Private Health Insurance (Benefit Requirements) Rules 2011

Transcription

1 Private Health Insurance (Benefit Requirements) Rules 2011 As amended Made under item 3A of the table in section of the Private Health Insurance Act This compilation was prepared on 21 June 2012 taking into account amendments up to the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 4). Prepared by the Department of Health and Ageing, Canberra 1

2 Contents Contents Part 1 Preliminary 3 1. Name of Rules 3 2. Commencement and Revocation 3 3. Definitions 3 4. Psychiatric care, rehabilitation and palliative care 5 5. Other hospital treatments 5 6. Benefit not to exceed hospital fees or charges 5 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 6 Schedule 2 Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, South Australia and Western Australia 17 Schedule 3 Same-day accommodation: hospitals in all States/Territories 18 Schedule 4 Nursing-home type patient accommodation: hospitals in all States/Territories 31 Schedule 5 Second-tier default benefits 34 Notes 50 2

3 Part 1 Preliminary Part 1 Preliminary 1. Name of Rules These Rules are the Private Health Insurance (Benefit Requirements) Rules Commencement and Revocation (1) These Rules commence on 1 November 2011, or if registered after 1 November 2011, the day after registration. (2) These Rules revoke the Private Health Insurance (Benefit Requirements) Rules Definitions In these Rules: Act means the Private Health Insurance Act 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 fee in the MBS means the Schedule fee as defined in subsection 8 (1A) of the Health Insurance Act general medical services table means the table prescribed under subsection 4 (1) of the Health Insurance Act insurer means a private health insurer. item has the same meaning as in subsection 3 (1) of the Health Insurance Act MBS comprises the: (a) general medical services table; (b) diagnostic imaging services table; and (c) pathology services table. 3

4 Part 1 Preliminary 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 pathology services table means the table prescribed under subsection 4A (1) of the Health Insurance Act policy means a complying health insurance policy. private hospital means a hospital in respect of which there is in force a statement under subsection (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 public hospital means a hospital in respect of which there is in force a statement under subsection (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. 4

5 Part 2 Minimum benefit requirements 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 nursinghome 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. 5

6 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 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; and Note: (c) The definition of hospital treatment in section 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 (1) (c) of the Act. 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: 2. Minimum benefit 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. (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 Accommodation at private hospitals in all States/Territories Class of patient Advanced surgical patient - first 14 days $384 - over 14 days $266 Minimum benefit payable per night 6

7 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Surgical patient or obstetric patient - first 14 days $356 - over 14 days $266 Psychiatric patient - first 42 days $ days $309 - over 65 days $266 Rehabilitation patient - first 49 days $ days $309 - over 65 days $266 Other patients - first 14 days $309 - over 14 days $266 Table 2 Victoria: shared ward accommodation at a public hospital Class of patient Advanced surgical patient - first 14 days $384 - over 14 days $266 Surgical patient or obstetric patient - first 14 days $356 - over 14 days $266 Psychiatric patient - first 42 days $ days $309 - over 65 days $266 Rehabilitation patient - first 49 days $ days $309 - over 65 days $266 Other patients - first 14 days $309 - over 14 days $266 Minimum benefit payable per night 7

8 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania Table 3 Tasmania: shared ward accommodation at a public hospital Class of patient Minimum benefit payable per night Advanced surgical patient - first 14 days $384 - over 14 days $266 Surgical patient or obstetric patient - first 14 days $356 - over 14 days $266 Psychiatric patient - first 42 days $ days $309 - over 65 days $266 Rehabilitation patient - first 49 days $ days $309 - over 65 days $266 Other patients - first 14 days $309 - over 14 days $266 8

9 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 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 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 (2) (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 item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS greater than $837.05:

10 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania

11 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 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, (excluding caesarean), 16525, or 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 and (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 or 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: 11

12 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania (a) (b) (c) Note: 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 preoperative period; or 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 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). The effect of the reference in subclause (2) (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 item numbers for this clause are the following items in the MBS, but only where those items have a fee in the MBS within the range of $ to $837.05:

13 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania

14 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania

15 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 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: 8. Rehabilitation patient 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'. 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: 9. Other patient 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'. (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'. 15

16 Schedule 1 Overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania 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. 16

17 Schedule 2 Overnight accommodation: shared accommodation at public hospitals in the ACT, NSW, Northern Territory, Queensland, Southern Australia and Western Australia Schedule 2 Overnight accommodation: shared ward accommodation at public hospitals in the ACT, NSW, 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; and Note: (c) The definition of hospital treatment in section 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 (1) (c) of the Act. 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: 2. Minimum benefit 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. 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 State/Territory Minimum benefit payable per night ACT $318 NSW $318 Northern Territory $318 Queensland $324 South Australia $318 Western Australia $318 17

18 Schedule 3 Same day accommodation: hospitals in all States/Territories 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: Note 2: 2. Minimum benefit 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. The definition of hospital treatment in section 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 (1) (c) of the Act. (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, Table 1 as those bands are described in Part 2 of this Schedule. Public hospitals Band 1 Band 2 Band 3 Band 4 NSW $230 $257 $283 $318 ACT $230 $257 $283 $318 Northern Territory $230 $262 $305 $318 Queensland $ $264 $291 $324 South Australia $230 $262 $290 $318 Tasmania $223 $265 $308 $356 Victoria $225 $266 $310 $356 Western Australia $260 $260 $260 $260 18

19 Schedule 3 Same day accommodation: hospitals in all States/Territories Table 2 Private hospitals $199 $251 $305 $356 19

20 Schedule 3 Same day accommodation: hospitals in all States/Territories 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: 4. Band 1 These procedures normally require hospital treatment that does not include part of an overnight stay. (1) Hospital treatment that involves a professional service of the type identified by the MBS item number specified in this subclause is Band 1 treatment for the purposes of the tables in clause 2 of this Schedule: (a) category 3 therapeutic procedures, being the items below in the general medical services table: T1: Miscellaneous Therapeutic Procedures: T8: Surgical Operations: (b) ; and category 5 diagnostic imaging services, being the items below in the diagnostic imaging services table: I1: Ultrasound: ; and (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 this clause is a non-band specific Type B day procedure

