Commonwealth Consolidated Acts

PRIVATE HEALTH INSURANCE ACT 2007

TABLE OF PROVISIONS

           Long Title

            

CHAPTER 1--Introduction
            

   PART 1-1--INTRODUCTION

           Division 1--Preliminary

   1.1.    Short title  
   1.5.    Commencement  
   1.10.   Identifying defined terms  
   1.15.   Extension to Norfolk Island  

           Division 3--Overview of this Act

   3.1.    What this Act is about  
   3.5.    Incentives (Chapter 2)  
   3.10.   Complying health insurance products (Chapter 3)  
   3.15.   Health insurance business, health benefits funds and miscellaneous obligations of private health insurers (Chapter 4)  
   3.20.   Enforcement (Chapter 5)  
   3.25.   Administration (Chapter 6)  
   3.30.   Dictionary (Schedule 1)  

           Division 5--Constitutional matters

   5.1.    Meaning of insurance  
   5.5.    Act not to apply to State insurance within that State  
   5.10.   Compensation for acquisition of property  
            

CHAPTER 2--Incentives
            

   PART 2-1--INTRODUCTION

           Division 15--Introduction

   15.1.   What this Chapter is about  

   PART 2-2--PREMIUMS REDUCTION SCHEME

           Division 20--Introduction

   20.1.   What this Part is about  
   20.5.   Private Health Insurance (Incentives) Rules  

           Division 22--PHIIB, PHII benefit and related concepts

              Subdivision 22-A--PHIIB, PHII benefit and related concepts

   22.1.   Application of Subdivision  
   22.5.   Meaning of PHIIB  
   22.10.  Meaning of PHII benefit  
   22.15.  Meaning of share of the PHII benefit --single PHIIB  
   22.20.  Meaning of share of the PHII benefit --multiple PHIIBs  
   22.25.  Application of subsection 22 - 15(1) after a person 65 years or over ceases to be covered by policy  

              Subdivision 22-B--Private health insurance tiers

   22.30.  Private health insurance tiers  
   22.35.  Private health insurance singles thresholds  
   22.40.  Private health insurance family thresholds  
   22.45.  Indexation  

           Division 23--Premiums reduction scheme

              Subdivision 23-A--Amount of reduction

   23.1.   Reduction in premiums  

              Subdivision 23-B--Participation in the premiums reduction scheme

   23.15.  Registration as a participant in the premiums reduction scheme  
   23.20.  Refusal to register  
   23.30.  Participants who want to withdraw from scheme  
   23.35.  Revocation of registration  
   23.40.  Variation of registration  
   23.45.  Retention of applications by private health insurers  

   PART 2-3--LIFETIME HEALTH COVER

           Division 31--Introduction

   31.1.   What this Part is about  
   31.5.   Private Health Insurance (Lifetime Health Cover) Rules  

           Division 34--General rules about lifetime health cover

   34.1.   Increased premiums for person who is late in taking out hospital cover  
   34.5.   Increased premiums for person who ceases to have hospital cover after his or her lifetime health cover base day  
   34.10.  Increased premiums stop after 10 years' continuous cover  
   34.15.  Meaning of hospital cover  
   34.20.  Meaning of permitted days without hospital cover  
   34.25.  Meaning of lifetime health cover base day  
   34.30.  When a person is overseas or enters Australia  

           Division 37--Exceptions to the general rules about lifetime health cover

   37.1.   People born on or before 1 July 1934  
   37.5.   People over 31 and overseas on 1 July 2000  
   37.7.   Person yet to turn 31  
   37.10.  Hardship cases  
   37.15.  Increases cannot exceed 70% of base rates  
   37.20.  Joint hospital cover  

           Division 40--Administrative matters relating to lifetime health cover

   40.1.   Notification to insured people etc.  
   40.5.   Evidence of having had hospital cover, or of a person's age  

   PART 2-4--EXCESS LEVELS FOR MEDICARE LEVY AND MEDICARE LEVY SURCHARGE PURPOSES

           Division 42--Introduction

   42.1.   What this Part is about  

           Division 45--Excess levels for medicare levy and medicare levy surcharge purposes

