PHI 02/19 Eligibility of "prehabilitation" services for private health insurance benefits

Page last updated: 07 January 2019

PHI 02/19 Eligibility of "prehabilitation" services for private health insurance benefits (PDF 57 KB)

The Private Health Ministerial Advisory Committee discussed at its most recent meeting uncertainties with regard to the payment of private health insurance benefits for “prehabilitation” services.

A prehabilitation program could require a four to six week lead in time to proposed surgery. Such a proposed pre-surgery period may enable:

  • assessment of existing medical conditions;
  • identification of additional, potentially complicating, factors for pre-operative management;
  • anaesthetic assessment;
  • education of the patient and carers on the proposed procedure, pain management, post-operative program and precautions, establishment of patient orientated goals, discharge planning and home requirements (including home assessments prior to surgery where indicated); and
  • communication with the surgeon and caring team on the proposed pathway.
Prehabilitation services may be rendered at a hospital, provided by a hospital outside their physical boundaries (ie, hospital in the home), or provided by an entity which is not a hospital (including hospital substitute treatments). Prehabilitation services may be within the scope of hospital treatment or general treatment.

Hospital Benefits

Benefits for these services may be payable from a private health insurance hospital treatment policy if those services meet the definition of hospital treatment. Section 121-5 of the Private Health Insurance Act 2007 (the Act) defines hospital treatment as meaning treatment (including the provision of goods and services) that:
  1. is intended to manage a disease, injury or condition; and
  2. is provided to a person:
    1. by a person who is authorised by a hospital to provide the treatment; or
    2. under the management or control of such a person; and
  3. either:
    1. is provided at a hospital; or
    2. is provided, or arranged, with the direct involvement of a hospital.

General Benefits

Benefits for these services may be payable from a private health insurance general treatment policy if those services meet the definition of general treatment and covered by the policy.

Section 121-10 of the Act defines general treatment (including the provision of goods and services) as treatment that:
  1. is intended to manage or prevent a disease, injury or condition; and
  2. is not hospital treatment.
There are some limitations applying to this definition, the primary one being that general treatment policies cannot pay benefits for a service for which Medicare benefits are payable, unless the Private Health Insurance (Health Insurance Business) Rules provide otherwise.

Conclusion

While each service model should be considered individually, many of the services commonly referred to as “prehabilitation” may be eligible for benefits under private health insurance policies. Identifying a service as “prehabilitation” does not mean that the insured person would be unable to claim benefits in relation to that particular service.

If you have any questions regarding this Circular please contact the Department at PHI@health.gov.au.