EXPLANATORY STATEMENT
Issued by Authority of the Minister for Health and Ageing
National Health Act 1953
Determination under Schedule 1, paragraph (bj)
(HIB 16/2005)
Schedule 1, paragraph (bj) to the National Health Act 1953 (the Act) provides that the Minister may determine the minimum levels of benefit payable by a Registered Health Benefits Organization (RHBO) for an episode of hospital treatment provided, other than in emergencies, in a hospital or day hospital facility with which the RHBO does not have a hospital purchaser-provider agreement which covers such treatment. These benefits are known in the industry as “default benefits”.
The current Determination dated 24 June 2005 (HIB11/2005) (as amended) comprises eight schedules setting out the minimum levels of benefit which are payable for a range of hospital treatment. These include benefits for overnight accommodation, day accommodation, prostheses and second tier default benefits.
Schedule 5 (Benefits Payable in Respect of Prostheses and Human Tissues) of the current Determination has two parts:
- Part A – Prostheses; and
- Part B – Human Tissues.
Schedule 5 prescribes the prostheses and human tissues that RHBOs must fully fund for their members who have taken out a policy under which benefits are payable for the items.
This determination makes amendments to Schedule 5 (Benefits Payable in Respect of Prostheses and Human Tissues).
Specifically, the following amendments are contained in the determination:
- Billing Code MC357 – AngioLink Vascular Closure System is deleted from the Schedule.
The deleted product was not the subject of a positive recommendation from the Prostheses and Devices Committee (PDC), and was inadvertently included in Schedule 5.
2. Billing Code KM001 – Endotine Forehead Fixation Device is added to the Schedule.
The inserted product was the subject of a positive recommendation from the PDC, and was inadvertently not included in Schedule 5.
3. Billing Codes MS020 – Infusa MPD, MS028 – Medical Specialties Microject Infusion Pump and MS029 – Medical Specialties Microject Drug Administration are deleted from the Schedule.
The Supplier had requested that these products be deleted from Schedule 5. The products were inadvertantly included in Schedule 5.
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4. Billing Codes MP020 – Gluteal Implants filled with Elastomer, MP028 and MP029 – Silicone Sheets are added to the Schedule.
The inserted products were the subject of a positive recommendation from the PDC and were inadvertently not included in Schedule 5.
CONSULTATION
This determination has been made having regard to advice provided by the Prostheses and Devices Committee (PDC), a ministerially appointed committee comprised of nominees from health funds, hospitals, clinicians, prostheses and devices suppliers, the Commonwealth, and consumer representatives. The PDC considered the applications for listing of new products and applications for changes to existing listings and made recommendations.
This determination takes effect on the day following registration on the Federal Register of Legislative Instruments. The determination and this explanatory statement have been lodged for registration on the Federal Register of Legislative Instruments.
PRIVATE HEALTH INSURANCE BRANCH
DEPARTMENT OF HEALTH AND AGEING
SEPTEMBER 2005
Overview
The National Health Act 1953, enacted by the Australian Parliament, established a framework to ensure Australians have access to necessary health services. This Act, under its Schedule 1, paragraph (bj), empowers the Minister for Health to set minimum benefit levels for hospital treatments, known as "default benefits," when an episode of hospital treatment is provided in a facility with which the Registered Health Benefits Organization (RHBO) does not have an agreement. The 2005 determination under this section, HIB 16/2005, amends the existing benefits payable for prostheses and human tissues by removing certain products from the schedule due to lack of recommendation or supplier requests, and adding others based on positive recommendations. The objective of these amendments is to align the benefits with the recommendations of the Prostheses and Devices Committee, ensuring that the benefits provided are both necessary and appropriately funded. This approach seeks to maintain the integrity and effectiveness of the health insurance system by ensuring that only recommended and necessary prostheses and human tissues are funded under the default benefits.
Scope and Application
The National Health Act 1953, as amended by this determination, applies to Registered Health Benefits Organizations (RHBOs) which must adhere to the stipulated minimum levels of benefit for specific hospital treatments when these are provided in facilities without an existing hospital purchaser-provider agreement. This legislation aims to ensure that members of these organizations receive a baseline level of care and funding for prostheses and human tissues when receiving hospital treatment. The amendments to the current determination primarily concern Schedule 5, which delineates the prostheses and human tissues that RHBOs must fully fund. These changes include the removal of certain products from the schedule based on non-recommendation or supplier requests, and the addition of others following positive recommendations from the Prostheses and Devices Committee (PDC). This PDC, a ministerially appointed committee, was instrumental in reviewing and advising on these amendments, ensuring that the determination reflects the current best practices and recommendations in the health sector. The changes will take effect on the day following their registration on the Federal Register of Legislative Instruments, thereby extending their jurisdictional reach nationally under the Commonwealth of Australia.
Key Provisions
The main operative sections of this determination, as stated in the Explanatory Statement, pertain to Schedule 5 (Benefits Payable in Respect of Prostheses and Human Tissues) of the current Determination HIB 11/2005, which is amended by the introduction of this document. The amendments involve the deletion and addition of certain billing codes corresponding to specific medical prostheses and devices. Section 2 of the determination specifies the deletion of Billing Code MC357 for the AngioLink Vascular Closure System, as it was not recommended by the Prostheses and Devices Committee (PDC) and was mistakenly included. Section 3 adds Billing Code KM001 for the Endotine Forehead Fixation Device, which was recommended by the PDC but omitted in error. Section 4 removes Billing Codes MS020, MS028, and MS029 for specific infusion pumps and drug administration devices, following a supplier’s request and due to their inadvertent inclusion. Finally, Section 5 introduces Billing Codes MP020, MP028, and MP029 for gluteal implants and silicone sheets, recommended by the PDC and previously omitted.
The obligations imposed by this determination on Registered Health Benefits Organizations (RHBOs) are primarily to comply with the amendments outlined in the new Schedule 5. This includes ensuring that the specified billing codes are correctly applied or removed from their records, and that they provide the prescribed benefits for their members as per the updated schedule. RHBOs must adhere to the recommendations of the PDC and ensure that their funding aligns with the stipulated prostheses and human tissue benefits.
Failure to comply with the provisions of this determination could result in civil or administrative penalties. Although the specific penalties are not detailed in the Explanatory Statement, it is implied that non-compliance could lead to regulatory action, fines, or other consequences as prescribed by the relevant legislative framework. The amendments aim to correct previous errors and ensure that the benefits provided are accurate and consistent with the committee’s recommendations, thus maintaining the integrity of the health benefits system.