   45.1.   Excess level amounts  
            

CHAPTER 3--Complying health insurance products
            

   PART 3-1--INTRODUCTION

           Division 50--Introduction

   50.1.   What this Chapter is about  
   50.5.   Private Health Insurance Rules relevant to this Chapter  

   PART 3-2--COMMUNITY RATING

           Division 55--Principle of community rating

   55.1.   What this Part is about  
   55.5.   Principle of community rating  
   55.10.  Closed products, and terminated products and product subgroups  
   55.15.  Pilot projects  

   PART 3-3--REQUIREMENTS FOR COMPLYING HEALTH INSURANCE PRODUCTS

           Division 60--Introduction

   60.1.   What this Part is about  

           Division 63--Basic rules about complying health insurance products

   63.1.   Obligation to ensure products are complying products  
   63.5.   Meaning of complying health insurance product  
   63.10.  Meaning of complying health insurance policy  

           Division 66--Community rating requirements

   66.1.   Community rating requirements  
   66.5.   Premium requirement  
   66.10.  Minister's approval of premiums  
   66.15.  Entitlement to benefits for general treatment  
   66.20.  Different amount of benefits depending on where people live  
   66.25.  Different amounts of benefits for travel or accommodation  

           Division 69--Coverage requirements

   69.1.   Coverage requirements  
   69.5.   Meaning of cover  
   69.10.  Meaning of hospital - substitute treatment  

           Division 72--Benefit requirements for policies that cover hospital treatment

   72.1.   Benefit requirements  
   72.5.   Rules requirement in relation to provision of benefits  
   72.10.  Minimum benefits for medical devices and human tissue products  
   72.11.  Meaning of medical device  
   72.12.  Meaning of human tissue product  
   72.15.  Fees for certain activities  
   72.20.  Delisting because of unpaid fees or levy  
   72.25.  Minister may direct that activities not be carried out  
   72.27.  Matters to have regard to before exercising certain powers  
   72.30.  When cost - recovery fee must be paid  
   72.35.  Payment of cost - recovery fee  
   72.40.  Recovery of fee  
   72.45.  Other matters  

           Division 75--Waiting period requirements

   75.1.   Waiting period requirements  
   75.5.   Meaning of waiting period  
   75.10.  Meaning of transfers  
   75.15.  Meaning of pre - existing condition  

           Division 78--Portability requirements

   78.1.   Portability requirements  

           Division 81--Quality assurance requirements

   81.1.   Quality assurance requirements  

           Division 84--Enforcement of this Part

   84.1.   Offence: advertising, offering or insuring under non - complying policies  
   84.5.   Offence: directors and chief executive officers liable if systems not in place to prevent breaches  
   84.10.  Injunction in relation to non - complying policies  
   84.15.  Remedies for people affected by non - complying policies  

   PART 3-4--OBLIGATIONS RELATING TO COMPLYING HEALTH INSURANCE PRODUCTS

           Division 90--Introduction

   90.1.   What this Part is about  

           Division 93--Giving information to consumers

   93.1.   Maintaining up to date private health information statements  
   93.5.   Meaning of private health information statement  
   93.10.  Making private health information statements available  
   93.15.  Giving information to newly insured people  
   93.20.  Keeping insured people up to date  
   93.25.  Giving advance notice of detrimental changes to rules  
   93.30.   Failure to give information to consumers  

           Division 96--Giving information to the Department and the Private Health Insurance Ombudsman

   96.1.   Giving private health information statements on request  
   96.5.   Giving private health information statements for new products  
   96.10.  Giving updated private health information statements  
   96.15.  Giving additional information on request  
   96.20.  Failure to give information to Department or Private Health Insurance Ombudsman  
   96.25.  Giving information required by the Private Health Insurance (Complying Product) Rules  

           Division 99--Transfer certificates

   99.1.   Transfer certificates  

           Division 102--Private health insurers to offer cover for hospital treatment

   102.1.  Private health insurers to offer cover for hospital treatment  
            

CHAPTER 4--Health insurance business, health benefits funds and miscellaneous obligations of private health insurers
            

   PART 4-1--INTRODUCTION

           Division 110--Introduction

   110.1.  What this Chapter is about  

   PART 4-2--HEALTH INSURANCE BUSINESS

           Division 115--Introduction

   115.1.  What this Part is about  
   115.5.  Private Health Insurance (Health Insurance Business) Rules  
   115.10. Whether a business etc. is health insurance business  

           Division 121--What is health insurance business?

