Private Health Insurance (Benefit Requirements) Amendment Rules 2008 (No. 3)

EXPLANATORY STATEMENT

Issued by the Authority of the Minister for Health and Ageing

Private Health Insurance Act 2007

Private Health Insurance (Benefit Requirements) Amendment Rules 2008 (No. 3)

Section 333-20 of the Private Health Insurance Act 2007 (the Act) provides that the Minister may make Private Health Insurance (Benefit Requirements) Rules providing for matters required or permitted by Part 3-3 of the Act, or necessary or convenient to be provided in order to carry out or give effect to Part 3-3 of the Act.

The Private Health Insurance (Benefit Requirements) Rules 2008 (No. 2), which commenced on 1 July 2008 (the Rules), provide for the minimum benefit requirements for psychiatric, rehabilitation and palliative care and other hospital treatment. Schedules 1 to 5 of the Rules set out the minimum levels of benefit which are payable for hospital treatment. Namely, benefits for overnight accommodation (Schedules 1 and 2), same day accommodation (Schedule 3), nursing-home type patients (Schedule 4) and second tier default benefits (Schedule 5).

The Private Health Insurance (Benefit Requirements) Amendment Rules 2008 (No. 2) made on 17 July 2008 amended Schedules 1, 3 and 5 of the Rules. The purpose of those amendments was to reflect changes in the minimum benefits payable for overnight shared accommodation at public hospitals in Victoria and to ensure that a new facility was eligible for second tier default benefits. In order to carry out that purpose, it was necessary for minimum benefit rates for Victoria in clause 2, Table 2 of Schedule 1 and clause 2, Table 1 of Schedule 3 to be amended, and for the new facility to be inserted into the table at clause 4 of Schedule 5 of the Rules.

The Private Health Insurance (Benefit Requirements) Amendment Rules 2008 (No. 3) (the Amending Rules) amend the items in Schedule 3, amends Table 1 and Table 2 of Schedule 4, and further amends Schedule 5 of the Rules (as amended). The purpose of the amendments to Schedule 3 of the Rules is to reflect changes in Medical Benefits Schedule (MBS) items as of 1 July 2008. The purpose of the amendments to Schedule 4 of the Rules is to reflect the changes in the minimum benefits for hospital treatment for those patients who are classified as “nursing-home type patients” at public hospitals in the Northern Territory, Queensland, Tasmania and Victoria, and at private hospitals nationally. The purpose of the amendments to Schedule 5 of the Rules is to ensure that four new facilities are eligible for second tier default benefits.

Details of the Amending Rules are set out in the Attachment.

Consultation

No specific consultation was undertaken in relation to the amendments to Schedule 3 of the Rules because the changes were machinery in nature and did not substantially alter existing arrangements.

The amendments to Schedule 4 of the Rules were made with the agreement of the relevant State and Territory health authorities.

Consultation for changes to Schedule 5 of the Rules occurred with industry through the Second Tier Advisory Committee, which includes equal representation from both the private hospital and the health insurance sectors.

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

SEPTEMBER 2008

ATTACHMENT

DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2008 (No. 3)

1. Name of Rules

Rule 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2008 (No. 3) (the Amending Rules).

2. Commencement

Rule 2 provides that the Amending Rules are to commence on 20 September 2008 or, if the Amending Rules are registered on a later date, the day after registration.

3.              Amendment of Private Health Insurance (Benefit Requirements) Rules 2008 (No. 2)

Rule 3 provides that the Schedule to the Amending Rules amends the Rules which commenced on 1 July 2008 and were amended on 17 July 2008.

Schedule – Amendments

Item 1 – Schedule 3, Part 3, Clause 8 Interpretation, Items in the general medical services table

Clause 8 provides that a Type C procedure is a procedure specified in clause 8 by reference to

Medical Benefits Schedule (MBS) items.

Item 1 of the Schedule of the Amending Rules amends clause 8, Part 3, Schedule 3 of the Rules to insert MBS items 15700, 15705, 15800 and 15850 at T2, Category 3 – therapeutic procedures. This insertion reflects new MBS items which commenced on 1 July 2008 due to the Health Insurance (Radiation Oncology) Determination 2008 which provided that the MBS items are to be treated as if inserted in Group T2 of the Health Insurance (General Medical Services Table) Regulations 2007 (“the GMST”).