21 Schedule 3 Same day accommodation: hospitals in all States/Territories (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 In this Schedule: Band 2 treatment means procedures, other than those that are Band 1 treatment, carried out under local anaesthetic with no sedation. 21

22 Schedule 3 Same day accommodation: hospitals in all States/Territories 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. Note: These procedures normally do not require hospital treatment. Items in the general medical services table The following items are items in the general medical services table. Category 1 Attendances A1:

23 Schedule 3 Same day accommodation: hospitals in all States/Territories A2: A3: A4: A28: A5: A6: A7: A8: A9: A12: A13:

24 Schedule 3 Same day accommodation: hospitals in all States/Territories A15: A17: A18: A19: A20: A21: A22: A23: A24: A25: A26:

25 Schedule 3 Same day accommodation: hospitals in all States/Territories A27: 4001 M3: M5: Category 2 Diagnostic procedures & investigations D1: D2: Category 3 Therapeutic procedures T1:

26 Schedule 3 Same day accommodation: hospitals in all States/Territories T2: T3: T4: T6: T7: T8: T11:

27 Schedule 3 Same day accommodation: hospitals in all States/Territories Category 4 Oral and maxillofacial O1: O3: O7: O9: O10: Items in the diagnostic imaging services table The following items are items in the diagnostic imaging services table. Category 5 Diagnostic Imaging Services I1: , I2:

28 Schedule 3 Same day accommodation: hospitals in all States/Territories I3: , I4: I5: Category 6 Pathology services The following items are items in the pathology services table. P1:

29 Schedule 3 Same day accommodation: hospitals in all States/Territories P2: P3: P4: P5:

30 Schedule 3 Same day accommodation: hospitals in all States/Territories P6: P7: P8: P9: P10: P11: P13: Category 8 Miscellaneous Services The following items are items in the miscellaneous services table. M13:

31 Schedule 4 - Nursing home type patient accommodation: hospitals in all States/Territories 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: 2. Interpretation The definition of hospital treatment in section 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 (1) (c) of the Act. 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: Note 2: Note 3: 3. Application 'Continuous period of hospitalisation' is defined in rule 3 of Part 1 of these Rules. Clause 4 deals with nursing-home type patients whose care needs change to requiring acute care. 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. (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. 31

32 Schedule 4 - Nursing home type patient accommodation: hospitals in all States/Territories (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 Table 1 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. Public hospital: State/Territory Minimum benefit per night NSW $ Northern Territory $75.83 Queensland $ South Australia $ Tasmania $ Victoria $ ACT $ Western Australia $

33 Schedule 4 - Nursing home type patient accommodation: hospitals in all States/Territories Table 2 Private hospitals $

34 Schedule 5 Second-tier default benefits Schedule 5 Second-tier default benefits 1. Interpretation (1) In this Schedule: facility means a private hospital specified in clause 4 of this Schedule. (2) In this Schedule, except in subclause (4) of this clause, the ACT is taken to be part of NSW and the Northern Territory is taken to be part of the State of South Australia. (3) In this Schedule, private hospitals are comparable if they fall within the same category from the following list: (a) private hospitals which provide psychiatric care for at least 50% of the episodes of hospital treatment; (b) private hospitals which provide rehabilitation care for at least 50% of the episodes of hospital treatment; (c) private hospitals which do not fall into categories (a) or (b), with up to and including 50 licensed beds; (d) private hospitals which do not fall into categories (a) or (b) with more than 50 licensed beds and up to and including 100 licensed beds; (e) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, without an accident and emergency unit or a specialised cardiac care unit; (f) private hospitals which do not fall into categories (a) or (b), with more than 100 licensed beds, with either (or both) an accident and emergency unit or a specialised cardiac care unit; (g) private hospitals which only provide hospital treatment which does not include any part of an overnight stay. (4) In subclause (3), 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. 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 facility. Note: The definition of hospital treatment in section 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 (1) (c) of the Act. 34

35 Schedule 5 Second-tier default benefits 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) (b) 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 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 facility 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 facility or booked for hospital treatment at the facility (as opposed to merely being on the facility s waiting list) before the day that the hospital ceased to be a facility is the minimum benefit that would have applied if the hospital continued to be a facility 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 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 in force on 1 August of the first year with all such comparable private hospitals in the State in which the facility is located. (5) The formula for calculating the average charge for the equivalent episode of hospital treatment by an insurer in each State is as follows: R j n i 1 n R ji Where: j = i = group of equivalent episodes of hospital treatment under the insurer's negotiated agreements; 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; 35

36 Schedule 5 Second-tier default benefits R ji = charge for episode of hospital treatment type j in the negotiated agreement i R j = 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 facility 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; and (b) Note: Policy holders financial obligations under such levels of cover will still apply. must not include any charges: (i) referred to in the insurer's negotiated agreements for prostheses; and (ii) that are minimum benefits for prostheses 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. Facilities Table The hospitals specified in the table below are facilities for the purpose of this Schedule. Facility Name Address Abbotsford Private Hospital Cambridge Street, WEST LEEDERVILLE WA 6007 ACT Endoscopy 2/70 Kent Street, DEAKIN ACT 2600 Adelaide Day Surgery 18 North Terrace, ADELAIDE SA 5000 Adelaide Eye & Laser Centre 215 Greenhill Road, EASTWOOD SA 5063 Adelaide Surgicentre 89 King William Street, KENT TOWN SA

