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Circular No 07/24

General PHIAC Circulars

CLARIFICATION OF REQUIREMENTS FOR COMPLETION OF THE PHIAC 1 FORM

This circular is issued to address a number of queries from the Private Health Insurers and clarifies the requirements for completing the PHIAC 1 Form.

For Part 6 of the PHIAC 1 Form (General Treatment excluding Hospital-Substitute and CDMP), Insurers are required to report:

• all insured persons with a general treatment policy, including those with Hospital-Substitute and CDMP
• services, benefits and fees charged excluding the Hospital-Substitute and CDMP services, benefits and fees.

In this regard Part 6 is similar to the section in the previous PHIAC1 where ancillary persons and benefits were reported by age group.

The Private Health Insurance (Risk Equalisation Administration) Rules 2007, subrule 9(2)(e), explains the reporting requirements for reporting persons and benefits in the age groups in parts 3 to 6. These Rules require that a person should be reported in the age group corresponding to the age of the person at the end of the quarter to which the return relates.

However, in determining the age group in which days, benefits and fees are reported, the person’s age at the date of service is used.
Example: Mr. X has treatment at the beginning of the quarter and is aged 54. Mr. X turns 55 in the last week of the quarter. The service and benefit is reported in the age group 50 to 54 and Mr. X is included in the count of persons in the age group 55 to 59.

In addition, subrule 7(6) of the Private Health Insurance (Risk Equalisation Policy) Rules 2007 requires that where treatment is provided to a person for days during which the person was in more than one age group, the benefits must be allocated proportionately in accordance with the number of days during which the insured person was in each age cohort.

Part 2 of the PHIAC 1 form (Total Benefits Paid for Hospital Treatment and Total Benefits Paid for General Treatment) provides for the reporting of Ineligible hospital benefits, being those benefits that do not satisfy the definition of eligible benefits for Risk Equalisation purposes. Ineligible hospital benefits must be reported in Part 2 of the PHIAC 1 Form and are not to be reported in any other part of the Form. In particular, they are not to be included in Part 3, Hospital Treatment by Age Category.

The PHIAC 1 Return Guidance for completion July 2007 provides additional information on requirements for completing the PHIAC 1 return.