Item 2 – Schedule 3, Part 2, Paragraph 4(1)(a)

Clause 4 provides that for the purpose of the table in clause 2 of Schedule 3, Band 1

treatment has the meaning given by clause 4.

Item 2 of the Schedule of the Amending Rules amends paragraph 4(1)(a), Part 2, Schedule 3 of the Rules to insert MBS item 42741 at T8. This insertion reflects the new MBS item in the GMST by Health Insurance (General Medical Services Table) Amendment Regulations 2008 (No 2) which commenced on 1 July 2008.

Item 3 – Schedule 3, Part 3, Clause 8 Interpretation, Items in the pathology services table

Clause 8 provides that a Type C procedure is a procedure specified in clause 8 by reference to

Medical Benefits Schedule (MBS) items.

Item 3 of the Schedule of the Amending Rules amends clause 8, Part 3, Schedule 3 of the Rules to delete MBS items 66515 and 66710 from ‘Items in the pathology services table’, P2. This insertion reflects the deletion of the MBS items from the Health Insurance (Pathology Services Table) Regulations 2007 (“the Pathology Services Table) by the Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No 2) which commenced on 1 July 2008.

Item 4 – Schedule 3, Part 3, Clause 8 Interpretation, Items in the pathology services table

Clause 8 provides that a Type C procedure is a procedure specified in clause 8 by reference to

Medical Benefits Schedule (MBS) items.

Item 3 of the Schedule of the Amending Rules amends clause 8, Part 3, Schedule 3 of the Rules to delete MBS item 69399 from ‘Items in the pathology services table’, P3. This insertion reflects the deletion of the MBS item from the Pathology Services Table by the Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No 2) which commenced on 1 July 2008.

Item 5 – Schedule 3, Part 3, Clause 8 Interpretation, Items in the pathology services table

Clause 8 provides that a Type C procedure is a procedure specified in clause 8 by reference to

Medical Benefits Schedule (MBS) items.

Item 3 of the Schedule of the Amending Rules amends clause 8, Part 3, Schedule 3 of the Rules to insert MBS item 73920 in ‘Items in the pathology services table’, P10. This insertion reflects the insertion of the MBS item in the Pathology Services Table by the Health Insurance (Pathology Services Table) Amendment Regulations 2008 (No 2) which commenced on 1 July 2008.

Item 6 – Schedule 4, Minimum benefit in clause 6, Table 1

Schedule 4 of the Rules set out the minimum benefit payable per night for patients that are classified as Nursing Home Type Patients in public hospitals in all States and Territories. The Amending Rules make increases to the Minimum benefit per night for the following States and Territories in clause 6, Table 1:

• Northern Territory - From: $59.08 to $60.72;
• Queensland -   From: $88.50 to $92.00;
• Tasmania -  From: $95.25 to $97.90; and
• Victoria -   From: $95.15 to $97.15.

Item 7 – Schedule 4, Minimum benefit in clause 6, Table 1

Schedule 4 of the Rules set out the minimum benefit payable per night for patients that are classified as Nursing Home Type Patients in private hospitals. The Amending Rules decreases the Minimum benefit per night for private hospitals in clause 6, Table 2:

• Private hospitals - From: $71.40 to $70.30.

Item 8 – Schedule 5, clause 4, Facilities

Schedule 5 of the Rules requires a health insurer to pay second tier default benefits for most episodes of hospital treatment provided in private hospital facilities that are specified in Schedule 5 with which the health insurer does not have a negotiated agreement. Schedule 5 sets a higher minimum level of benefit (for overnight treatment and day only treatment provided in specified facilities) than the minimum benefit set for such treatment by

Schedules 1, 2 and 3 of the Rules.

Item 8 of the Schedule to the Amending Rules amend clause 4 of Schedule 5 of the Rules to specify that four new facilities are entitled to second tier default benefits.

The new facilities are:

As a result of these insertions, the table has increased from 280 listed facilities to 284 listed facilities. No change has been made to the previously listed facilities.

The Amending Rules commence on 20 September 2008 or the day after registration on the Federal Register of Legislative Instruments, if not registered by 20 September 2008. 

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

SEPTEMBER 2008