Commonwealth Numbered Acts

NATIONAL HEALTH AMENDMENT ACT (No. 2) 1978 No. 132, 1978 - SCHEDULE

SCHEDULE
Section 43

SCHEDULE TO BE ADDED AT THE END OF THE PRINCIPAL ACT

''SCHEDULE
Section 73BA

CONDITIONS OF REGISTRATION OF AN ORGANIZATION

   (a)  The organization will not carry on business in Australia as a
        registered medical benefits organization or as a registered hospital
        benefits organization except in a State or Territory in respect of
        which it is registered as a registered medical benefits organization
        or a registered hospital benefits organization, as the case may be.

   (b)  The organization will permit any contributor to a medical benefits
        fund or a hospital benefits fund conducted by it to contribute for
        benefits in respect of himself and his dependants (if any) in
        accordance with a basic table.

   (c)  Where the organization conducts a hospital benefits fund, the
        organization will not offer to the contributors to that fund, whether
        on its own behalf or on behalf of another person or organization,
        health insurance in respect of nursing home care other than in
        accordance with a basic table or an optional table.

   (d)  The amount of fund benefit payable to a contributor by the
        organization in respect of a professional service or hospital
        treatment or other service will not exceed-

        (i)    in the case of a professional service-the amount by which the
               medical expenses incurred in respect of that professional
               service exceed the Commonwealth medical benefit in respect of
               that professional service; or

        (ii)   in the case of hospital treatment or other service-the fees or
               charges incurred in respect of that hospital treatment or other
               service.

   (e)  Where the organization conducts a medical benefits fund, the
        organization will not offer to the contributors to that fund
        fund benefits in respect of professional services that exceed the
        amounts by which the fees applicable to those professional services
        for the purpose of the calculation of Commonwealth medical benefits in
        respect of those professional services exceed those Commonwealth
        medical benefits.

   (f)  The organization will not offer health insurance, whether on its own
        behalf or on behalf of another person or organization, under which the
        liability of the insurer is to pay fund benefits in respect of
        professional services of such amounts that, if they were offered to
        contributors to a medical benefits fund conducted by the organization,
        the organization would be in breach of the condition set out in
        paragraph (e).

   (g)  Where the organization conducts a hospital benefits fund, the
        organization will not permit a person to contribute to the fund for
        benefits in accordance with a supplementary hospital table unless the
        person also contributes to that fund for benefits in accordance with
        a basic table or an optional table.

   (h)  Where the organization conducts a hospital benefits fund, the
        organization will not offer to the contributors to that fund a table
        of benefits, not being a basic table or an optional table, that
        includes benefits with respect to the provision of hospital treatment
        in a hospital in respect of a private patient in other than a single
        room.

   (j)  Where a contributor to a medical benefits fund or a hospital benefits
        fund conducted by the organization, being a contributor for benefits
        in accordance with a basic table or an optional table, has ceased to
        pay contributions, the rules of the organization will-

        (i)    permit the contributor, at any time before the expiration of a
               period, being a period of not less than 2 months, specified in
               the rules to pay the contributions due in respect of the period
               (in this paragraph referred to as 'the period in arrears')
               commencing on the expiration of the period in respect of which
               he has paid contributions and ending not later than the date on
               which he makes the payment; and

        (ii)   provide that, if the contributor makes the payment referred to
               in sub-paragraph (i), he is to continue to be eligible for
               benefits, in accordance with the appropriate table, in respect
               of the period in arrears.

   (k)  The organization will institute, and maintain, in a form and manner
        satisfactory to the Minister, a record of the contributors, and the
        dependants of the contributors, to any medical benefits fund or
        hospital benefits fund conducted by it.

   (l)  Where the organization is a party to an agreement under section 20C of
        the Health Insurance Act 1973, the organization will institute, and
        maintain, in a form and manner satisfactory to the Minister-

        (i)    a record of the persons registered with it as registered
               persons and the dependants of those persons; and

        (ii)   a record of such other information in relation to the persons
               referred to in sub-paragraph (i) as the Minister directs, from
               time to time, by notice in writing served on the organization.

   (m)  Where the rules of the organization provide for a waiting period with
        respect to contributors for benefits in accordance with a basic table,
        that waiting period will not exceed 2 months.

   (n)  The rules of the organization will not provide for a waiting period
        for-

        (i)    contributors for benefits in accordance with
               a basic table or an optional table who have transferred to a
               medical benefits fund or a hospital benefits fund conducted by
               the organization from such a fund conducted by another
               organization whose registration under Part VI has been
               cancelled or is under consideration by the Minister with a view
               to cancellation; or

        (ii)   eligible persons who, on or before 1 January 1979, become
               contributors to a medical benefits fund or a hospital benefits
               fund conducted by the organization, being contributors for
               benefits in accordance with a basic table or an optional table.

   (o)  Where the organization conducts a medical benefits fund, the
        organization will not pay a benefit from the fund to a person who has
        taken an assignment of the benefit from the person who is entitled
        under the rules of the organization to payment of the benefit unless-

        (i)    that last-mentioned person is a pensioner; and

        (ii)   the service in respect of which the benefit is payable was
               rendered in respect of the pensioner or a dependant of the
               pensioner.

   (p)  Where the organization conducts a medical benefits fund, the
        organization will institute and maintain procedures satisfactory to
        the Minister for the payment out of the funds of the organization or
        out of advances made under section 20E of the
        Health Insurance Act 1973 of all claims for Commonwealth medical
        benefit lodged with the organization in accordance with section 20B of
        the Health Insurance Act 1973.

   (q)  Where-

        (i)    a claim for a Commonwealth medical benefit in respect of a
               professional service is lodged with the organization in
               accordance with section 20B of the Health Insurance Act 1973
               (including such a claim lodged together with a claim for fund
               medical benefit in respect of the professional service); and

        (ii)   the medical expenses incurred in respect of the professional
               service have not been paid,

the organization will not pay the claimant the Commonwealth medical benefit or
the fund benefit (if any) but, if the claimant so requests, the organization
will, in lieu of that payment, give him, or post to him at his last known
address, a cheque for the amount of the Commonwealth medical benefit or the
Commonwealth medical benefit and the fund benefit, as the case may be, drawn
in favour of the person who rendered the professional service or, if the
professional service was rendered by that person on behalf of another person,
in favour of that other person.

   (r)  Where there is forwarded with a claim for a Commonwealth medical
        benefit lodged with the organization in accordance with section 20B of
        the Health Insurance Act 1973 a statement by the person by, or on
        whose behalf, the service was rendered that the service was of unusual
        length or complexity, the organization will refer the claim to the
        Department to be dealt with under section 11 of that Act.

   (s)  Where an exemption is in force under section 73F in relation to the
        organization, the organization will-

        (i)    furnish to all contributors to any medical benefits fund
               conducted by the organization and to all persons registered
               with it as registered persons; and

        (ii)   publish, in a manner satisfactory to the Minister, for the
               information of eligible persons who may wish to register with
               the organization as registered persons,

the particulars of the exemption, including a description of the professional
service or professional services affected by the exemption, and a statement
setting out the effect of the exemption on the rights of contributors and
registered persons.

   (t)  The organization will comply with any direction of the Minister under
        this Act served on it.''.
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