37 Schedule 5 Second-tier default benefits Aesthetic Day Surgery 14 Kensington Street, KOGARAH NSW 2217 Albury Day Surgery 4 Baker Court, ALBURY NSW 2640 Albury-Wodonga Private Hospital Allamanda Private Hospital 1125 Pemberton Street, ALBURY NSW Spendelove Avenue, SOUTHPORT QLD 4215 Armidale Private Hospital New England Regional Hospital, Armidale Campus, Rusden St, ARMIDALE NSW 2350 Ashford Community Hospital 55 Anzac Highway, ASHFORD SA 5035 Attadale Private Hospital 21 Hislop Road, ATTADALE WA 6156 Avenue Plastic Surgery 20 The Avenue, WINDSOR VIC 3181 Ballina Day Surgery Baringa Private Hospital Bathurst Private Hospital Suite 6, 46 Tamar Street, BALLINA NSW 2478 Mackays Road, COFFS HARBOUR NSW 2450 Gorman s Hill Road, BATHURST NSW 2795 Bedford Day Surgery 1284 South Road, CLOVELLY PARK SA 5042 Bega Valley Private Hospital 31 Parker Street, BEGA NSW 2550 Beleura Private Hospital 925 Nepean Highway, MORNINGTON VIC 3931 Bellbird Private Hospital 198 Canterbury Road, BLACKBURN SOUTH VIC 3130 Belmont Private Hospital 1220 Creek Road, CARINA QLD 4152 Bendigo Day Surgery 1-7 Chum Street, BENDIGO VIC 3550 Bentleigh Surgicentre 157 Jasper Road, BENTLEIGH VIC 3204 Berkeley Vale Private Hospital 8 Lorraine Avenue, BERKELEY VALE NSW 2261 Bondi Junction Private Hospital Level 1, 21 Spring Street, BONDI JUNCTION NSW 2022 Brindabella Endoscopy Centre Suite 7, 5 Dann Close, GARRAN ACT 2605 Brisbane Private Hospital 259 Wickham Terrace, BRISBANE QLD 4000 Brisbane Waters Private Hospital 21 Vidler Avenue, WOY WOY NSW 2256 Broadmeadow Day Surgery Brunswick Private Hospital 1 st Floor (Suite 1), 18 Lambton Road, BROADMEADOW NSW Moreland Road, BRUNSWICK VIC 3056 Suite 5, 102 Wises Road, MAROOCHYDORE QLD 4558 Buderim Gastroenterology Centre (Maroochydore) Bunbury Day Surgery 140 Spencer Street, BUNBURY WA 6230 Caboolture Private Hospital McKean Street, CABOOLTURE QLD 4510 Cabrini Brighton 243 New Street, BRIGHTON VIC 3186 Cabrini Health Elsternwick Rehabilitation Service Cabrini Hopetoun Rehabilitation Hospital 494 Glenhuntly Road, ELSTERNWICK VIC Hopetoun Road, ELSTERNWICK VIC

38 Schedule 5 Second-tier default benefits Cabrini Hospital Malvern Cabrini Hospital Prahran Cairns Central Day Hospital Wattletree Road, MALVERN VIC High Street, PRAHRAN EAST VIC 3181 Ground & 4 th Floors, Cairns Central Plaza, Aplin Street, CAIRNS QLD 4870 Cairns Day Surgery Grafton Street, CAIRNS QLD 4870 Cairns Private Hospital 1 Upward Street, CAIRNS QLD 4870 Caloundra Private Hospital Calvary Central Districts Hospital Calvary College Grove Rehabilitation Hospital Calvary Day Procedure Centre Calvary Health Care Tasmania (Hobart) Calvary Health Care Tasmania (Launceston) Calvary Health Care Tasmania - St John s Campus Calvary John James Hospital Calvary North Adelaide Hospital 96 Beerburrum Street, CALOUNDRA QLD Jarvis Road, ELIZABETH VALE SA North East Road, WALKERVILLE SA , 331, 333 Edward Street, WAGGA WAGGA NSW Augusta Road, LENAH VALLEY TAS Lyttleton Street, LAUNCESTON TAS Cascade Road, SOUTH HOBART TAS 7004 Strickland Crescent & 12 Napier Close, DEAKIN ACT 89 Strangways Terrace, NORTH ADELAIDE SA 5006 Calvary Private Hospital Hardy Avenue, WAGGA WAGGA NSW 2650 Calvary Private Hospital Haydon Drive, BRUCE ACT 2617 Calvary Wakefield Hospital 300 Wakefield Street, ADELAIDE SA 5000 Campbelltown Private Hospital 42 Parkside Crescent, CAMPBELLTOWN NSW 2560 Canberra Specialist Surgical Centre Level 3, Building 2, Equinox Business Park, 70 Kent Street, DEAKIN ACT 2600 Canossa Day Surgery Centre 169 Seventeen Mile Rocks Road, OXLEY QLD 4075 Capital Day Surgical Centre 2/9 Sydney Avenue, BARTON ACT 2600 Castle Hill Hospital Castlecrag Private Hospital Cecil Avenue, CASTLE HILL NSW Edinburgh Road, CASTLECRAG NSW 2068 Central Coast Day Hospital Suite 1, 2 Ilya Ave, ERINA NSW 2250 Charlestown Private Hospital Level 3, 250 Pacific Highway, CHARLESTOWN NSW 2290 Chermside Day Hospital Suite 9, Chermside Medical Complex, 956 Chermside Dialysis Unit Gympie Road, CHERMSIDE QLD Gympie Road, CHERMSIDE QLD 4032 Chesterville Day Hospital 28 Chesterville Road, CHELTENHAM VIC 3192 Churchill Day Surgery 136 Churchill Avenue, SUBIACO WA 6008 Coffs Harbour Day Surgical Centre 69 Albany Street, COFFS HARBOUR NSW