   121.1.  Meaning of health insurance business  
   121.5.  Meaning of hospital treatment  
   121.7.  Conditions on declarations of hospitals  
   121.8.  Application for inclusion of hospital in a class  
   121.8A. Minister to decide application  
   121.8B. Period of inclusion of hospital in a class  
   121.8C. Revocation of inclusion of hospital in a class  
   121.8D. Private Health Insurance (Health Insurance Business) Rules  
   121.10. Meaning of general treatment  
   121.15. Extension to employee health benefits schemes  
   121.20. Exception: accident and sickness insurance business  
   121.25. Exception: liability insurance business  
   121.30. Exception: insurance business excluded by the Private Health Insurance (Health Insurance Business) Rules  

   PART 4-4--HEALTH BENEFITS FUNDS

           Division 131--Health benefits funds

   131.1.  What this Part is about  
   131.5.  Private Health Insurance (Health Benefits Fund Policy) Rules  
   131.10. Meaning of health benefits fund  
   131.15. Meaning of health - related business  
   131.20. Risk equalisation jurisdictions  
   131.25. Operation of health - related businesses through health benefits funds  

   PART 4-5--MISCELLANEOUS OBLIGATIONS OF PRIVATE HEALTH INSURERS

           Division 157--Introduction

   157.1.  What this Part is about  
   157.5.  Private Health Insurance (Data Provision) Rules  

           Division 169--Notification obligations

   169.10. Private health insurers to notify any changes to rules  

           Division 172--Other obligations

   172.5.  Agreements with medical practitioners  
   172.10. Private health insurers to give information to Secretary  
   172.15. Restrictions on payment of pecuniary penalties etc.  
            

CHAPTER 5--Enforcement
            

   PART 5-1--INTRODUCTION

           Division 180--Introduction

   180.1.  What this Chapter is about  

   PART 5-2--GENERAL ENFORCEMENT METHODS

           Division 185--What this Part is about

   185.1.  Introduction  
   185.5.  Meaning of enforceable obligation  

           Division 188--Performance indicators

   188.1.  Performance indicators  

           Division 191--Explanation of private health insurer's operations

   191.1.  Minister may seek an explanation from a private health insurer  
   191.5.  Minister must respond to insurer's explanation  

           Division 194--Investigation of private health insurer's operations

   194.1A. Purposes for which powers may be exercised etc.  
   194.1.  Minister may investigate a private health insurer  
   194.5.  Notice to give information  
   194.10. Notice to produce documents  
   194.15. Notice to give evidence  
   194.20. Offences in relation to investigation notices  
   194.25. Authorisation to examine books and records etc.  
   194.35. Minister must notify outcome of investigation  

           Division 197--Enforceable undertakings

   197.1.  Minister may accept written undertakings given by a private health insurer  
   197.5.  Enforcement of undertakings  

           Division 200--Ministerial directions

   200.1.  Minister may give directions  
   200.5.  Direction requirements  

           Division 203--Remedies in the Federal Court

   203.1.  Minister may apply to the Federal Court  
   203.5.  Declarations of contravention  
   203.10. Pecuniary penalty order  
   203.15. Compensation order  
   203.20. Adverse publicity order  
   203.25. Other order  
   203.30. Time limit for declarations and orders  
   203.35. Civil evidence and procedure rules for declarations and orders  
   203.40. Civil proceedings after criminal proceedings  
   203.45. Criminal proceedings during civil proceedings  
   203.50. Criminal proceedings after civil proceedings  
   203.55. Evidence given in proceedings for penalty not admissible in criminal proceedings  
   203.60. Minister may require person to assist  
   203.65. Relief from liability for contravening an enforceable obligation  
   203.70. Powers of Federal Court  

           Division 206--Revoking entitlement to offer rebate as a premium reduction

   206.1.  Revocation of status of participating insurer  
            

CHAPTER 6--Administration
            

   PART 6-1--INTRODUCTION

           Division 230--Introduction

   230.1.  What this Chapter is about  

   PART 6-4--ADMINISTRATION OF PREMIUMS REDUCTION SCHEME

           Division 276--Introduction

   276.1.  What this Part is about  

           Division 279--Reimbursement of participating insurers and powers of Chief Executive Medicare

              Subdivision 279-A--Reimbursement of private health insurers for premiums reduced under scheme

