality in Health Care Inc (ISQua); or
(b)                   the Joint Accreditation System of Australia and New Zealand (JAS-ANZ); or
(c)                    an entity which has been accredited by ISQua or JAS-ANZ,
to accredit or certify health care organisations or health care providers against standards for the delivery of health care services.
Act means the Private Health Insurance Act 2007.
chronic disease management program has the same meaning as in rule 12 of the Private Health Insurance (Health Insurance Business) Rules made under the Act and in force from time to time.
health care organisation means an organisation that as part of its business is responsible for the clinical and administrative management of patients, but does not include a hospital.  For the avoidance of doubt, an individual providing treatment to a patient as a health care provider is not a health care organisation.
Note:   'Treatment' is a defined term in these Rules.
health care provider means an individual who provides treatment, but, for the avoidance of doubt, does not include a person who is acting in the capacity of a health care organisation.
health management program has the same meaning as in subrule 11 (2) of the Private Health Insurance (Health Insurance Business) Rules made under the Act and in force from time to time.
National Law means:
                (a)    for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or
               (b)    for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 that corresponds to the Health Practitioner Regulation National Law.
Note   The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions that was made on 26 March 2008 provides for the enactment of the State and Territory legislation mentioned in this definition.
treatment means treatment as referred to in section 69-5 of the Act, other than treatment :
(a)                    that is the provision of goods or ambulance services; or
(b)                   provided by a personal care attendant that is general or hospital treatment under a program of care for the patient; or
(c)                    that primarily takes the form of sport, recreation or entertainment and is part of:
(i)                      a chronic disease management program; or
(ii)                    a health management program; or
(d)                   that is a quit-smoking program or weight-loss program that is general or hospital treatment other than as provided by a person mentioned in rules 7 and 9.
Part 2       
5.               Standards
(1)        These Rules specify the standards, for section 81-1 of the Act, for treatment covered by a health insurance policy.
Note:   Treatment does not include the provision of goods or ambulance services―see the definition in rule 4.
(2)        If a health care provider provides more than one kind of treatment, each of the treatments provided must meet the relevant standard applying to that particular treatment.
6.               Treatments provided by hospitals and health care organisations
(1)        In this rule:
(a)                    treatment provided by a hospital is taken to include treatment provided at a hospital or with the direct involvement of a hospital, including treatment provided by a health care provider who is:
(i)                      authorised by the hospital to provide the treatment; or
(ii)                    under the management or control of a health care provider referred to in subparagraph (a) (i); and
(b)                   treatment provided by a health care organisation is taken to include treatment provided by a health care provider who is:
(i)                      authorised by the organisation to provide the treatment; or
(ii)                    under the management or control of a health care provider referred to in subparagraph (b) (i).
(2)        The standard for treatment provided by a hospital or health care organisation is that:
(a)                    for a hospital―if the hospital is required under a State or Territory law to have a permission or approval, or be registered, in the State or Territory in which it operates, so as to operate as a hospital and to provide the treatment in that State or Territory, it has the permission or approval, or is registered, under that law; and
Note:   'Hospital' is defined in the Act.
(b)                   for a health care organisation, including where the organisation is providing treatment on behalf of a hospital:
(i)                      if the organisation is required under a State or Territory law to have a permission or approval, or be registered, to provide the treatment in the State or Territory, it has the permission or approval, or is registered, under that law; and
(ii)                    the organisation must be:
(A)                  accredited or certified by an appropriate accrediting body; or
(B)                  formally engaged in the process of an appropriate accrediting body to be accredited or certified by that body, where 'formally engaged' means having made a valid application to the body for accreditation or certification, the application has been accepted and the applicant is undertaking the requirements of the body in the timeframes required; and
(c)                    the treatment must be provided by a health care provider who meets the standard in these Rules relevant to the provision of that treatment.
7.               Treatments by health care providers regulated under State and Territory laws
(1)        If a treatment is provided in a State or Territory where a law of that State or Territory prohibits the provision of the treatment without a permission or approval, or registration, to provide a treatment of that kind, the standard for the treatment is that the health care provider providing the treatment must have the permission or approval, or be registered, under that law.
(2)        A person who has a permission, approval or registration as required by subrule (1) but also provides treatment of a type referred to in rule 8, 9 or 10 which is not of a kind covered by the permission, approval or registration must comply with rule 8, 9 or 10, as the case may be, in respect of the other treatment.
Note:   This rule covers medical practitioners, allied health professionals and others who meet requirements imposed under State and Territory laws in respect of the provision of certain health services.
8.               Treatments provided by podiatric surgeons
If the treatment is of a kind practised by a podiatric surgeon, the standard for that kind of treatment is that it must be provided by a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.
9.               Treatments provided by allied health professionals
(1)        If the treatment is a service within a field mentioned in regulation 3A of the Health Insurance Regulations 1975 as in force from time to time, the standard is that the treatment within that field must be provided by an allied health professional who is qualified in that field.
(2)        In subrule (1), an allied health professional will be qualified in the field if he or she meets the qualification requirements for a service within that field as specified in Schedule 1 of the Health Insurance (Allied Health Services) Determination 2007 or if that instrument is repealed and remade, with or without modifications, the remade instrument.
(3)        If the treatment is provided by an allied health professional practising in a field not mentioned in subrule (1), the standard is that the allied health professional must be a member of a professional organisation which covers health care providers who provide that type of treatment and which is an ordinary member of Allied Health Professions Australia Ltd or any successor organisation.
10.            Treatments provided by other health care providers
If the treatment is provided by a health care provider who is not referred to in subrule 7(1) or rule 8 or 9, the standard for that treatment is that the health care provider providing the treatment must be a member of a professional organisation which covers health care providers who provide that type of treatment (the profession) and which:
(a)                    is a national entity which has membership requirements for the profession; and
(b)                   provides assessment of the health care provider in terms of the appropriate level of training and education required to practise in that profession; and
(c)                    administers a continuing professional development scheme in which the health care provider is required, as a condition of membership, to participate; and
(d)                   maintains a code of conduct which the health care provider must uphold in order to continue to be a member; and
(e)                    maintains a formal disciplinary procedure, which includes a process to suspend or expel members, and an appropriate complaints resolution procedure.
11.            Premises where treatments are provided
If a treatment is provided in a State or Territory where a law of that State or Territory requires the premises in which the treatment is provided to have a permission or approval to provide a treatment of that kind, the standard for the treatment is that the premises must have the permission or approval under that law.
Note
1.       All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003.  See www.frli.gov.au