39 Schedule 5 Second-tier default benefits Como Private Hospital 152 Como Parade West, PARKDALE VIC 3195 Concept Day Hospital 218 Nicholson Road, SUBIACO WA 6008 Concord Private Hospital Coolenberg Day Surgery Burwood Road, CONCORD NSW Lake Road, PORT MACQUARIE NSW 2444 Corymbia House David Street, DANDENONG VIC 3175 Cotham Private Hospital 209 Cotham Road, KEW VIC 3101 Crows Nest Day Surgery Level 1, Clarke Street, CROWS NEST NSW 2065 Dalcross Adventist Hospital 28 Stanhope Road, KILLARA NSW 2071 Dandenong Eye Clinic & Day Surgery Centre Darwin Private Hospital Rocklands Drive, TIWI NT Falkiner Crescent, DANDENONG VIC 3175 Dee Why Endoscopy Unit 21/818 Pittwater Road, DEE WHY NSW 2099 Delmar Private Hospital 58 Quirk Street, DEE WHY NSW 2099 Delmont Private Hospital 298 Warrigal Road, GLEN IRIS VIC 3146 Diagnostic Endoscopy Centre 601/438 Victoria Street, DARLINGHURST NSW Leila Street, CANNINGTON WA 6107 Diaverum Cannington Dialysis Clinic Diaverum Diamond Valley Dialysis Clinic Diaverum North Melbourne Dialysis Clinic Diaverum Rockingham Dialysis Level 1, 35 McNicholl Street, Clinic ROCKINGHAM WA 6168 Diaverum Stirling Dialysis Clinic 1 Puccini Court, STIRLING WA 6021 Donvale Rehabilitation Hospital Dorset Rehabilitation Hospital 15 Grimshaw Street, GREENSBOROUGH VIC 3088 Level 1, Boundary Road, NORTH MELBOURNE VIC Doncaster Road, DONVALE VIC Derby Street, PASCOE VALE VIC 3044 Double Bay Day Surgery, The 20 Manning Road, DOUBLE BAY NSW 2028 Dubbo Private Hospital River Street, DUBBO NSW 2830 Dudley Private Hospital 261 March Street, ORANGE NSW 2800 Eastern Suburbs Private Hospital 8 Chapel Street, RANDWICK NSW 2031 Epping Surgery Centre 3/44 Oxford Street, EPPING NSW 2121 Epworth Cliveden 29 Simpson Street, EAST MELBOURNE VIC 3002 Epworth Eastern Hospital 1 Arnold Street, BOX HILL VIC 3128 Epworth Freemasons 166 Clarendon Street & 320 Victoria Parade, EAST MELBOURNE VIC 3002 Epworth Rehabilitation Brighton Wilson Street, BRIGHTON VIC 3186 Epworth Rehabilitation Camberwell 888 Toorak Road, CAMBERWELL VIC

40 Schedule 5 Second-tier default benefits Epworth Richmond 89 Bridge Road, RICHMOND VIC 3121 Essendon Day Procedure Centre Essendon Private Hospital Eye-Tech Day Surgeries Level 2, 665 Mt Alexander Road, MOONEE PONDS VIC Rosehill Road, ESSENDON WEST VIC 3040 Level 3, St Andrew's Place, North Street, SPRING HILL QLD 4000 Eye-Tech Day Surgeries Southside Sanders Street, UPPER MOUNT GRAVATT QLD 4122 Figtree Private Hospital 1 Suttor Place, FIGTREE NSW 2525 Flinders Private Hospital Flinders Drive, BEDFORD SA 5042 Forest Hill Dialysis Clinic Shops 26 & 27 Forest Hill Chase, Mahoneys Road, FOREST HILL VIC 3131 Forster Private Hospital South Street, FORSTER NSW 2428 Frances Perry House Frankston Private Day Surgery Friendly Society Private Hospital Fullarton Private Hospital Geelong Private Hospital Genea Day Surgery Genea IVF Liverpool Genea IVF Northwest Glen Iris Private Levels 6 and 7, cnr Grattan Street and Flemington Road, PARKVILLE VIC 3052 Lot T5, Levels 1 and 2, Frankston Flinders Road, FRANKSTON VIC Bingera Street, BUNDABERG QLD Fullarton Road, PARKSIDE SA 5063 cnr Ryrie & Bellarine Streets, GEELONG VIC 3220 Level 4, 321 Kent Street, SYDNEY NSW Bigge Street, LIVERPOOL NSW 2170 Level 1, Suite 101, 10 Norbrik Drive, BELLA VISTA NSW Warrigal Road, GLEN IRIS VIC 3146 Glen Osmond Surgicentre 45 Glen Osmond Road, EASTWOOD SA 5063 Glenferrie Private Hospital 29 Hilda Crescent, HAWTHORN VIC 3122 Glengarry Private Hospital 53 Arnisdale Road, DUNCRAIG WA 6023 Gosford Private Hospital Burrabil Avenue, GOSFORD NSW 2250 Greenslopes Private Hospital Newdegate Street, GREENSLOPES QLD 4120 Griffith Rehabilitation Hospital 13 Dunrobin Road, HOVE SA 5045 Gympie Private Hospital Channon Street, GYMPIE QLD 4570 Harley Place Day Surgery Suite 605, Harley Place, 251 Oxford Street, BONDI JUNCTION NSW 2022 Hartley Dialysis Clinic 17 Hartley Road, BRIGHTON SA 5048 Hastings Day Surgery cnr Parker & Savoy Streets, PORT MACQUARIE NSW 2444 cnr Macquarie and Day Streets, WINDSOR NSW 2756 Hawkesbury District Health Service Healthbridge Hawthorn Private 50 Burwood Road, HAWTHORN VIC 3122 Hospital Healthwoods Specialist Centre 53 Cowper Street, GRANVILLE NSW

