Private Health Insurance (Complying Product) Amendment Rules 2009 (No. 3)
I, PENNY SHAKESPEARE, delegate of the Minister for Health and Ageing, make these Rules under item 3 of the table in section 333-20 of the Private Health Insurance Act 2007.
Dated 9 July 2009
Private Health Insurance Branch
Acute Care Division
Department of Health and Ageing
Part 1 Preliminary 3
1. Name of Rules 3
2. Commencement 3
3. Amendment of the Private Health Insurance (Complying Product) Rules 2009 (No. 1) 3
Schedule ― Amendments 4
Part 1 Preliminary
1. Name of Rules
These Rules are the Private Health Insurance (Complying Product) Amendment Rules 2009 (No. 3).
These Rules commence on the day after they are registered.
3. Amendment of the Private Health Insurance (Complying Product) Rules 2009 (No. 1)
The Schedule amends the Private Health Insurance (Complying Product) Rules 2009 (No. 1).
Schedule – Amendments
 Schedule 4―Standard information statements: permitted content
Insert Schedule 4, Part 3:
Part 3―general treatment
[If available with hospital policy only]:
The statement is to be placed below the premium on the general treatment SIS if the policy cannot be purchased on its own. Not required for a combined policy.
(must be purchased with a hospital policy) (where the general treatment policy can be purchased with any hospital policy offered by the insurer)
(must be purchased with certain hospital policies) (where there is a set range of hospital policies the general policy can be combined with)
Preferred Service Provider Arrange-ments:
Describes special arrangements with particular providers.
Text in this box must not exceed 3 lines, including the line with the heading.
Free text up to 3 lines (including the line with the heading)
By using this health insurer’s “preferred providers” you will have lower out of pocket costs on [insert services or use many allied health] services and have access to more “no gap” services. A list of “preferred providers” is available from the health insurer.
Insurers that do not have preferred provider arrangements must use this phrase.
This health insurer does not operate a preferred provider scheme.
A list of a number of services covered by general treatment.
As provided in form. Additions, deletions, modifications or rearrangements not permitted
Indicates if the service is covered or not.
A service is considered to be covered if a benefit is paid for at least one of the examples in the “examples of maximum benefits” columns.
Ambulance is considered to be covered if the description in the “examples of maximum benefits” column indicates it has comprehensive cover or partial cover.
ü (service is covered)
û (service is not covered)
¬ (see note below)
n/a (for ambulance where it is covered by the state government)
‘Waiting Period (max Months)’ column:
The maximum period of time before a member can claim benefits.
Waiting periods for ambulance can be expressed in days or months.
Choose one of…:
the service is not covered
waiting period in months
no waiting period
short term waiting period for ambulance cover
‘Benefit Limits (per 12 months)’ column:
Limits on benefits.
If there is a limit on general dental, but not on preventative dental, the “(no limit on preventative dental)” words should be used.
If services with combined limits are in adjacent rows in the table, lines between the boxes can be deleted and the limit and list of combined services only written once.
If a sub limit applies on any of these services, use “Sub-limits apply”.
Combined limits for services in non-adjacent boxes must be written in this field in the first occurrence; thereafter “(Combined limit – see [service])”, inserting the name of the service where the list first occurs.
If benefit limits increase over time for any services, only the lowest payable benefit is to be used.
Any combination of:
· $[number] per person
· $[number] per service
· $[number] per policy
If more than one of the above phrases is used, they are to be linked by the words “up to” eg $X per person up to $Y per service up to $Z per policy.
The following may also be used:
· $[number] lifetime limit AND/OR
· ([number] appliance(s)/service(s) [delete one] every [number] years (if there is a limit on claims every X years) AND/OR
· (combined limit for [list services]) OR
· (combined limit – see [service]) AND/OR
· Sub-limits apply AND/OR
· (no limit on preventative dental) OR
· No annual limit OR
· - (service is not covered)
For combined limits, choose from services:
· general dental
· major dental
· non PBS pharmaceuticals
· remedial massage
· hearing aids
· blood glucose monitors
· other services
‘Examples of Maximum Benefits’ column:
Examples of the maximum benefit paid for the listed treatments when an insured person visits a practitioner who is not a ‘preferred service provider’.
Only the examples listed may be used.
A percentage figure can only be used where the insurer does not have a maximum limit on the particular item, other than an annual limit. If an insurer pays a benefit that is a percentage of the charge up to a specified dollar limit (i.e. a limit for that item, separately specified from the annual limit), then the specified dollar limit must be used.
General dental, major dental and endodontic examples must be listed even if the service is not covered.
Other examples should be deleted if not covered.
The maximum benefit paid on the following dental item numbers are to be used for the listed examples:
Periodic oral examination – 012
Scale & clean – 114
Fluoride treatment – 121
Surgical tooth extraction – 322
Full crown veneered – 615
Filling of one root canal – 417
Braces for upper & lower teeth, including removal plus fitting of retainer – 881
If surgical tooth extraction is covered under general dental instead of major dental, this example can be moved to the general dental box.
Orthodontics – if different benefits are offered for treatments provided for orthodontists and general dentists, the maximum benefit for an orthodontist should be used.
Optical – if benefits for frames and lenses are paid separately, add together the maximum benefit for each component.
Initial/subsequent visit examples are for individual sessions.
If there is no maximum benefit for the examples listed, the annual benefit limit figure should be used.
Comprehensive cover can only be used to describe ambulance cover where the product at least covers 100% medically necessary ambulance transport. Otherwise, ‘partly covered’ should be used.
amount of maximum benefit
[number]% of charge
where there is no maximum benefit limit on the particular item, other than an annual limit.
For general dental, major dental and endodontic if not covered
Other services if not covered – delete example(s)
Ambulance – one of:
· Comprehensive cover (see insurer for details) OR
· Partly covered (see insurer for details) OR
· See hospital policy information (if part of a combined product in states those where ambulance is covered by the State government) OR
· Covered by State government OR
· - (not covered)
¬ Special Features:
This space must be used to describe special features of the product where ¬ is used.
Free text up to 4 lines.
Health Care Programs and Other Features: (box)
OPTIONAL – this box may be used to describe (for example):
· services covered that are not listed in the first column of the main table
· discounts for direct debit, paying in advance etc
· preventative health/health management programs
· loyalty bonus/incentive schemes
· other significant product features
Free text up to 4 lines, including the line with the heading.
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.
2. These Rules amend the Private Health Insurance (Complying Product) Rules 2009 (No.1) which commenced on 1 July 2009.