EXPLANATORY STATEMENT
Issued by Authority of the Minister for Health and Ageing
National Health Act 1953
Determination under Schedule 1, paragraph (1)(bj)
(HIB 31/2006)
Schedule 1, paragraph (1)(bj) of the National Health Act 1953 (the Act) provides that the Minister may determine the minimum levels of benefits payable by a registered health benefits organization (RHBO) for hospital treatment provided to contributors, other than in emergencies, in a hospital or day hospital facility with which the RHBO does not have a hospital purchaser-provider agreement (HPPA) which covers such treatment. These benefits are known in the industry as “default benefits”.
The current Determination, dated 19 September 2006 (HIB20/2006) (as amended), is comprised of seven schedules setting out the minimum benefit levels payable for a range of hospital treatment.
This Determination amends HIB20/2006 by omitting Schedule 1, 3, 4 and 6 and substituting with new Schedules 1, 3, 4 and 6.
Amendments to Schedule 1
Schedule 1 of this determination sets default benefits for overnight accommodation in certain situations by specifying the default benefits that are payable in relation to the Medicare Benefits Schedule (MBS) item numbers. Schedule 1 categorises MBS item numbers into patient classifications (e.g. Advanced Surgical, Surgical/Obstetric or Other Patient).
Schedule 1 has been amended by adding and deleting MBS item numbers to reflect equivalent changes made to the MBS effective on and from 1 November 2006.
Schedule 1 has been amended to specify that advanced surgical patients are those undergoing a procedure with an MBS fee greater than $753.72 and surgical patients are those undergoing a procedure with an MBS fee within the range of $224.43 to $753.71. These new amounts reflect a 2.1% fee increase which has been applied to MBS fees from 1 November 2006. This amendment will ensure that MBS services that have been classified as surgical will not move up to the advanced surgical classification simply as a result of the MBS fee increase.
These changes were necessary because Schedule 1 links the default benefits that are payable to the types of professional services rendered to admitted hospital patients. The types of professional services rendered are identified by reference to MBS item numbers and fees
Amendments to Schedule 3
Schedule 3 sets the default benefit payable for same day accommodation by specifying the default benefits that are payable in relation to MBS item numbers.
Schedule 3 has been amended by adding and deleting MBS item numbers to reflect changes made to the MBS effective on and from 1 November 2006.
These changes were necessary because Schedule 3 links the default benefits that are payable to the types of professional services rendered to admitted hospital patients. The types of professional services rendered are identified by reference to MBS item numbers and fees.
Amendments to Schedule 4
Schedule 4 of this determination sets out the default benefits that are payable per night for patients that are classified as Nursing Home Type Patients (NHTP) in recognized hospitals in particular States and Territories and private hospitals in all States and Territories.
This Determination adjusts the default benefit payable to NHTP in recognized hospitals within Queensland and Tasmania to take into account an increase to the bed day charge. This determination also amends the private hospital default benefit in all States/Territories from $74.70 to $73.80. The default benefit amounts are effective the day after registration on the Federal Register of Legislative Instruments (FRLI).
This determination does not change the default benefit payable to NHTP in recognized hospitals in Western Australia, Australian Capital Territory, Victoria, South Australia, New South Wales or the Northern Territory.
Amendments to Schedule 6
Schedule 6 of this determination sets out the care plans and case conferencing. The change to this schedule is the inclusion of two new MBS care plan item numbers effective from 1 November 2006.
Consultation
The changes to the MBS resulted from reviews by the Medicare Benefit Consultative Committee (MBCC). The MBCC is an informal consultative forum with representation drawn from the Department of Health and Ageing, Medicare Australia, the Australian Medical Association and relevant professional groups of the medical profession. The reviews conducted by the MBCC are designed to ensure that the MBS reflects current medical practice and encourages best practice.
The subsequent changes to Schedule 1, Schedule 3 and Schedule 6 were necessary to ensure that health funds, at a minimum, pay the ‘default benefit’ for their members where members receive hospital treatment corresponding to one of the new MBS item numbers, in a hospital where that health fund does not have a contractual arrangement with that hospital. Amendments to Schedule 1, 3 and 6 are machinery in nature and do not substantially alter existing arrangements.
The amendments made to Schedule 4 relating to default benefits for NHTPs in recognized hospitals within Queensland and Tasmania, were made with the agreement of Queensland Health and the Department of Human Services, Tasmania. No consultation was undertaken for the private hospital default benefit within all States/Territories as the instrument is mechanical in nature. The changes are linked to the biannual change to the pension increase, which occurred on the 20 September 2006 and do not substantially alter existing arrangements for the private hospital sector.
Schedules 1, 3 & 6 of this Determinations commence on 1 November 2006, however Schedule 4 commences the day after registration on the FRLI.
PRIVATE HEALTH INSURANCE BRANCH
DEPARTMENT OF HEALTH AND AGEING
OCTOBER 2006