41 Schedule 5 Second-tier default benefits Hervey Bay Surgical Hospital Hillcrest-Rockhampton Private Hospital Hills Private Hospital cnr O Rourke Street & Boat Harbour Drive, PIALBA QLD Talford Street, ROCKHAMPTON QLD Windsor Road, BAULKHAM HILLS NSW 2153 Hobart Day Surgery 10 Warneford Street, SOUTH HOBART TAS 7004 Hobart Private Hospital Argyle Street, HOBART TAS 7000 Mater 293 Vulture Street, SOUTH BRISBANE QLD 4101 Wesley 1st Floor, Wesley Medical Centre, 40 Chasley Street, AUCHENFLOWER QLD HOCA Chermside 4066 Chermside Medical Centre, Gympie Road, CHERMSIDE QLD 4032 HOCA Gold Coast Level 9, Premion Place, 39 White Street, SOUTHPORT QLD 4215 Hollywood Private Hospital Monash Avenue, NEDLANDS WA 6009 Holroyd Private Hospital Chetwynd Road, GUILDFORD NSW 2161 Holy Spirit Northside 627 Rode Road, CHERMSIDE QLD 4032 Hopewell Hospice 11 Dunkirk Close, ARUNDEL QLD 4214 Hunter Valley Private Hospital Hunters Hill Private Hospital Hurstville Private 20 Mawson Street, SHORTLAND NSW Mount Street, HUNTERS HILL NSW Gloucester Road, HURSTVILLE NSW 2220 Imaging@Olympic Park AAMI Park, Suite 2, 60 Olympic Boulevard, MELBOURNE VIC 3000 Ipswich Day Hospital 10 Churchill Street, IPSWICH QLD 4305 Ipswich Hospice Care 37 Chermside Road, Eastern Heights, IPSWICH QLD 4305 Jessie McPherson Private Hospital 246 Clayton Road, CLAYTON VIC 3168 John Fawkner Private Hospital 275 Moreland Road, COBURG VIC 3058 John Flynn-Gold Coast Private 42 Inland Drive, TUGUN QLD 4224 Hospital Joondalup Health Campus Shenton Avenue, JOONDALUP WA 6027 Kahlyn Private Hospital 40 Briant Road, MAGILL SA 5072 Kareena Private Hospital Kawana Private Hospital Kingsgrove Day Hospital Knox Private Hospital La Trobe Private Hospital Lady Davidson Private Hospital 86 Kareena Road, CARINGBAH NSW 2229 Suite 14, Level 1, 5 Innovation Parkway, BIRTINYA QLD 4575 Level 1, 322 Kingsgrove Road, KINGSGROVE NSW Mountain Highway, WANTIRNA VIC 3152 cnr Plenty Road and Kingsbury Drive, BUNDOORA VIC Bobbin Head Road, NORTH TURRAMURRA NSW

42 Schedule 5 Second-tier default benefits Lake Macquarie Private Hospital 3 Sydney Street, GATESHEAD NSW 2290 Lawrence Hargrave Private 72 Phillip Street, THIRROUL NSW 2515 Hospital Linacre Private Hospital 12 Linacre Road, HAMPTON VIC 3188 Lindfield Dialysis Clinic Liverpool Eye Surgery Logan Endoscopy Services Longueville Private Hospital Macquarie St Day Surgery 280 Pacific Highway, LINDFIELD NSW 2070 Ground Floor, 1 Moore Street, LIVERPOOL NSW 2170 Unit Beaudesert Road, BROWNS PLAINS QLD Kenneth Street, LONGUEVILLE NSW 2066 Level 11, 187 Macquarie Street, SYDNEY NSW 2000 Macquarie University Hospital 3 Technology Place, MACQUARIE PARK NSW 2109 Malvern Dialysis Clinic 1133 Malvern Road, MALVERN VIC 3144 Malvern Private Hospital 3-9 Wilton Vale Crescent, MALVERN EAST VIC 3145 Manly Waters Private Hospital 17 Cove Avenue, MANLY NSW 2095 Manningham Day Procedure Level 3, 200 High Street, LOWER Centre TEMPLESTOWE VIC 3107 Marie Stopes International Bowen 8 Campbell Street, BOWEN HILLS QLD Hills 4006 Marie Stopes International 163Lambton Road, BROADMEADOW Broadmeadow NSW 2292 Marie Stopes International - Level 1 Moore & Alinga Streets, Canberra CANBERRA CITY ACT 2601 Marie Stopes International East St 338 Dandenong Road, EAST ST KILDA Kilda VIC 3182 Marie Stopes International Dorset Road, CROYDON VIC Maroondah Centre 3142 Marie Stopes International Midland 8 Sayer Street, MIDLAND WA 6056 Centre Marie Stopes International 123 Bolsover Street, ROCKHAMPTON Rockhampton QLD 4700 Marie Stopes International 11 Hayling Street, SALISBURY QLD 4107 Salisbury Marie Stopes International 34 Cougal Street, SOUTHPORT QLD 4215 Southport Marie Stopes International 26 Mcilwraith Street, TOWNSVILLE QLD Townsville 4810 Maryvale Private Hospital 286 Maryvale Road, MORWELL VIC 3840 Masada Private Hospital Mater Adult Hospital 26 Balaclava Road, EAST ST KILDA VIC 3183 Raymond Terrace, SOUTH BRISBANE QLD 4101 Mater Children s Hospital Raymond Terrace, SOUTH BRISBANE QLD 4101 Mater Hospital Pimlico 21 Fulham Road, PIMLICO QLD

