Private Health Insurance Act 2007 (Cth)

Private Health Insurance Act 2007

No. 31, 2007

Compilation No. 38

Compilation date: 15 February 2025

Includes amendments: Act No. 8, 2025

About this compilation

This compilation

This is a compilation of the Private Health Insurance Act 2007 that shows the text of the law as amended and in force on 15 February 2025 (the compilation date).

The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.

Uncommenced amendments

The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Register (www.legislation.gov.au). The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the Register for the compiled law.

Application, saving and transitional provisions for provisions and amendments

If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.

Editorial changes

For more information about any editorial changes made in this compilation, see the endnotes.

Modifications

If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the Register for the compiled law.

Self‑repealing provisions

If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.

Contents 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 1 Dictionary Endnotes Endnote 1—About the endnotes Endnote 2—Abbreviation key Endnote 3—Legislation history Endnote 4—Amendment history