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1009
Circular No 10/09
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Review of CDMP benefits reported by insurers – 2009/10
PHIAC and the Department of Health and Ageing recently conducted a review of benefits and services associated with eligible Chronic Disease Management Programs (CDMPs) reported by insurers for inclusion in Risk Equalisation. The review identified anomalies in the statistics reported by some insurers relating to the services and benefits reported on Part 8 of the PHIAC 1 form (Benefits paid for CDMPs). It is noted that should the reporting be incorrect it may have consequences for Risk Equalisation calculations and payments.
Details of the mandatory requirements for a program to be recognised as an eligible CDMP for Risk Equalisation purposes are set out in Part 1 of the Private Health Insurance (Risk Equalisation Policy) Rules 2007 and Part 3 of the Private Health Insurance (Health Insurance Business) Rules 2009. The Rules specify that, for an eligible CDMP, there must be (at least):
- a written plan
- coordination of the program
- an allied health service.
The benefits and services review expected to find that insurers’ reporting of eligible CDMP benefits and services would include each of the above mentioned essential elements. The review of PHIAC 1 returns showed that in some instances where benefits and services for some of the CDMP essential elements were reported, benefits and services for other essential elements were not.
PHIAC recommends that each insurer reviews the statistics submitted by them in Part 8 of the PHIAC 1 form for the September 2009 and later quarters, to ensure reported benefits and services in relation to eligible CDMPs are correct.
Should an insurer determine that any submitted PHIAC 1 return contains error, notice must be given to the Council of adjustments necessary and a revised PHIAC 1 return submission is required.
Any adjustments necessary for Risk Equalisation in the current (2009/10) year will be made by PHIAC in the usual course of Risk Equalisation processing.
Insurers that appear to have misreported in previous years have been contacted separately.