43 Schedule 5 Second-tier default benefits Mater Hospital Yeppoon 55 Cliff Street, YEPPOON QLD 4703 Mater Misericordiae Day Unit 1 Wellington Street, MACKAY QLD 4740 Mater Misericordiae Hospital Bundaberg Mater Misericordiae Hospital Gladstone Mater Misericordiae Hospital Mackay Mater Misericordiae Hospital Rockhampton Mater Mother s Hospital 313 Bourbong Street, BUNDABERG QLD 4670 Rossella Street, GLADSTONE QLD Willetts Road, NORTH MACKAY QLD 4740 cnr Ward & Jessie Streets, ROCKHAMPTON QLD 4700 Raymond Terrace, SOUTH BRISBANE QLD 4101 Mater Private Hospital Raymond Terrace, SOUTH BRISBANE QLD 4101 Mater Private Hospital Redland Weippin Street, CLEVELAND QLD 4163 Mater Sydney 35 Rocklands Road, NORTH SYDNEY NSW 2060 Mater Women s & Children s cnr Raymond Terrace & Stanley Street, Private Health Services SOUTH BRISBANE QLD 4101 Mater Women s and Children s Oxford Street, HYDE PARK QLD Hospital Hyde Park 4812 Mayo Private Hospital Lot 1, Potoroo Drive, TAREE NSW 2430 Melbourne MediBrain Centre and MediSleep Melbourne Private Hospital Royal Parade, PARKVILLE VIC 3052 Memorial Hospital 631 Inkerman Road, CAULFIELD NORTH VIC 3161 Sir Edwin Smith Avenue, NORTH ADELAIDE SA Addison Road, PETERSHAM NSW 2049 Metropolitan Rehabilitation Hospital Mildura Base Hospital Ontario Avenue, MILDURA VIC 3500 Minchinbury Community Hospital Rupertswood Road, MOUNT DRUITT NSW 2770 Mitcham Private Hospital 27 Doncaster East Road, MITCHAM VIC 3132 Modbury Dialysis Clinic Smart Road, MODBURY SA 5092 Mogo Day Surgery 2-4 Charles Street, MOGO NSW 2536 Montserrat Day Hospitals Samford Road, GAYTHORNE (Gaythorne) QLD 4051 Montserrat Day Hospitals 12 Riverview Terrace, INDOOROOPILLY (Indooroopilly) QLD 4068 Mosman Private Hospital 1 Ellamatta Avenue, MOSMAN NSW 2088 Mount Hospital 150 Mounts Bay Road, PERTH WA 6000 Mt Wilga Private Hospital 2 Manor Road, HORNSBY NSW 2077 Murray Valley Private Hospital Nordsvan Drive, WODONGA VIC 3690 Nambour Day Surgery 115 Howard Street, NAMBOUR QLD 4560 Nambour Selangor Private Hospital 62 Netherton Street, NAMBOUR QLD

44 Schedule 5 Second-tier default benefits National Capital Private Hospital Gilmore Crescent & Hospital Road, GARRAN ACT 2605 National Day Surgery - Sydney Level 1, Derby Street, KOGARAH NSW 2217 Nepean Private Hospital Barber Avenue, KINGSWOOD NSW 2747 New Farm Clinic 22 Sargent Street, NEW FARM QLD 4005 Newcastle Eye Hospital 182 Christo Road, WARATAH NSW 2298 Newcastle Private Hospital 2 Lookout Road, NEW LAMBTON HEIGHTS NSW 2305 Ngala Family Services 9 George Street, KENSINGTON WA 6151 Noosa Hospital North Eastern Community Hospital Inc North Eastern Rehabilitation Centre North Lakes Day Hospital North Shore Private Hospital North Shore Specialist Day Surgery North Tas Urology 111 Goodchap Street, NOOSAVILLE QLD Lower North East Road, CAMPBELLTOWN SA Ford Street, IVANHOE VIC Endeavour Boulevard, NORTH LAKES QLD 4509 Westbourne Street, ST LEONARDS NSW Pacific Highway, GREENWICH NSW Canning Street, LAUNCESTON TAS Flockton Street, EVERTON PARK QLD 4053 North West Brisbane Private Hospital Northern Endoscopy Centre 127 Frost Road, SALISBURY SOUTH SA 5106 Northpark Private Hospital Greenhills Road, BUNDOORA VIC 3083 Northside Clinic Private Hospital 2 Greenwich Road, GREENWICH NSW 2065 Northside Cremorne Clinic 3 Harrison Street, CREMORNE NSW 2090 Northside West Clinic Northwest Day Hospital Lytton Street, WENTWORTHVILLE NSW Maribyrnong Road, ASCOT VALE VIC 3032 Norwest Private Hospital 11 Norbrik Drive, BELLA VISTA NSW 2153 Nowra Private Hospital Weeroona Place, NOWRA NSW 2541 Ophthalmic Surgery Centre (North Suite 6, Malvern Avenue, Shore) CHATSWOOD NSW 2067 Oral Surgery Day Centre Suite 10, Malvern Avenue, CHATSWOOD NSW 2067 Orange Day Surgery Centre 60 McNamara Street, ORANGE NSW 2800 Oromax Day Surgery Pty Ltd Level 3, 1 Hutt Street, ADELAIDE SA 5000 Oxford Day Surgery and Dermatology Oxford Day Surgery Centre 54 Oxford Terrace, UNLEY SA 5061 Pacific Day Surgery Suite 4, 1 st Floor, Oxford Street, MOUNT HAWTHORN WA Misterton Street, FORTITUDE VALLEY QLD

45 Schedule 5 Second-tier default benefits Pacific Private Day Hospital Nerang Street, SOUTHPORT QLD 4215 Parkwynd Private Hospital 137 East Terrace, ADELAIDE SA 5000 Pendlebury Clinic Private Hospital Peninsula Eye Hospital Peninsula Private Hospital Peninsula Private Hospital Pennant Hills Day Endoscopy Centre Perfect Vision Eye Surgery Perth Clinic Suite 3, 52 Pendlebury Road, CARDIFF NSW Redcliffe Parade, REDCLIFFE QLD 4020 cnr Cranbourne Road & McClelland Drive, FRANKSTON VIC 3199 cnr George and Florence Streets, KIPPA RING QLD Ramsay Road, PENNANT HILLS NSW 2120 Suite 3, Hunter Street, HORNSBY NSW Havelock Street, WEST PERTH WA 6005 Perth Day Surgery Centre Cambridge Street, LEEDERVILLE WA 6007 Pindara Day Procedure Centre 13 Carrara Street, BENOWA QLD 4217 Pindara Private Hospital Allchurch Avenue, BENOWA QLD 4217 Pine Rivers Private Hospital Dixon Street, STRATHPINE QLD 4500 Port Macquarie Private Hospital Prince of Wales Private Hospital Queensland Eye Hospital Randwick Day Surgery Ringwood Private Hospital Rivercity Private Hospital Lake Road, PORT MACQUARIE NSW 2444 Levels 5-7, Ambulatory Care Services Centre Building, Prince of Wales Campus, Baker Street, RANDWICK NSW Little Edward Street, SPRING HILL QLD Eurimbla Avenue, RANDWICK NSW Mount Dandenong Road, EAST RINGWOOD VIC Milton Road, AUCHENFLOWER QLD 4066 Robina Procedure Centre Tenancy 4110, Level 3, Robina Town Centre Drive, ROBINA TOWN CENTRE QLD 4230 Roderick Street Day Surgery 23 Roderick Street, IPSWICH QLD 4305 Rosebery Day Surgery Rosebud SurgiCentre Sentiens Clinic 308 Gardeners Road, ROSEBERY NSW Point Nepean Road, ROSEBUD WEST VIC Parliament Place, WEST PERTH WA 6008 Shellharbour Private Hospital 27 Captain Cook Drive, BARRACK HEIGHTS NSW 2528 Shepparton Private Hospital Fitzgerald Street, SHEPPARTON VIC 3630 Short Street Day Surgery 2 Short Street, SOUTHPORT QLD 4215 Sight Foundation Theatre Sir John Monash Private Hospital Level 3, Clinical Service Building, Sydney Eye Hospital, 8 Macquarie Street, SYDNEY NSW Clayton Road, CLAYTON VIC

