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 2009 (No.7)
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 2009 (No. 2) (the Principal Rules) (as amended), which commenced on 30 July 2009, provide for the minimum benefit requirements for psychiatric, rehabilitation and palliative care and other hospital treatment. Schedules 1 to 5 of the Principal 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 2009 (No.7) (the Amendment Rules) amend Schedules 1 and 3 of the Principal Rules to ensure that insured persons receive minimum benefits from private health insurers where appropriate.
Schedule 1
Part 2, Schedule 1 of the Principal Rules (overnight accommodation: private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania) sets out the specifics of a Type A procedure and defines categories of patient, including “advanced surgical patient” and “surgical patient”.
In working out whether a particular admitted patient is an advanced surgical patient or a surgical patient, regard is made to the Medicare Benefits Schedule (MBS) item that relates to the professional service rendered to the patient. Prior to the Amendment Rules amending the Principal Rules, if the fee for the relevant MBS item is greater than $788.01, the patient may be an advanced surgical patient. If the fee is within the range of $234.65 to $788.01, the patient may be a surgical patient.
On 1 November 2009, the fees that apply in respect of the items set out in the MBS will be increased. To ensure that a patient does not move from the “surgical patient” category to the “advanced surgical patient” category as a result of the increase in MBS fees, the Amendment Rules amend the Principal Rules increasing the “advanced surgical patient” specified amount to $806.13 and the “surgical patient” specified range to “$240.05 to $806.13”. Thus, after the Amendment Rules amend the Principal Rules, if the fee for the MBS item that relates to the professional service rendered to a patient is greater than $806.13, the patient may be an advanced surgical patient. If the fee is within the range of $240.05 to $806.13, the patient may be a surgical patient.
Part 2, Schedule 1 of the Principal Rules is also amended to include three new MBS items, delete one MBS item and re-categorise one MBS item.
Schedule 3
The purpose of the amendment to Schedule 3 is to include new MBS items in Part 3 - Type C procedures. Type C procedures are procedures for which hospital treatment is not normally required. Minimum benefits for either overnight accommodation or day-only accommodation are payable for patients receiving certified Type C procedures where the certification requirements in the Principal Rules have been satisfied.
Details of the Amendment Rules are set out in the Attachment.
Consultation
The changes to the MBS resulted from reviews by the Medicare Benefit Consultative Committee (MBCC) and the Medicare Services Advisory Committee (MSAC). The MBCC is an advisory committee established by agreement between the Minister for Health and Ageing and the Australian Medical Association. MBCC’s major function is to review particular services or groups of services in the MBS, including consideration of appropriate
fees. MSAC advises the Minister of new and emerging medical services and under what circumstances public funding, including listing in the MBS, should be supported.
No specific consultation was undertaken in relation to the amendments to Schedules 1 and 3 of the Principal Rules because the changes are machinery in nature and do not substantially alter existing arrangements. The amendments to Schedule 1 and 3 are part of the ongoing management of the Private Health Insurance (Benefit Requirements) Rules.
PRIVATE HEALTH INSURANCE BRANCH
DEPARTMENT OF HEALTH AND AGEING
OCTOBER 2009
ATTACHMENT
DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2009 (No.7)
1. Name of Rules
Rule 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2009 (No.7) (the Amendment Rules).
2. Commencement
Rule 2 provides that the Amendment Rules are to commence on 1 November 2009 or, if registered after 1 November 2009, the day after registration.
3. Amendment of Private Health Insurance (Benefit Requirements) Rules 2009 (No. 2)
Rule 3 provides that the Schedule to the Amendment Rules amends the Private Health Insurance (Benefit Requirements) Rules 2009 (No. 2) (the Principal Rules) which commenced on 30 July 2009, and were subsequently amended on 28 August 2009, 20 September 2009 and 27 October 2009.
Schedule – Amendments
Item 1 – Schedule 1, Part 2, Subclause 4(3)
Subclause 4(3), Part 2, Schedule 1 of the Principal Rules sets out the item numbers in the Medical Benefits Schedule (MBS) for the purpose of clause 4, Part 2, Schedule 1 of the Principal Rules, but indicates that a listing in subclause 4(3) only applies where an item has a fee in the MBS greater than the specified amount.
Item 1 of the Schedule of the Amendment Rules amends subclause 4(3), Part 2, Schedule 1 of the Principal Rules by increasing the specified amount from “$788.01” to “$806.13”. This increase reflects an increase in MBS fees which commences on 1 November 2009.
Item 2 – Schedule 1, Part 2, Subclause 4(3)
Subclause 4(3), Part 2, Schedule 1 of the Principal Rules sets out the item numbers in the MBS for the purpose of clause 4, Part 2, Schedule 1 of the Principal Rules, but indicates that a listing in subclause 4(3) only applies where an item has a fee in the MBS greater than the specified amount.