   279.1.  Participating insurers may claim reimbursement  
   279.5.  Participating insurers  
   279.10. Requirements for claims  
   279.15. Amounts payable to the private health insurer  
   279.20. Notifying private health insurers if amount is not payable  
   279.25. Additional payment if insurer claims less than entitlement  
   279.30. Additional payment if insurer makes a late claim  
   279.35. Content and timing of application  
   279.40. Decision on application  
   279.45. Reconsideration of decisions  

              Subdivision 279-B--Powers of Chief Executive Medicare in relation to participating insurers

   279.50. Audits by Chief Executive Medicare  
   279.55. Chief Executive Medicare may require production of applications  

           Division 282--Recovery of amounts and other matters

              Subdivision 282-A--When and how payments can be recovered

   282.1.  Recovery of payments  
   282.5.  Interest on amounts recoverable  
   282.10. Chief Executive Medicare may set off debts against amounts payable  
   282.15. Reconsideration of certain decisions under this Division  

              Subdivision 282-AA--Recovery of certain amounts by Commissioner of Taxation

   282.16. Administration of this Subdivision by Commissioner of Taxation  
   282.17. Subdivision operates in addition to Subdivision 282 - A  
   282.18. Liability for excess private health insurance premium reduction or refund  
   282.19. When general interest charge payable  

              Subdivision 282-B--Miscellaneous

   282.20. Notification requirements--private health insurers  
   282.25. Use etc. of information relating to another person  
   282.30. Information to be provided to the Commissioner of Taxation  
   282.35. Delegation  
   282.40. Appropriation  

   PART 6-6--PRIVATE HEALTH INSURANCE LEVIES

           Division 304--Introduction

   304.1.  What this Part is about  
   304.5.  Private Health Insurance (Levy Administration) Rules  
   304.10. Meaning of private health insurance levy  

           Division 307--Collection and recovery of private health insurance levies

   307.1.  When private health insurance levy must be paid  
   307.5.  Late payment penalty  
   307.10. Payment of levy and late payment penalty  
   307.15. Recovery of levy and late payment penalty  
   307.20. Waiver of late payment penalty  
   307.30. Other matters  

           Division 310--Returns, requesting information and keeping records: private health insurers

   310.1.  Returns relating to complaints levy  
   310.5.  Insurer must keep records  
   310.10. Power to request information from insurer  

           Division 313--Power to enter premises and search for documents related to complaints levy

   313.1.  Authorised officer may enter premises with consent  
   313.5.  Authorised officer may enter premises under warrant  
   313.10. Announcement before entry  
   313.15. Executing a warrant to enter premises  
   313.20. Identity cards  

   PART 6-7--PRIVATE HEALTH INSURANCE RISK EQUALISATION SPECIAL ACCOUNT

           Division 318--Private Health Insurance Risk Equalisation Special Account

   318.1.  Private Health Insurance Risk Equalisation Special Account  
   318.5.  Credits to the Risk Equalisation Special Account  
   318.10. Purpose of the Risk Equalisation Special Account  
   318.15. Record keeping  

   PART 6-8--DISCLOSURE OF INFORMATION

           Division 323--Disclosure of information

   323.1.  Prohibition on disclosure of information  
   323.5.  Authorised disclosure: official duties  
   323.10. Authorised disclosure: sharing information about insurers among agencies  
   323.15. Authorised disclosure: sharing information about insurers other than among agencies  
   323.20. Authorised disclosure: public interest  
   323.25. Authorised disclosure: by the Secretary if authorised by affected person  
   323.30. Authorised disclosure: court proceedings  
   323.40. Offence: disclosure of information obtained by certain authorised disclosures  
   323.45. Offence: soliciting disclosure of information  
   323.50. Offence: use etc. of unauthorised information  
   323.55. Offence: offering to supply protected information  

   PART 6-9--REVIEW OF DECISIONS

           Division 328--Review of decisions

   328.1.  What this Part is about  
   328.5.  ART review of decisions  

   PART 6-10----MISCELLANEOUS

           Division 333--Miscellaneous

   333.1.  Delegation by Minister  
   333.5.  Delegation by Secretary  
   333.10. Approved forms  
   333.15. Signing approved forms  
   333.20. Private Health Insurance Rules made by the Minister  
   333.25. Private Health Insurance Rules made by APRA  
   333.30. Regulations  
           SCHEDULE 1 Dictionary