46 Schedule 5 Second-tier default benefits Skin and Cancer Foundation (Westmead) Day Procedure Centre Sole Vita Surgery 7 Phipps Close, DEAKIN ACT 2600 South Burnett Private Hospital 7 Ashley Lane, WESTMEAD NSW Markwell Street, KINGAROY QLD Ashmore Road, BUNDALL QLD 4217 South Coast Digestive Diseases Centre South Eastern Private Hospital cnr Princes Highway & Heatherton Road, NOBLE PARK VIC 3174 South Pacific Private Hospital 24 Beach Street, CURL CURL NSW 2096 South Perth Endoscopy South Terrace Urology Day Surgery Southern Eye Centre, Day Surgery & Laser Clinic Southern Highlands Private Hospital Southern Highlands Private Hospital Specialist Centre (SHPHSC) Southern Medical Day Care Centre Southern Respiratory and Sleep Disorders Centre Southport Day Hospital 20 Fortune Street, SOUTH PERTH WA South Terrace, ADELAIDE SA Cranbourne Road, FRANKSTON VIC Bowral Street, BOWRAL NSW Holmhale Street, BOWRAL NSW Crown Street, WOLLONGONG NSW 2500 Level 2, Sutherland Hospital, The Kingsway, CARINGBAH NSW a Marine Parade, SOUTHPORT QLD 4215 Spendelove House Private Hospital 24 Spendelove Avenue, SOUTHPORT QLD 4215 Sportsmed.SA Hospital 32 Payneham Road, STEPNEY SA 5069 Spring Hill Specialist Day Hospital 1 st and 4 th Floor St Andrew's Place, 33 North Street, SPRING HILL QLD Balmoral Avenue, Springvale VIC 3171 Springvale Endoscopy Centre and Day Hospital St Andrew s Ipswich Private Hospital St Andrew s Toowoomba Hospital 280 North Street, TOOWOOMBA QLD 4350 St George Private Hospital 1 South Street, KOGARAH NSW 2217 cnr Roderick and Pring Streets, IPSWICH QLD 4305 St Helens Private Hospital 186 Macquarie Street, HOBART TAS 7000 St John of God Hospital, Ballarat 101 Drummond Street North, BALLARAT VIC 3350 St John of God Hospital, Bendigo Lily Street, BENDIGO VIC 3552 St John of God Hospital, Berwick Gibb Street, BERWICK VIC 3806 St John of God Hospital, Bunbury St John of God Hospital, Geelong St John of God Hospital, Geraldton cnr Robertson Drive & Bussell Highway, BUNBURY WA and 83 Myers Street, GEELONG VIC Hermitage Street, GERALDTON WA

47 Schedule 5 Second-tier default benefits St John of God Hospital, Murdoch 100 Murdoch Drive, MURDOCH WA 6150 St John of God Hospital, Subiaco 12 Salvado Road, SUBIACO WA 6008 St John of God Hospital, Warrnambool St John of God Nepean Rehabilitation Hospital St John of God Pinelodge Clinic St John of God Private Hospital 136 Botanic Road, WARRNAMBOOL VIC Cranbourne Road, FRANKSTON VIC Heatherton Road, DANDENONG VIC Grantham Street, BURWOOD NSW Grose Vale Road, NORTH RICHMOND VIC 2754 St John of God Private Hospital (Richmond) St Kilda Day Hospital 26A Dickens Street, ELWOOD VIC 3184 St Luke s Hospital 18 Roslyn Street, POTTS POINT NSW Grey Street, MELBOURNE EAST VIC 3002 St Vincent s & Mercy Private Hospital (Mercy Campus) St Vincent s Hospital Scott Street, TOOWOOMBA QLD 4350 St Vincent s Hospital Brisbane 411 Main Street, KANGAROO POINT QLD 4169 St Vincent s Private Hospital 59 Victoria Parade, FITZROY VIC 3065 St Vincent s Private Hospital 406 Victoria Street, DARLINGHURST (Darlinghurst) NSW 2010 Steele Street Clinic 166 Steele Street, DEVONPORT TAS 7310 Stirling District Hospital 20 Milan Terrace, STIRLING SA 5152 Strathfield Private Hospital Sunnybank Private Hospital Sunshine Coast Day Surgery Sydney Adventist Hospital 3 Everton Road, STRATHFIELD NSW McCullough Street, SUNNYBANK QLD 4109 cnr Memorial and Second Avenues, MAROOCHYDORE QLD Fox Valley Road, WAHROONGA NSW 2076 RPAH Medical Centre, 106/100 Carillon Avenue, NEWTOWN NSW 2042 Sydney Day Surgery (Prince Alfred) Sydney Oculoplastic Surgery 229 Macquarie Street, SYDNEY NSW 2000 Sydney Retina Clinic & Day Level 13, 187 Macquarie Street, SYDNEY Surgery NSW 2000 Sydney Southwest Private Hospital Bigge Street, LIVERPOOL NSW 2170 Tamara Private Hospital 2-6 Dean Street, TAMWORTH NSW 2340 Tarietta Day Surgery 73 Kooyong Road, CAULFIELD NORTH VIC 3161 Tennyson Centre Day Hospital 520 South Road, KURRALTA PARK SA 5037 The Adelaide Clinic 33 Park Terrace, GILBERTON SA 5081 The Albert Road Clinic 31 Albert Road, MELBOURNE VIC 3000 The Avenue Private Hospital 40 The Avenue, WINDSOR VIC