Item 2 of the Schedule of the Amendment Rules amends subclause 4(3), Part 2, Schedule 1 of the Principal Rules by deleting MBS item number 42702 because the fee for this MBS item is no longer greater than the specified amount. This deletion reflects a change to the fee for MBS item number 42702, which commences on 1 November 2009.
Item 3 – Schedule 1, Part 2, Subclause 4(3)
Subclause 4(3), Part 2, Schedule 1 of the Principal Rules sets out the item numbers in the MBS for the purpose of clause 4, Part 2, Schedule 1 of the Principal Rules.
Item 3 of the Schedule of the Amendment Rules amends subclause 4(3), Part 2, Schedule 1 of the Principal Rules to insert new MBS item number 42718. This insertion reflects this new MBS item which commences on 1 November 2009.
Item 4 – Schedule 1, Part 2, Subclause 6(3)
Subclause 6(3), Part 2, Schedule 1 of the Principal Rules sets out the item numbers in the MBS for the purpose of clause 6, Part 2, Schedule 1 of the Principal Rules, but indicates that a listing in subclause 6(3) only applies where an item has a fee in the MBS which is within the specified range.
Item 4 of the Schedule of the Amendment Rules amends subclause 6(3), Part 2, Schedule 1 of the Principal Rules by inserting MBS item number 42702 because the fee for this MBS item will change on 1 November 2009 and will then fall within the specified range. This insertion reflects a change to the fee for MSB item number 42702, which commences on 1 November 2009.
Item 5 – Schedule 1, Part 2, Subclause 6(3)
Subclause 6(3), Part 2, Schedule 1 of the Principal Rules sets out the item numbers in the MBS for the purpose of clause 6, Part 2, Schedule 1 of the Principal Rules, but indicates that a listing in subclause 6(3) only applies where an item has a fee in the MBS which is within the specified range.
Item 5 of the Schedule of the Amendment Rules amends subclause 6(3), Part 2, Schedule 1 of the Principal Rules by increasing the specified range from the previous range of “$234.65 to $788.01” to the new range of “$240.05 to $806.13”. This increase reflects an increase in MBS fees which commences on 1 November 2009.
Item 6 – Schedule 1, Part 2, Subclause 6(3)
Subclause 6(3), Part 2, Schedule 1 of the Principal Rules sets out the item numbers in the MBS for the purpose of clause 6, Part 2, Schedule 1 of the Principal Rules, but indicates that a listing in subclause 6(3) only applies where an item has a fee in the MBS within the specified range.
Item 6 of the Schedule of the Amendment Rules amends subclause 6(3), Part 2, Schedule 1 of the Principal Rules to insert new MBS item numbers 30696 and 30710. This insertion reflects these two MBS items which commenced on 1 July 2009.
Item 7 – Schedule 1, Part 2, Subclause 6(3)
Subclause 6(3), Part 2, Schedule 1 of the Principal Rules sets out the item numbers in the MBS for the purpose of clause 6, Part 2, Schedule 1 of the Principal Rules, but indicates that a listing in subclause 6(3) only applies where an item has a fee in the MBS within the specified range.
Item 7 of the Schedule of the Amendment Rules amends subclause 6(3), Part 2, Schedule 1 of the Principal Rules by deleting MBS item number 42701 because the fee for this MBS item will change on 1 November 2009 and will then no longer fall within the specified range. This
deletion reflects a change to the fee for MBS item number 42701, which commences on 1 November 2009.
Item 8 – Schedule 3, Part 3, Clause 8 Interpretation, Items in the diagnostic imaging services table, in the list after I5
Clause 8, Part 3, Schedule 3 of the Principal Rules provides that a Type C procedure is a procedure specified in clause 8 by reference to MBS items.
Item 8 of the Schedule of the Amendment Rules amends clause 8, Part 3, Schedule 3 of the Principal Rules to insert new MBS item number 63476 at I5 under Category 5 – Diagnostic Imaging Services. This insertion reflects this MBS item which commenced on 1 July 2009.
Item 9 – Schedule 3, Part 3, Clause 8 Interpretation, Category 6 – Pathology services, in the list after P11
Clause 8, Part 3, Schedule 3 of the Principal Rules provides that a Type C procedure is a procedure specified in clause 8 by reference to MBS items.
Item 9 of the Schedule of the Amendment Rules amends clause 8, Part 3, Schedule 3 of the Principal Rules to insert new MBS item numbers 74992, 74993, 74994, 74995, 74996, 74997, 74998 and 74999 at P13 under Category 6 – Pathology Services. This insertion reflects these new MBS items which commence on 1 November 2009.
PRIVATE HEALTH INSURANCE BRANCH
DEPARTMENT OF HEALTH AND AGEING
OCTOBER 2009