48 Schedule 5 Second-tier default benefits The Bays Hospital The Burnside War Memorial Hospital Inc. The Cairns Clinic The Eye Hospital The Geelong Clinic The Glen Endoscopy Centre Main Street, MORNINGTON VIC Kensington Road, TOORAK GARDENS SA Sheridan Street, NORTH CAIRNS QLD Charles Street, LAUNCESTON TAS Townsend Road, ST ALBANS PARK VIC Springvale Road, GLEN WAVERLEY VIC Warana Drive, HAMPTON PARK VIC 3976 The Hampton Park Women s Health Care Centre The Hills Clinic Memorial Avenue, KELLYVILLE NSW 2155 The Melbourne Clinic 130 Church Street, RICHMOND VIC 3121 The Melbourne Eastern Private 157 Scoresby Road, BORONIA VIC 3155 Hospital The Oculoplastics Centre Sydney Suite 25, Gibbs Street, MIRANDA NSW 2228 The San Day Surgery 1a Northcote Road, HORNSBY NSW 2077 The Surgery Centre - Hurstville Level 1, 31 Dora Street, HURSTVILLE NSW 2220 The Sydney Clinic Murray Street, BRONTE NSW 2024 The Sydney Private Hospital 63 Victoria Street, ASHFIELD NSW 2131 The Valley Private Hospital cnr Police & Gladstone Roads, MULGRAVE VIC 3170 The Victoria Clinic 324 Malvern Road, PRAHRAN VIC 3181 The Victorian Rehabilitation 499 Springvale Road, GLEN WAVERLY Centre VIC 3150 Toowong Private Hospital 496 Milton Road, TOOWONG QLD 4066 Toowoomba Hospice 57b O'Quinn Street, TOOWOOMBA QLD 4350 Toowoomba Surgicentre 18 Scott Street, TOOWOOMBA QLD 4350 Toronto Private Hospital Cary Street, TORONTO NSW 2283 Townsville Day Surgery Tweed Day Surgery 1 Martinez Avenue, West End, TOWNSVILLE QLD 4810 Suite 4, Boyd Street, TWEED HEADS NSW Princes Highway, ULLADULLA NSW 2539 Ulladulla Endoscopy & Medical Centre Victoria Parade Surgery Centre Level 1, 100 Victoria Parade, EAST MELBOURNE VIC 3002 Vimy Private Hospital 5 Studley Avenue, KEW VIC 3101 Vision Eye Institute, Chatswood Vista Laser Eye Clinics NSW Wangaratta Private Hospital Levels 3 & 4, 270 Victoria Street, CHATSWOOD NSW McClaren Street, NORTH SYDNEY NSW Templeton Street, WANGARATTA VIC

49 Schedule 5 Second-tier default benefits Warners Bay Private Hospital Fairfax Road, WARNERS BAY NSW 2282 Warringal Private Hospital 216 Burgundy Street, HEIDELBERG VIC 3084 Waverley Private Hospital Blackburn Road, MOUNT WAVERLEY VIC 3149 Wesley Hospital Ashfield 91 Milton Street, ASHFIELD NSW 2131 Wesley Hospital Kogarah 7 Blake Street, KOGARAH NSW 2217 West Lakes Day Surgery 151 Brebner Drive, WEST LAKES SA 5021 Western Hospital 168 Cudmore Terrace, HENLEY BEACH SA 5022 Western Private Hospital 1-9 Marion Street, FOOTSCRAY VIC 3011 Westmead Private Hospital Westmead Rehabilitation Hospital Westmed Centre Westpoint Endoscopy Day Hospital Woodvale Private Hospital for Women cnr Mons and Darcy Roads, WESTMEAD NSW Coleman Street, MERRYLANDS NSW Railway Parade, WESTMEAD NSW Heaths Road, HOPPERS CROSSING VIC Timberlane Drive, WOODVALE WA

50 Notes Notes The as shown in this compilation are amended as indicated in the Tables below. Table of Instruments Instrument Private Health Insurance (Benefit Requirements) Rules 2011 Date of FRLI registration 31 October 2011 (see F2011L02160) Date of commencement 1 November 2011 Application, saving or transitional provision Private Health Insurance (Benefit Requirements) Amendment Rules 2011(No.10) 19 December 2011 (see F2011L02731) 20 December 2011 Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 1) 20 March 2012 (see F2012L00604) 20 March 2012 Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 2) 11 April 2012 (see F2012L00822) 12 April 2012 Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3) 20 April 2012 (see F2012L00905) 21 April 2012 Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 4) 20 June 2012 (see F2012L01264) 1 July

51 Notes Table of Amendments ad. = added or inserted am. = amended rep. = repealed rs. = repealed and substituted Provision affected Schedule 1 Part 1, Subclause 2(2) Part 2, Subclause 6(3) Schedule 2 Clause 2, Table Schedule 3 Part 1, Subclause 2( 2), Table 1 Part 1, Subclause 2( 2), Table 2 Part 2, Paragraph 4(1)(a) Part 2, Subclause 5(1) Part 3, Subclause 8 Part 3, Clause 8, Category 6 Part 3, Subclause 8, Category 3 (T8) Part 2, Subclause 5(1) Schedule 4 Clause 6, Table 1 Clause 6, Table 1 Clause 6, Table 2 Schedule 5 Clause 4, Table How affected am. F2012L01264 am. F2012L00604 am. F2012L01264 am. F2012L01264 am. F2012L01264 am. F2012L01264 am. F2012L00604 am. F2012L00604 am. F2012L01264 am. F2012L00604 am. F2012L01264 am. F2012L00905 am. F2012L00905 am. F2012L00604 am. F2012L01264 am. F2012L00604 am. F2011L02731 am. F2012L00604 am. F2012L00822 am. F2012L